End-Stage Renal Disease

Excerpt

More than 500,000 people in the United States (US) live with end-stage renal disease (ESRD). The development of chronic kidney disease (CKD) and its progression to ESRD remains a significant cause of reduced quality of life and premature mortality. CKD is a debilitating disease, and standards of medical care involve aggressive monitoring for signs of disease progression and early referral to specialists for dialysis or possible renal transplant. The Kidney Disease Improving Global Outcomes (KDIGO) foundation guidelines define CKD using kidney damage markers, specifically those that determine proteinuria and glomerular filtration rate (GFR). By definition, the presence of both factors (GFR <60 mL/min and albumin >30 mg/g of creatinine) along with abnormalities of kidney structure or function for greater than three months signifies chronic kidney disease. ESRD is defined as a GFR of less than 15 mL/min.

According to KDIGO 2012 clinical practice guideline, CKD is classified into the following 6 stages based on the GFR level:

1. Stage 1: Kidney damage with normal GFR (>90 mL/min) but other abnormalities in urine production

2. Stage 2: Mild reduction in GFR (60-89 mL/min)

3. Stage 3a: Moderate reduction in GFR (45-59 mL/min)

4. Stage 3b: Moderate reduction in GFR (30-44 mL/min)

5. Stage 4: Severe reduction in GFR (15-29 mL/min)

6. Stage 5: Renal failure (GFR <15 mL/min)

In the US, in 2008, over 100,000 patients were initiated on dialysis; of those, 44% had received no predialysis care, which may have contributed to the observed high mortality within the first 3 months of dialysis initiation. Most patients in the US are treated with in-center dialysis. They are not offered alternative forms of renal replacement, such as home dialysis, peritoneal dialysis, or pre-emptive kidney transplant. Providing education on alternative forms of renal replacement is crucial, as it enables the establishment of permanent access to the dialysis method of choice. Study results indicate a low rate of renal replacement therapy, excluding in-center dialysis, despite no contraindications, primarily due to a lack of patient education and preparation.