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INTRODUCTION

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In the United States, there are now approximately 530,000 patients with ESRD. The incidence rate is 350 cases per million per year; however, it is disproportionately higher in African Americans, 1000 per million per year. Diabetes mellitus is the leading cause of ESRD, accounting for 55% of newly diagnosed cases each year. In addition, hypertension causes about 33% of newly diagnosed cases; other causes include glomerulonephritis, polycystic kidney disease, and obstructive uropathy. In the United States, the mortality rate of patients on dialysis is 18%–20% per year with a 5-year survival rate of approximately 30%–35%. These deaths are mainly due to cardiovascular disease (50%) or infection (15%). Older age, male sex, nonblack race, diabetes mellitus, malnutrition, and underlying heart disease are all predictors of mortality in these patients.

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DIALYSIS

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Dialysis is the main treatment modality of end stage renal disease (ESRD) patients. ESRD may be managed with hemodialysis, peritoneal dialysis—either continuous ambulatory peritoneal dialysis (CAPD) or continuous cyclical peritoneal dialysis (CCPD), or transplantation. Although there are multiple options, greater than 90% of ESRD patients in the United States are treated with hemodialysis. Hemodialysis can be broken down in to three essential components: the dialyzer, the dialysate, and the blood delivery system (Figure 91-1). In addition, there must be a way to access this blood—the dialysis access.

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FIGURE 91-1

The dialysis unit. (Reproduced with permission from Kasper DK, Fauci A, Hauser S, Longo D, Jameson JL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine. 19th ed. New York, NY: McGraw-Hill Education, Inc.; 2015: Fig. 336-1.)

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Indications

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Indications for dialysis can be broken in to two categories: acute dialysis or chronic (maintenance) dialysis. Acute dialysis is indicated in severe hyperkalemia, unrelenting metabolic acidosis, fluid overload, symptomatic uremia, metabolic encephalopathy, pericarditis, coagulopathy, refractory gastrointestinal symptoms, and drug toxicity. Uremia is usually only seen if the GFR is below 25 mL/min. Neurological, metabolic, hematological, cardiovascular, pulmonary, gastrointestinal, endocrine, skeletal, and skin manifestations (Table 88-2) can all be seen as symptoms of “uremia.” Indications for starting maintenance dialysis include uremic symptoms, hyperkalemia unresponsive to conservative measures, persistent extracellular volume expansion despite diuretic therapy, acidosis refractory to medical therapy, a bleeding diathesis, and a creatinine clearance or estimated glomerular filtration rate below 10 mL/min.

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Dialysis Access

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Dialysis access is obtained through a fistula, graft, or catheter. Fistulas are created by the anastomosis of an artery to a vein; the most common being the Brescia–Cimino fistula. In a Brescia–Cimino fistula the cephalic vein is anastomosed end-to-side to the radial artery. Fistulas have the highest long-term patency rate of all access options however they are only created in a minority of patients. An arteriovenous graft is the option of choice for many dialysis patients. In placement of the graft ...

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