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Dialysis Concepts: A Review for Clinical Pharmacists

Release Date: May 1, 2011
Expiration Date: May 31,
2013
FACULTY:
Christy M. Gorbach, PharmD Candidate
Patricia L. Darbishire, PharmD
Clinical Assistant Professor of Pharmacy
Practice, Director of Introductory Pharmacy
Practice Experiences
Brian M. Shepler, PharmD
Clinical Assistant Professor of Pharmacy Practice, Director of Advanced Pharmacy Practice
Experiences
Purdue University College of Pharmacy
West Lafayette, Indiana

FACULTY DISCLOSURE STATEMENTS:

Ms. Gorbach and Drs. Darbishire and Shepler have no actual or potential conflicts of interest in
relation to this activity.
Postgraduate Healthcare Education, LLC does not view the existence of relationships as an
implication of bias or that the value of the material is decreased. The content of the activity was
planned to be balanced, objective, and scientifically rigorous. Occasionally, authors may express
opinions that represent their own viewpoint. Conclusions drawn by participants should be derived
from objective analysis of scientific data.

ACCREDITATION STATEMENT:
Pharmacy
Postgraduate Healthcare Education, LLC is accredited by the Accreditation Council for Pharmacy
Education as a provider of continuing pharmacy education.
UAN: 0430-0000-11-016-H01-P
Credits: 2.0 hours (0.20 ceu)
Type of Activity: Knowledge

TARGET AUDIENCE:
This accredited activity is targeted to pharmacists. Estimated time to complete this
activity is 120 minutes.
Exam processing and other inquiries to:

CE Customer Service: (800) 825-4696 or cecustomerservice@jobson.com

DISCLAIMER:
Participants have an implied responsibility to use the newly acquired information to enhance
patient outcomes and their own professional development. The information presented in this
activity is not meant to serve as a guideline for patient management. Any procedures,
medications, or other courses of diagnosis or treatment discussed or suggested in this activity
should not be used by clinicians without evaluation of their patients' conditions and possible
contraindications or dangers in use, review of any applicable manufacturer's product information,
and comparison with recommendations of other authorities.

GOAL:
To provide clinical pharmacists with an understanding of the dialysis process, an update on
emerging trends, and a review of dosing considerations in this population.

OBJECTIVES:
After completing this activity, the participant should be able to:
1. Determine whether a drug is likely to be dialyzed, given specific characteristics such as
molecular weight and volume of distribution.
2. Differentiate between conventional, short daily, and daily nocturnal hemodialysis
modalities.
3. Discuss the dialysis process, including how fluid, toxins, and electrolytes are affected by
the dialysis membrane.
4. Evaluate patient-specific data to determine whether a given dialysis session is effective
per Kidney Disease Outcomes Quality Initiative guidelines.
5. Compare and contrast the different vascular-access procedures.

End-stage renal disease (ESRD), the final stage of chronic kidney disease (CKD), occurs when
the kidneys have deteriorated to the point that they are no longer capable of sustaining life. There
are several mechanisms by which a patient can develop ESRD. For many patients, ESRD is the
final chapter in a long battle with CKD as a direct consequence of poorly managed hypertension
and diabetes. ESRD may result from an episode of acute renal failure that is not reversed, such
as a severe adverse drug reaction or exposure to a nephrotoxin that irreversibly shuts down
kidney function. A patient who develops ESRD has two choices: renal replacement therapy (RRT)
or kidney transplantation.
The inability of the kidneys to function results in the accumulation of toxins, electrolytes, and fluid
in the body, which can be managed with RRT. There are different types of RRT, including
hemodialysis (HD) and peritoneal dialysis (PD). RRTs are further classified as intermittent or

continuous based on their modality.

Pharmacists play a key role in the management of patients receiving dialysis. In this review, the
concept of dialysis is explored, along with the staging and presentation of patients leading up to
ESRD and dialysis. Drug-dosing considerations for HD patients will be provided, as well as a
discussion covering new concepts and research initiatives.

ESRD AND RRT IN THE UNITED STATES

As of December 31, 2008, an estimated 354,600 U.S. patients received HD and 26,517 patients
received PD. There were 102,876 and 6,577 incident HD and PD patients, respectively, in 2008. 1
Among dialysis modalities, HD and PD constitute the two largest groups, with HD the most
commonly prescribed. Subclasses of HD and PD, such as home HD and continuous cyclic PD,
will be discussed later in this article.
Dialysis represents a significant cost in the U.S. Total costs for ESRD in 2008, as measured by
Medicare spending, reached $26.8 billion. Significantly more was spent on HD ($19.4 billion)
compared with PD ($1.04 billion) and renal transplants ($2.08 billion). 1 The annual per-person
cost of HD in 2008 was $77,506.

KIDNEY DETERIORATION AND PROGRESSION TO ESRD

The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) set
forth guidelines for staging CKD in 2002.2 In these guidelines, the patients glomerular filtration
rate (GFR) is estimated using the Modification of Diet in Renal Disease Study equation and
measured in mL/min/1.73 m2. There are five stages of CKD, with stages 1 and 2 reserved for
patients exhibiting normal or slightly decreased GFR and the presence of some form of kidney
damage. Stage 3 is when GFR falls below 60 mL/min/1.73 m2, stage 4 is GFR below 30
mL/min/1.73 m2, and stage 5 is GFR below 15 mL/min/m2. A patient who reaches stage 5 is
considered to have ESRD. Current terminology for categorizing CKD patients indicates whether a
patient is receiving HD; e.g., a nonHDdependent CKD patient has not yet reached stage 5,
whereas an HD-dependent CKD patient is in stage 5.
Patients typically do not present with clinical symptoms until stage 4, although exceptions exist.
As kidney function declines, serum creatinine and blood urea nitrogen (BUN) begin to rise.
Serum phosphorus increases, as this element is primarily eliminated renally. Toxic waste
molecules such as urea and uric acid start to accumulate in the blood, causing the patient to
become symptomatic. Patients often experience nausea and vomiting, weight loss, poor appetite,
and fatigue as they approach kidney failure. Uric acid may accumulate and crystallize on the skin,
a condition termed uremic frost.3,4 As a consequence of uremic encephalopathy, patients may
become disoriented and confused and have difficulty concentrating. 5 Anemia develops as the
kidney becomes unable to produce enough erythropoietin to maintain adequate hemoglobin
concentrations. Alterations in vitamin D, calcium, and parathyroid hormone concentrations also
develop in conjunction with the rise in serum phosphorus.
Many of these conditions require medications for correction. For example, erythropoiesisstimulating agents are used to treat anemia, phosphate binders correct hyperphosphatemia, and
vitamin D analogues treat secondary hyperparathyroidism. Mental-status changes, uremic frost,
and volume overload, as well as nausea and vomiting, can be improved through adequate
dialysis therapy.

THE HD PROCESS
The first working HD machine was constructed in 1943 by Dr. Willem Kolff; however, it was not
specifically designed for long-term use in the typical stage 5 ESRD patient. 6 The basic concept of
modern HD involves running a patients blood through an external circuit, where it is funneled
through a semipermeable membrane filter and exposed to a dialysate (dialysis fluid). Here the
blood is cleansed of uremic toxins and excess fluid while, simultaneously, beneficial solutes are
transported from the dialysate to the blood. For example, bicarbonate serum concentrations
often low in ESRD patientscan be corrected by dialyzing the blood against a rich bicarbonate
solution. In the U.S., an HD session typically lasts 3 to 4 hours and occurs 3 to 4 days per week,
usually in a free-standing center or clinic. In 2008, 66% of HD patients were treated in chain HD
centers, while about 31% were treated in hospitals and nonchain centers. 1
HD requires a vascular-access site, a dialyzer, and a dialysate. 7 The dialysate consists of a
concentrated electrolyte solution dissolved in water. Different types of dialysate solutions are
available commercially. A typical dialysate contains 130 to 145 mEq/L sodium, 2 to 3 mEq/L
potassium, 2.5 to 3.5 mEq/L calcium, and 100 to 200 mg/dL glucose, along with magnesium and
alkaline buffers.8 The bicarbonate, which comes as a dry powder, is added later, as it is too
unstable to be mixed with the dialysate. The water must initially be passed through a reverse
osmosis system each week to remove the aluminum and biomaterials such as bacteria and
endotoxins.
The dialyzer, also referred to as a filter or artificial kidney, is a semipermeable membrane
responsible for diffusion and ultrafiltration. Diffusion is the movement of solutes from high to low
concentration through a semipermeable membrane. This mechanism removes waste products
from the blood during HD. Ultrafil tration, the movement of fluid across a semipermeable
membrane that is caused by differences in pressure, removes excess fluids from the body and is
used primarily to treat edema.7
Many different types of dialyzers are available. The most common form is the hollow-fiber or
capillary dialyzer, which contains thousands of hollow fibers surrounded by a rigid polyurethane
shell. Two ports are located on each end of the dialyzer to allow the blood and dialysate to flow in
and out. The blood flows through the fibers and the dialysate surrounds the fibers. The two fluids
flow in opposite directions, allowing a concentration gradient to form and resulting in diffusion and
ultrafiltration. Low-molecularweight (LMW) molecules (<5 kDa) move freely across the
membrane, while large molecules are restricted. The LMW molecules that are cleared include
urea, creatinine, vitamin B12, phosphate, and inulin, among others.7
One of the best-known dialyzerdrug interactions occurs between ACE inhibitors and certain
dialyzers. Several studies in the early 1990s reported on anaphylactic reactions observed when
AN69 dialyzer membranes were used in conjunction with ACE inhibitors. 9-14 AN69 dialyzers were
composed of polyacrylonitrile membranes that could increase bradykinin generation. When this
effect was magnified by the ability of ACE inhibitors to decrease bradykinin breakdown, patients
experienced severe and sometimes life-threatening anaphylactic reactions.
Because dialysis requires access to the patients blood supply on a regular basis, one of the
challenges in delivering successful treatment is finding a reliable mode of ongoing IV access.
Dialysis needles are large in diameter (generally 14-17 gauge) to allow for maximal blood flow in
a relatively short period of time; it would take too long to dialyze a patient using a needle with a
very small bore. The three types of access commonly employed in ESRD patients are the
arteriovenous fistula (AVF), polytetrafluoroethylene (PTFE) graft, and central venous catheter. 15

An AVF is created surgically by joining an artery to a vein, thereby increasing pressure in the vein
so that it swells and creates a site for cannulation. The forearm is the most common site, but the
upper arm or leg may also be used. In some cases, different methods have been used to locate
acceptable vasculature for fistula creation, including regional anesthesia. 15 Once the procedure is
completed, the AVF may take up to 2 months to fully mature before it can be used. AVF is the
preferred choice in many cases and is recommended by the NKF-KDOQI clinical practice
guidelines for vascular access and the Fistula First Breakthrough Initiative because it carries the
lowest risk of infection.16,17
PTFE grafts use a synthetic tube to connect the artery to the vein and provide a point of access
for cannulation. The PTFE graft takes less time to fully mature, but it carries a higher infection
rate. Central venous catheters may be used immediately, which is their greatest advantage over
AVF and PTFE grafts. They may also have some use in bridge therapy for ESRD patients who
are waiting either for a kidney transplant or for their fistula or graft to fully mature. In some
instances, a central venous catheter may be the only option if the patient has unusable or
unsuitable vasculature.18 For example, a diabetic patient with poor blood flow to the extremities
may not have veins suitable for fistula creation or graft insertion. The greatest drawback of central
venous catheters is their high infection rate compared with PTFE grafts and AVF. For this reason,
central venous catheters are utilized much less for HD access. In 2008, 18% of U.S. HD patients
used catheters for HD access, 27% used PTFE grafts, and 55% used AVF.1

THE PD PROCESS
There are two types of PD: continuous ambulatory PD (CAPD) and continuous cyclic PD
(CCPD).19 Unlike HD, which is administered intermittently, PD is performed continuously.20 PD
also allows for ambulation during dialysis and can
be administered by the patient at home or work.

A patient who
develops end-stage
renal disease
the final stage of
chronic kidney
diseasehas two
choices: renal
replacement therapy
or kidney
transplantation.

In PD, a plastic catheter is permanently placed in

the peritoneal cavity. The catheter allows
approximately 1.5 to 3 L of an electrolyte solution
(dialysate) to flow into the peritoneal cavity.19,20 The
solution remains in the peritoneal cavity for roughly
2 to 4 hours (maximum 6 hours), after which it is
removed via the catheter.19,20 This process is
repeated multiple times per day to allow for proper
removal of toxins, salt, and water.20 Toxins are
removed from the peritoneal cavity by diffusion; salt
and water are removed by osmosis due to the high
concentration of glucose in the dialysate. The rate
of diffusion slows and eventually stops once
equilibrium between plasma and dialysate is
reached.19 Solutes and water are absorbed from
the peritoneal cavity by crossing the peritoneal membrane and entering the peritoneal capillary
circulation; they also are absorbed by crossing from the peritoneal lymphatics to the lymphatic
circulation. The rate of solute transportation is individualized, and factors such as infection
(peritonitis), drugs, and physical makeup affect the rate.
During CAPD, the dialysate is manually infused into the peritoneal cavity via the catheter and
exchanged three to five times daily.19 Another dialysate may be instilled at bedtime and left
overnight. The removal of dialysate from the peritoneal cavity is performed manually and with the
help of gravity. CCPD, the second type of PD, differs from CAPD in that it is performed during the

night by an automated cycler that conducts exchange cycles while the patient sleeps. The
number of exchange cycles required for adequate peritoneal solute clearance is patient specific
and requires close monitoring.
The dialysate used in PD may consist of lactate (preferred buffer), heparin (to prevent catheter
obstruction), and antibiotics during an episode of acute peritonitis. 19 Insulin may be added if the
patient has diabetes. Major complications of PD include peritonitis, catheter-associated
nonperitonitis infections, weight gain, metabolic disturbances, and residual uremia.

MEASURING THE EFFICACY OF THE HD SESSION

For HD to be maximally effective, certain parameters must be maintained. Two values that the
clinician assesses when determining dialysis efficacy are the Kt/V (K urea= clearance of urea, t =
time spent on dialysis, V = volume of distribution of urea) and the urea reduction ratio (URR).
Urea, a solute that is removed during dialysis, is a marker representing solute clearance. The
target Kt/V for HD patients is 1.4. Since Kurea is measured in millimeters per minute, T is
measured in minutes, and V is measured in millimeters, the calculated Kt/V is a unitless
parameter. Often, Kt/V is reported as an adjusted or total value. If the patient has any residual
kidney function, that value may be calculated into the Kt/V to give a more accurate figure; if this
has been done, the Kt/V is reported as an adjusted value. 21
The URR, a simpler calculation, is essentially the difference between predialysis BUN and
postdialysis BUN divided by predialysis BUN and expressed as a percentage (e.g., if predialysis
BUN = 110 and postdialysis BUN = 38, then URR = 65%). According to NKF-KDOQI guidelines,
the recommended URR goal for ESRD patients is 70%. If target goals (Kt/V = 1.4, URR >70%)
are not achieved, the patient may receive additional HD sessions or be prescribed additional time
for each session (e.g., 4 hours three times/week vs. 3.5 hours). 21 Maintaining adequate HD will
help manage conditions associated with ESRD, including edema, uremia, and acid or base
disorders. Clinicians can then focus on maximizing drug therapy for complications not corrected
by HD (e.g., hyperphosphatemia, anemia, secondary hyperparathyroidism).

DOSING CONSIDERATIONS IN HD
Factors That Affect Drug Clearance
In order to appreciate alterations in drug dosing during dialysis, it is important to understand the
process of drug removal. Drug removal resembles the mechanism utilized to remove solutes in
conventional HD.22 Drugs primarily undergo diffusion across the dialysis membrane by moving
from a high concentration to a low concentration via the concentration gradient that forms
between the plasma and the dialysate.
HD is much more efficient than PD at removing drugs.22 PD does not remove drugs rapidly, but
instead allows them to be adequately absorbed when placed in the peritoneal dialysate. This
explains why many antibiotics require intraperitoneal placement to reach concentrations needed
to appropriately treat peritonitis. Other factors favoring absorption of drugs during peritonitis
treatment include inflamed membranes and high-concentration gradients. Many drugs reach
inconsistent concentrations in the peritoneal fluid if administered IV or orally.
Specific drug properties can render an agent more likely to be removed by HD. 22 Drugs that are
less than 500 Da and less than 90% protein bound are most effectively removed by HD. Highmolecularweight drugs with low protein binding are more easily removed by PD than by HD

because of secretion into peritoneal lymphatic fluid.23 A drug with a small volume of distribution
indicating that less of the drug distributes into adipose tissueis also more effectively removed
by dialysis.22 Larger molecules require more porous membranes to allow for increased removal
by HD. The type of membrane also plays a role in drug removal during dialysis; this is due to the
clearance characteristics of the dialyzer as well as to the membrane charge that is present. The
drugs charge and its ability to bind to charged proteins will affect removal. It is also important to
consider whether the dialyzer has been reused, as the functional ability to remove drugs
decreases with increasing use.

Appropriate Dosing
Appropriate dosing of drugs in patients undergoing dialysis requires the clinician to conduct a
thorough medication history to obtain drug-related allergy or toxicity information and identify
concurrent medications.24 The patients weight and height, physical examination, and laboratory
data assessing renal function are also pertinent to determining appropriate dosing. 23 On average,
patients undergoing dialysis receive approximately 11 different medications and are three times
more likely than patients with normal renal function to experience an adverse drug event. 24 This
exemplifies the importance of individualizing the medication therapy for each patient and
appropriately dosing each medication.
Recommendations are available for drug dosing in dialysis patients. These recommendations are
merely guidelines; adjustments may be required for individual patients. 22 Drugs with a long halflife may be initiated with a loading dose that is equal to the usual dose in patients with normal
renal function. Once the patient has initiated a drug, the clinician may adjust the dose by
decreasing the individual doses or increasing the dose interval. Altering the dose interval is more
convenient and less expensive for the patient. It is common to adjust the dose by combining the
two methods.

Dosing in Specific Drug Classes

Antihypertensives and Cardiovascular Agents: The most commonly prescribed drugs in
patients with renal disease are antihypertensives and cardiovascular agents. 22 This is because of
the close relationship between the renal and cardiovascular systems with regard to blood
pressure control. Many of the medications in these two classes are administered by dose titration
based upon the patients clinical response. Long-acting drugs are more desirable because of
improved compliance and should be considered when the patients medication regimen is being
selected.
Because these drug classes are often used in patients with renal disease, it is important for the
clinician to understand the pharmacokinetic and pharmacodynamic alterations that occur when
these drugs are administered to a patient with CKD. 22 Cardiovascular agents and their
metabolites can accumulate when renal insufficiency is present. There is also a risk of proteinand
drug-binding abnormalities, which cause an increase in free drug at the site of action and result in
enhanced drug efficacy and toxicity. Antihypertensives have toxicity risks as well, and in general
their adverse-event profiles are related to their pharmacologic effects. Medications that alter the
normal pressor response and compensatory cardiac output in dialysis are undesirable to initiate.
CKD patients started on antiarrhythmic agents require close monitoring, as the medication may
cause the arrhythmia it was intended to treat.
Diuretics are another drug class often used in patients with renal disease. 22 These agents may be
used to treat fluid overload and are a common part of an antihypertensive regimen. Proteinuria
and renal impairment are two complications that can alter the pharmacokinetics and

pharmacodynamics of diuretic agents. Protein binding in the tubule fluid decreases the efficacy of
thiazide and loop diuretics. If kidney function continues to decline, there is a risk of hypovolemia
with diuretic use; this can result in a further decline in renal function. If hypertension is being
managed with diuretics, it is important to control blood pressure with little volume contraction.
Hyperkalemia is an adverse event that is possible with potassium-sparing diuretics, so these
agents should not be used in patients with a creatinine clearance (CrCl) below 30 mL/min. 22 The
risk of hyperkalemia increases if potassium-sparing diuretics are administered with potassium
supplements, ACE inhibitors, angiotensin receptor antagonists (ARBs), or nonsteroidal
antiinflammatory drugs (NSAIDs). When used alone to reduce fluid volume, potassium-sparing
diuretics are less effective than thiazide diuretics and loop diuretics, but they may be used to
prevent and treat diuretic-induced hypokalemia and edema when administered concurrently with
thiazide or loop diuretics.25 Organic-acid diuretics must compete with endogenous organic acids
to reach the tubule lumen and become active.22 As kidney function declines, larger doses are
required. Thiazides become ineffective once the GFR falls below approximately 30 mL/min, but
large doses of loop diuretics still may produce a diuretic effect. The combination of a loop diuretic
and a thiazide diuretic may be required to achieve an adequate effect.
ACE inhibitors and ARBs are two common antihypertensives with renal-protective effects in
patients with diabetes.22,25 These agents must be used with caution in patients who have
decreased renal function or are on dialysis.
Patients with renal artery occlusion or
microvascular renal disease may have a sudden
decline in renal function because of the
hemodynamic effects resulting from decreased
angiotensin II in the body. If an ACE inhibitor or
ARB is used, the initial dose should be low, the
dose should be titrated slowly, and renal function
should be monitored closely. Renal function may
decrease modestly while these agents are being
used, which may be acceptable. If renal function
progressively declines, these agents should be
discontinued.

Dialysis represents a
significant cost
in the U.S., with
significantly more
spent on
hemodialysis
($19.4 billion) than on
peritoneal dialysis
($1.04 billion) and
renal transplants
($2.08 billion).

Antimicrobials: Patients undergoing dialysis

respond differently to antimicrobial therapy than
patients with normal renal function do.22 Most
antimicrobials are excreted renally and thus require
dosing alterations. The most important goal of
antimicrobial therapy in patients with renal
insufficiency is to initiate appropriate and effective therapy early and at doses that can achieve
therapeutic concentrations quickly. It would be inappropriate to maintain drug concentrations
below therapeutic range; this could be dangerous to the patient.

Drug selection hinges on which pathogen is present. 22 Therapy could initially start with empirical
drugs and then be narrowed to focus on a specific pathogen once results of microbial-sensitivity
tests are available. Signs and symptoms of infection may be absent in patients with renal
insufficiency, and it is common for uremic symptoms and dialysis to mask symptoms such as
fever.22 A single loading dose equivalent to the typical maintenance dose in patients with normal
renal function should be initiated in patients with renal insufficiency. From there, the dose can be
adjusted appropriately based on therapeutic drug-concentration monitoring and microbial

sensitivities.
Adverse reactions and drug toxicities are a high risk in patients with impaired renal function. 22
These may be caused by the accumulation of a drug and or its metabolites after repeated doses.
Adverse reactions can affect any organ system, and neurotoxicity, nephrotoxicity, hematologic
toxicity, and coagulopathy are common reactions. If new symptoms arise after therapy is initiated,
drug toxicity should be considered and evaluated. Side effects that are uncommon in patients
with normal renal function may occur more frequently in patients with kidney failure. For example,
accumulation of beta lactam rarely causes seizures in normal patients, but when large doses are
given to CKD patients and the drug accumulates, seizures are more likely.
Two ways antimicrobial drugs can induce nephrotoxicity are direct cellular toxicity and allergic
interstitial nephritis.22 Aminoglycosides are a specific class of antimicrobials that are nephrotoxic.
Patients with normal renal function who are receiving aminoglycoside therapy may have a
reduction in renal function that goes unnoticed. However, a CKD patient with a CrCl of 20 mL/min
who experiences the same reduction might require dialysis. This underscores the need for careful
drug-concentration monitoring in CKD patients receiving antimicrobials.
Antiplatelet and Anticoagulant Agents: Antiplatelet agents are often used to maintain adequate
blood flow to the vascular access site.22 Available classes of antiplatelet therapies are heparin,
LMW heparin (LMWH), aspirin, and clopidogrel. Each antiplatelet medication has its own risks
and benefits in dialysis patients.
The combination of aspirin and clopidogrel in HD patients has been shown to cause hemorrhagic
side effects. Some antiplatelet medications are cleared renally and require dose adjustments.
Low-dose aspirin does not have a significant effect on renal function in CKD, but LMWH may be
risky in patients with significant kidney dysfunction. Standard weight-based dose adjustments of
LMWH may result in excessive anticoagulation in patients with a GFR less than 50%. To reduce
the risk of excessive anticoagulation, enoxaparin (an LMWH) in patients with a CrCl of less than
30 mL/min is dosed at half of the normal dose.26 Because of its unpredictable anticoagulation
effects and the need for close therapeutic monitoring, enoxaparin is not recommended in dialysis
patients. The anticoagulant heparin is commonly used to prevent clots from forming in the
vascular access site.22,27
Nonsteroidal Anti-Inflammatory Drugs: The mechanism of action of NSAIDs is to inhibit
prostaglandin synthesis, which results in anti-inflammatory effects. 22 Because prostaglandins are
vital in maintaining renal vasodilation and adequate blood flow to the kidneys, inhibiting this
natural process can result in renal arteriolar constriction, decreased renal blood flow, and reduced
GFR.22,28 Decreased prostaglandin synthesis also may cause salt and water retention by
increasing tubule chloride reabsorption in the loop of Henle and increasing the antidiuretic
hormone effect on the distal tubule. Renin synthesis also may be inhibited, resulting in a
reduction in plasma aldosterone production. This can lead to hyperkalemia in patients with renal
insufficiency.
This medication class should generally be avoided in CKD patients, as there is a risk of reducing
kidney function even further.22 Patients with concomitant congestive heart failure, volume
contraction, or ascites or edema from liver failure are at greatest risk for developing adverse
events owing to their dependence on endogenous renal vasodilator properties.
Cyclo-oxygenase-2 selective NSAIDs demonstrate equivalent effects on the kidneys, and there is
no advantage of these agents over nonselective NSAIDs. 22 The nephrotoxicity of NSAIDs is
determined by their potency, length of action, and period of administration. The cardiovascular

side effects seen with NSAID use have not been determined in patients with CKD.

EMERGING CONCEPTS IN HD AND RRT

Historically, it been recommended to begin HD in a CKD patient when the CrCl is below the 10 to
15 mL/min value and is accompanied by signs and symptoms of uremia. 2 However, there remains
some controversy regarding the optimal start time for dialysis. 29 The Initiating Dialysis Early and
Late Study is a prospective, multicenter, randomized, controlled trial investigating whether an
early start (CrCl 10-14 mL/min/1.73m2) or late start (CrCl 5-7 mL/min/1.73m2) has any impact on
the survival of ESRD patients. Results of the trial are forthcoming. 30
Alternative HD regimens that vary the length of dialysis sessions are undergoing increasing
evaluation and consideration.31,32 In the U.S., conventional HD is used for most ESRD patients
and requires the patient to dialyze for 3 to 4 hours three times per week. Two types of daily, or
quotidian, dialysisshort dialysis and nocturnal dialysisare alternative HD regimens that may
offer some advantages for HDdependent CKD patients. 33,34 Short daily dialysis requires the
patient to dialyze for shorter sessions on more days per week. A typical schedule might be 1.5 to
2 hours for 6 days per week. Patients may tolerate this schedule better and experience improved
blood pressure control. Although phosphate removal is greater than with conventional HD, it is
not of a sufficient degree to negate the use of phosphate binders. 34
Daily nocturnal dialysis occurs while the patient sleeps (6-7 nights/week for 6-8 hours). It is well
tolerated, reduces phosphorus serum concentrations enough that phosphate binders are often no
longer needed, and in some cases controls blood pressure to a greater degree, even to the point
of reducing left ventricular hypertrophy.35 In addition, patients may resume a normal diet without
regard to salt or phosphate intake. Daily nocturnal dialysis is also the only modality that can help
regulate patients with sleep apnea.33 Unfortunately, longer and more frequent dialysis sessions
do not necessarily result in better mortality rates.36 Furthermore, the high cost of short daily
dialysis and daily nocturnal dialysis is a barrier for many patients.

CONCLUSION
In conclusion, HD and PD are the most common forms of RRT administered to CKD patients in
the U.S. who have progressed to ESRD. Pharmacists who care for these patients are required to
manage an extensive list of medications; they also must understand how HD and PD can affect
the patients medications and uremic status.

REFERENCES
1.

U.S. Renal Data System. Annual Data Report 2010. www.usrds.org/adr. htm. Accessed January
15, 2011.

2.

National Kidney Foundation. KDOQI clinical practice guidelines for chronic kidney disease:
evaluation, classification, and stratification.
www.kidney.org/professionals/KDOQI/guidelines_ckd/toc.htm. Accessed February 1, 2011.

3.

Udayakumar P, Balasubramanian S, Ramalingam KS, et al. Cutaneous manifestations in patients

with chronic renal failure on hemodialysis. Indian J Dermatol Venereol Leprol. 2006;72:119-125.

4.

Kuo CC, Hung JB, Tsai CW, Chen YM. Uremic frost. CMAJ. 2010; 182:E800.

5.

Lacerda G, Krummel T, Hirsch E. Neurologic presentations of renal dis eases. Neurol Clin.
2010;28:45-59.

6.

Kolff W, Berk H. The artificial kidney: a dialyser with a great area. Acta Med Scand. 1944;117:121134.

7.

Ashley C, Morlidge C. Introduction to Renal Therapeutics. London, Eng land: Pharmaceutical

Press; 2008:85-104.

8.

Himmelfarb J, Ikizler TA. Hemodialysis. N Engl J Med. 2010;363: 1833-1845.

9.

Ebo DG, Bosmans JL, Couttenye MM, Stevens WJ. Haemodialysis-asso ciated anaphylactic and
anaphylactoid reactions. Allergy. 2006;61:211-220.

10. Fink E, Lemke HD, Verresen L, Shimamoto K. Kinin generation by hemodialysis membranes as a
possible cause of anaphylactoid reactions. Braz J Med Biol Res. 1994;27:1975-1983.
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