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End-Stage Renal Disease

AuthorsOnecia Benjamin1; Sarah L. Lappin2.

Affiliations

1 SUNY Upstate

2 Upstate University Hospital

Last Update: December 2, 2018.

Introduction

More than 500,000 people in the United States live with end-stage renal disease (ESRD). The
development of chronic kidney disease (CKD) and its progression to this terminal disease remains a
major source of reduced quality of life and significant premature mortality. Chronic kidney disease (CKD)
is a very debilitating disease and standards of medical care involve aggressive monitoring for signs of
disease progression as well as early referral to specialists for dialysis or possible renal transplant. KDIGO
guidelines define CKD using markers of kidney damage, specifically markers that determine proteinuria
and glomerular filtration rate. By definition, the presence of both of these factors (glomerular filtration
rate [GFR] less than 60mL/min and albumin greater than 30mg per gram of creatinine) along with
abnormalities of kidney structure or function for greater than three months signifies chronic kidney
disease. End-stage renal disease, moreover, is defined as a GFR less than 15mL/min.[1][2]
Etiology

End-stage renal disease can be caused by many chronic diseases. In the United States, diabetes is the
leading cause. Other causes include hypertension, glomerulonephritis, polycystic kidney disease,
prolonged obstruction of the urinary tract, vesicoureteral reflux, recurrent pyelonephritis, and certain
medications such as NSAIDs, calcineurin inhibitors, and antiretrovirals.

Epidemiology

According to the United States Renal Data System, in 2015, there were 124,411 new ESRD diagnoses,
reflecting an increasing burden of kidney failure. The prevalence of the disease has been rising at a
stable number of about 20,000 cases per year.[3][4]

The degree of kidney failure varies widely by race in the US. In 2015, the rate of ESRD was three times
higher in African Americans as compared to Caucasians (393.5 versus 139.9 per million population). In
that same year, the ESRD prevalence was about ten times higher in American Indians or Alaska Natives
and twice higher in Native Hawaiians or Pacific Islanders. Rates were 1.3 times higher in Asian
Americans. Of note, rates in the African American population have been decreasing each year since
2006, leading to an overall decrease of 21%. This reduction has been even more pronounced in
American Indians/Alaska Natives.

Pathophysiology

The decline of kidney function is gradual and initially may present asymptomatically. The natural history
of renal failure depends on the etiology of the disease but ultimately involves early homeostatic
mechanisms involving hyperfiltration of the nephrons. As nephrons become damaged, the kidney
increases the rate of filtration in the residual normal ones. As a result, the patient with mild renal
impairment can show normal creatinine values, and the disease can go undetected for some time. This
adaptive mechanism will run its course and will eventually cause damage to the glomeruli of the
remaining nephrons. It is at this point that antihypertensives such as ACEs or ARBs may be beneficial in
slowing the progress of the disease and preserve renal function.

History and Physical

End-stage renal disease can present with a constellation of signs and symptoms. Some include volume
overload refractory to diuretics, hypertension poorly responsive to medication, anemia, mineral and
bone disorders, and metabolic derangements including hyperkalemia, hyponatremia, metabolic acidosis,
hypo/hypercalcemia, and hyperphosphatemia. Uremic toxicity also can present as anorexia, nausea,
vomiting, bleeding diatheses, pericarditis, uremic neuropathy or encephalopathy, seizure, coma, and
death. Uremic toxicity is an indication for urgent dialysis.

Evaluation

Chronic kidney disease is diagnosed when there is evidence of kidney damage for at least 3 months or in
any patient who has a GFR less than 60 mL/min for that same amount of time.[5][6]

To calculate GFR, three equations are commonly used (the MDRD, CKD-EPI and Cockcroft-Gault formula).
However, the best estimate of GFR is the CKD-EPI equation, which adjusts for age, race, and gender. It is
important to note, however, that the formula tends to underestimate the true GFR at a GFR greater than
60mL/min.

To quantitate albuminuria, a spot urine protein/creatinine ratio can be done. A value greater than 30 mg
of albumin per gram of creatinine is considered abnormal while values greater than 300mg/g is
considered severely impaired renal function. Additionally, a 24-hour urine protein can also be
performed. A value greater than 3.5 g is concerning for nephrotic range proteinuria.

Further evaluation of kidney disease can include a renal ultrasound, CBC, BMP, urinalysis, and/or kidney
biopsy. An ultrasound can provide data estimating size, obstructions, stones, cystic renal disease, mass
lesions, echogenicity, and cortical thinning. Blood work will determine if there is secondary anemia and
will detect evidence of electrolyte derangement. In cases of severe anemia secondary to CKD,
erythropoiesis-stimulating agents should be started at a hemoglobin level below 10g/dL.

Finally, a renal biopsy may be necessary if the etiology remains unclear.

Treatment / Management
Treatment of end-stage renal disease involves correcting parameters at the level of the patient
presentation. Interventions aimed at slowing the rate of kidney disease should be initiated and can
include:

Treating the underlying cause and managing blood pressure and proteinuria. Blood pressure should be
targeted to a systolic blood pressure less than 130 mmHg and diastolic blood pressure less than 80
mmHg in both diabetic and non-diabetic adults whose urine albumin excretion exceeds 30 mg for 24
hours. For diabetics with proteinuria, an ACEI or ARB should be started in cases where urine albumin
values range between 30 and 300mg in 24 hours and greater than 300 mg in 24 hours. These drugs slow
the disease progression, particularly when initiated before the GFR decreases to less than 60 mL/min or
before plasma creatinine concentration exceeds 1.2 and 1.5 in women and men, respectively.

Other targets in preventive care and monitoring should include tight glycemic control, cardiovascular risk
reduction, and general lifestyle recommendations such as smoking cessation and dietary restriction.
Glycemic control is critical. An A1C less than 7 is generally recommended to prevent or delay
microvascular complications in this population. Management with sodium glucose transporter 2 (SGLT-2)
inhibitors may reduce the burden of disease in those with Type II diabetes mellitus.

Treatment of chronic metabolic acidosis with supplemental renal bicarbonate also may slow the
progression of end-stage renal disease.

Patients with CKD tend to have dyslipidemia, particularly hypertriglyceridemia. So monitoring with lipid
panels and initiation of statins or other hypoglycemic agents can be started.

Lifestyle modification and dietary restriction are recommended. Adhering to a low salt diet (less than 2
g/day), a renal diet (avoiding foods that are high in phosphorus), and restricting daily protein to 0.8g per
kg body weight per day are essential to managing disease burden.

Hypocalcemia should also be monitored. A 25-OH vitamin D level less than 10 ng/mL warrants initiation
of ergocalciferol 50,000 IU weekly for 6 to 8 weeks before switching to cholecalciferol 800 to 1000 IU
daily.
Staging

KDIGO 2012: CKD classification takes into account the GFR level as well as the severity of albuminuria. It
can be found on the KDIGO guidelines website.

Complications

Coronary Heart Disease is an important complication of chronic kidney disease and is the most common
cause of death in this population. Patients on dialysis have a 10 to 30 times higher cardiovascular
mortality risk than in the general population. The peripheral vascular disease is also commonly seen. It is
associated with the following:

Hypertension

Mineral and bone disorders (secondary to hyperparathyroidism, vitamin D deficiency)

Hyperuricemia (urate concentration greater than 7) has been associated with adverse cardiovascular
outcomes

Metabolic acidosis

Hyperphosphatemia

Hypoalbuminemia

Anemia
Pearls and Other Issues

ESRD is a terminal illness defined as having a glomerular filtration rate less than 15 mL/min.

The most common cause in the US is diabetic nephropathy followed by hypertension.

Other etiologies can include glomerulonephritis, cystic kidney disease, recurrent kidney infection,
chronic obstruction, etc.

The disease can present with nausea, vomiting, metabolic, hematologic, electrolyte derangements,
seizures, coma, bleeding diathesis, refractory fluid overload and hypertension unresponsive to
pharmacotherapy, uremic pericarditis, etc.

Vigilant monitoring of GFR and proteinuria in diabetics and non-diabetics is essential for management of
progression of disease in patients with chronic kidney disease.

Early referral to specialists is necessary as dialysis or renal transplant planning can be started
immediately.

Enhancing Healthcare Team Outcomes

Once a patient has been diagnosed with ESRD, a significant number of them will require dialysis and the
lucky few may be eligible for a renal transplant. The nurse plays a vital role in both education of the
patient and ensuring that the patient's arm is protected for the creation of an AV fistula. The nurse
should place a sign at the bedside that no blood pressure or any intravenous line should be obtained
from the non-dominant arm. This is to ensure that the vein for a possible AV fistula is not damaged. The
nurse should also inform the patient that he or she should refuse any blood work from that arm. Patients
selected for a renal transplant should be seen by a transplant nurse so that they can be educated about
the procedure and what to expect. A dialysis nurse should also speak to the patient to educate them
about the process of dialysis and the different options available. Finally, the pharmacist should pay
attention to the medications the patient is taking and discontinue any that can adversely affect the
kidneys. [7][8]

Questions

To access free multiple choice questions on this topic, click here.

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