Chronic Renal Failure

Aka: Chronic Renal Failure, Chronic Kidney Failure, End Stage Renal Disease, Chronic Kidney Disease, Chronic Kidney Insufficiency, Chronic Renal Insufficiency, ESRD, CRF, Renal Insufficiency

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II. Definitions

  1. Chronic Kidney Disease
    1. Abnormal Kidney structure or function lasting more than 3 months, with associated health implications
  2. End Stage Renal Disease
    1. Kidney Function not adequate for longterm survival without Dialysis or Renal Transplant
    2. Stage 5 Chronic Kidney Disease (GFR <15 ml/min/1.73m2)

III. Epidemiology

  1. Chronic Kidney Disease (2016)
    1. Prevalence in U.S.: 47 million (14-15% of the adult U.S. population)
    2. Accounts for 20% of all medicare costs ($52 Billion/year in 2014)
  2. End Stage Renal Diseases
    1. Prevalence 2002: 435,000 in U.S.
    2. Prevalence 2016: 660,000 in U.S.
    3. Prevalence 2018: 750,000 in U.S.
    4. Accounts for 10% of all medicare fee-for-service costs

IV. Causes: Percentage is that of conditions responsible for ESRD

  1. Diabetes Mellitus (37%)
    1. See Diabetic Nephropathy
    2. Glycemic control is critical to slow progression
    3. Type I Diabetes Mellitus (represents 5% of ESRD patients)
      1. Progresses to ESRD in 40% of patients
    4. Type II Diabetes Mellitus (represents 32% of ESRD patients)
      1. Progresses to ESRD in 20% of patients
      2. Type II Diabetes is 10 times as common as Type
  2. Hypertension or Hypertensive Kidney Disease (30% overall, 40% in black patients)
  3. Human Immunodeficiency Virus Infection (HIV Infection)
  4. Glomerulonephritis and other glomerular diseases (21%)
    1. Includes Vasculitis (e.g. Systemic Lupus Erythematosus)
  5. Hereditary conditions
    1. Polycystic Kidney Disease (7%)
    2. Alport Syndrome
    3. Medullary Cystic disease
  6. Tubulointerstitial disease (4%)
    1. Infection with scarring
      1. Chronic Urinary Tract Infections (Pyelonephritis)
      2. Reflux nephropathy in children
    2. Urologic obstruction
      1. Nephrolithiasis (obstruction)
      2. Benign Prostatic Hyperplasia (BPH)
    3. Medication-induced Nephrotoxicity (Nephrotoxins)
      1. See Intravenous Contrast Related Acute Renal Failure
      2. See Risk Score for Prediction of Contrast-Induced Nephropathy After Percutaneous Coronary Intervention

V. Risk Factors

  1. Diabetes Mellitus (leading cause)
  2. Autoimmune Conditions
  3. Chemical exposures (Lead, Cadmium, Arsenic, Mercury, Uranium)
  4. Nephrotoxin exposure (e.g. Intravenous Contrast Related Acute Renal Failure)
  5. Family History of Chronic Kidney Disease
  6. Hypertension
  7. Low birth weight
  8. Lower Urinary Tract Obstruction
  9. Cancer
  10. Nephrolithiasis
  11. Advanced age
  12. Acute Kidney Injury in past
  13. Decreased Renal Mass
  14. Serious systemic infection (e.g. Sepsis)
  15. Recurrent Urinary Tract Infections
  16. Minority status (blacks, native american, asian, pacific islander)

VI. History

  1. Recent infections
    1. Poststreptococcal Glomerulonephritis
  2. Sexually Transmitted Infection (STI, STD) risk factors including IV Drug Abuse
    1. HIV Infection
    2. Hepatitis B Infection
    3. Hepatitis C Infection
  3. Arthritis or dermatitis
    1. Systemic Lupus Erythematosus
    2. Cryoglobulinemia
  4. Urinary symptoms
    1. Urinary Tract Infection
    2. Nephrolithiasis
    3. Urinary Outflow Obstruction
  5. PMH
    1. Diabetes Mellitus
      1. Present for 5-10 years: Microalbuminuria, Pre-Hypertension
      2. Present for 10-15 years: Albuminuria, Retinopathy, Hypertension
    2. Hypertension
      1. Severe Hypertension
      2. End-organ effects
  6. Family History
    1. Autosomal Dominant Polycystic Kidney Disease
      1. Affects men and women in every generation
      2. May also occur less frequently if Autosomal Recessive
    2. Alport Syndrome (X-linked recessive)
      1. Affects men in every generation

VII. Exam

  1. Vital Signs
    1. Hypertension
    2. Increased Body Mass Index
  2. Eye Exam
    1. Hypertensive Retinopathy (A-V Nicking)
    2. Diabetic Retinopathy
  3. Cardiovascular Exam
    1. Carotid Bruit (Cerebrovascular Disease)
    2. Decreased peripheral pulses (Peripheral Vascular Disease)
    3. Lower Extremity Edema (e.g. Congestive Heart Failure)
    4. Ventricular Hypertrophy
  4. Abdominal Exam
    1. Renal artery bruit (e.g. Renal Artery Stenosis)
    2. Flank Pain (e.g. Ureterolithiasis, Pyelonephritis)
    3. Bladder Distention (outflow obstruction)
  5. Musculoskeletal Exam
    1. Arthritis or synovitis
  6. Skin Exam
    1. Autoimmune Disease (e.g. Systemic Lupus Erythematosus)
    2. Neurofibromatosis

VIII. Symptoms: Stage 4-5

  1. Fatigue (75% of patients)
  2. Pruritus (75% of patients)
  3. Weakness
  4. Headaches
  5. Anorexia
  6. Nausea
  7. Vomiting
  8. Polyuria
  9. Nocturia
  10. Pain
    1. Musculoskeletal pain
    2. Dialysis associated pain
    3. Peripheral Neuropathy
    4. Peripheral Vascular Disease related pain

IX. Signs

  1. See Edema in Chronic Renal Failure
  2. Hypertension
  3. Congestive Heart Failure
  4. Proteinuria
  5. Pericarditis

X. Criteria: Chronic Kidney Disease (at least one of the following criteria)

  1. GFR < 60 ml/min/1.73 m2 (based on two GFR calculations 3 months or more apart)
    1. Men: Serum Creatinine >1.5 mg/dl
    2. Women: Serum Creatinine >1.3 mg/dl
  2. Significant Proteinuria or albuminuria for >3 months (positive on 2 of 3 samples in 3-6 months)
    1. Urine Albumin to Creatinine Ratio >30 mg/g (Microalbuminuria, moderate) or >300 mg/g (severe)
      1. Urine Protein to Creatinine Ratio is less sensitive (but useful in albumin ratio >500 mg/g)
  3. Structural Kidney Disease or Kidney damage for >3 months
    1. Identify with renal Ultrasound
  4. Other criteria
    1. All Renal Transplant patients have Chronic Kidney Disease regardless of GFR or Proteinuria

XI. Stages: NKF Classification System

  1. Stage 1: GFR >90 ml/min despite Kidney damage
    1. Microalbuminuria present
  2. Stage 2: Mild reduction (GFR 60-89 min/min)
    1. GFR of 60 may represent 50% loss in function
    2. Parathyroid Hormone starts to increase
  3. Stage 3: Moderate reduction (GFR 30-59 ml/min, 3a: 45-59, 3b: 30-44)
    1. Calcium absorption decreases
    2. Malnutrition onset
    3. Anemia secondary to Erythropoietin deficiency
    4. Left Ventricular Hypertrophy
  4. Stage 4: Severe reduction (GFR 15-29 ml/min)
    1. Serum Triglycerides increase
    2. Hyperphosphatemia
    3. Metabolic Acidosis
    4. Hyperkalemia
  5. Stage 5: Kidney Failure (GFR <15 ml/min)
    1. Azotemia
  6. References
    1. (2002) Am J Kidney Dis 39:S1 [PubMed]
    2. Snively (2004) Am Fam Physician 70:1921-30 [PubMed]

XII. Labs: Screening for Chronic Kidney Disease

  1. Indications
    1. Diabetes Mellitus
    2. Hypertension
    3. Age over 55-60 years old
    4. Consider in Family History of Chronic Kidney Disease (see causes listed above)
  2. Tests
    1. Serum Creatinine (with Estimated Glomerular Filtration Rate)
    2. Urine Albumin to Creatinine Ratio
    3. Urinalysis with microscopy
  3. Assess Glomerular Filtration Rate (GFR)
    1. Estimations generally as accurate as 24 hour urine
      1. See Creatinine Clearance for exceptions
      2. GFR may also be estimated from Serum Cystatin C instead of Serum Creatinine
        1. Consider if abnormal GFR based on Creatinine Clearance suspected to be False Positive
    2. Formulas
      1. Chronic Kidney Disease Epidemiology Collaboration Equation or CKD-EPI (preferred standard)
        1. https://www.kidney.org/professionals/kdoqi/gfr_calculator
      2. Cockcroft-Gault equation
        1. Used only to calculate medication Renal Dosing
      3. Modification of Diet in Renal Disease (MDRD)
        1. CKD-EPI is preferred
  4. Assess for Proteinuria
    1. Previously Urinalysis dipstick was used to triage testing for spot Urine Protein or albumin
    2. As of 2012, Urinalysis is no longer recommended for Urine Protein screening
      1. Urine Albumin to Creatinine Ratio is recommended instead as a first-line study
  5. Assess other urinary sediment on Urinalysis
    1. Microscopic Hematuria
    2. Urine White Blood Cells (pyuria)
    3. Cellular Casts
    4. Lipiduria (seen in nephrotic sediment)
      1. Indicated by Fatty Casts, oval fat bodies, or free fat in urine sediment
      2. Increases significance of Proteinuria
    5. Eosinophiluria
      1. Tubulointerstitial disease
      2. Atheroembolic dsisease

XIII. Labs: Urine sediment found in causes of Chronic Kidney Disease

  1. Polycystic Kidney Disease
    1. Protein to Creatinine ratio 200-1000 mg/g
    2. Red Blood Cells present
  2. Diabetic Nephropathy
    1. Albumin to Creatinine ratio 30-300 early (and exceeds 300 in later disease)
  3. Hereditary Nephritis
    1. Protein to Creatinine ratio <1000 mg/g
    2. Red Blood Cells, tubular cells and Granular Casts present
  4. Hypertensive Nephropathy
    1. Protein to Creatinine ratio 200-1000 mg/g
  5. Noninflammatory Glomerular Disease
    1. Protein to Creatinine ratio >1000 mg/g
  6. Proliferative Glomerulonephritis
    1. Protein to Creatinine ratio >500 mg/g
    2. Red Blood Cells, Red Blood Cell Casts, White Blood Cells, White Blood Cell Casts present
  7. Tubulointerstitial Nephritis
    1. Protein to Creatinine ratio 200-1000 mg/g
    2. Red Blood Cells, White Blood Cells, White Blood Cell Casts present
  8. IgA Nephropathy or Rapidly Progressive Glomerulonephritis (RPGN)
    1. Dysmorphic urinary Red Blood Cells or
    2. Red Blood Cell Casts

XIV. Labs: Findings in Chronic Kidney Disease Stages 3-4

  1. Anemia (Normochromic, Normocytic)
    1. Hematocrit decreases
      1. Serum Creatinine > 2-3
      2. Glomerular Filtration Rate <20-30
    2. Results from decreased Erythropoietin synthesis
  2. Azotemia
  3. Decreased Serum Protein
  4. Serum chemistry abnormalities
    1. Hyperkalemia or Hypokalemia
    2. Metabolic Acidosis
    3. Hypocalcemia
    4. Hyperphosphatemia

XV. Labs: Initial presentation

  1. Screening labs (see above)
    1. Serum Creatinine (with Estimated Glomerular Filtration Rate)
    2. Urine Albumin to Creatinine Ratio
    3. Urinalysis with microscopy
      1. Evaluates for intrinsic renal disease causes
  2. Basic labs
    1. Basic metabolic panel (includes serum Electrolytes)
    2. Fasting lipid profile
    3. Hemoglobin A1C
    4. Serum Calcium
    5. Serum Phosphorus
    6. Complete Blood Count (CBC)
    7. Vitamin D
  3. Additional labs as indicated
    1. Antinuclear Antibody (ANA)
      1. Lupus Nephritis
    2. Urine and Serum Protein Electrophoresis
      1. Multiple Myeloma
    3. Hepatitis B Serology (HBsAg)
      1. Membranous Nephropathy
      2. Membranoproliferative nephritis)
    4. Hepatitis C Serology (xHBC Antibody)
      1. Membranous Nephropathy
      2. Membranoproliferative Glomerulonephritis
      3. Mixed Cryoglobulinemia
    5. HIV Test
      1. Focal and segmental glomerulosclerosis
    6. Antistreptolysin O Antibody (ASO Titer)
      1. Post-Streptococcal Glomerulonephritis
    7. Antineutrophil Cytoplasmic Antibody (ANCA)
      1. Granulomatosis with Polyangiitis (previously known as Wegener's Granulomatosis)
      2. Microscopic Polyangiitis
      3. Pauci-immune Rapidly Progressive Glomerulonephritis
    8. Anti-Glomerular Basement Membrane Antibody (Anti-GBM Antibody)
      1. Goodpasture Syndrome (xGBM Antibody associated with rapid progression)
    9. Consider serum complement studies (C3, C4, CH50)
      1. Post-Streptococcal Glomerulonephritis
      2. Membranoproliferative Glomerulonephritis
      3. Lupus Nephritis
      4. Cryoglobulinemia
    10. Cryoglubulin Test
      1. Cryoglobulinemia
    11. Eosinophiluria
      1. Tubulointerstitial Disease
  4. Other diagnostics
    1. Consider baseline Electrocardiogram (coronary disease is a common complication of CKD)

XVI. Labs: Monitoring

  1. General labs
    1. Basic metabolic panel (Serum Creatinine and serum Electrolytes) every 3-12 months or more
    2. Urine Albumin to Creatinine Ratio every 12 months
  2. Anemia monitoring (at least annually, or more often as indicated)
    1. Complete Blood Count with differential
    2. Reticulocyte Count
    3. Serum Iron
    4. Serum Ferritin
    5. Serum Transferrin
    6. Vitamin B12
    7. Serum Folate
  3. Malnutrition monitoring (every 6-12 months, up to every 1 to 3 months in stage 4-5 CKD)
    1. Serum Albumin
    2. Body weight
    3. Dietary history
  4. Bone disorders
    1. See Chronic Kidney Disease related Bone Disease (Renal Osteodystrophy)
    2. Alkaline Phosphatase
      1. Obtain at baseline
      2. Obtain every 12 months in Stage 4 and 5 CKD
    3. Serum Calcium and Serum Phosphorus
      1. Obtain every 3 to 6 months (as often as every 1 to 3 months in Stage 5 CKD)
    4. 25-hydroxyvitamin D and Intact Parathyroid Hormone (iPTH)
      1. Obtain at baseline
      2. Obtain every 3 to 6 months in Stage 4 (or every 1 to 3 months in Stage 5)

XVII. Imaging: Renal Ultrasound (indicated in most patients on initial presentation)

  1. Doppler Ultrasound
    1. Renal veins: Venous thrombosis
    2. Renal arteries: Lower efficacy in diagnosing Renal Artery Stenosis
  2. General findings
    1. Nephrocalcinosis
    2. Hydronephrosis
    3. Renal Mass or complex cysts (concerning for malignancy risk)
    4. Renal stones
  3. Increased echogenicity
    1. Renal disease
  4. Enlarged Kidneys
    1. Renal tumors
    2. Infiltrating disease
    3. Nephrotic Syndrome related conditions
  5. Asymmetric Kidney size or scarred Kidneys
    1. Vascular disease
    2. Urologic disease
    3. Tubulointerstitial disease
  6. Small, hyperechoic Kidneys
    1. Chronic Kidney Disease

XVIII. Imaging: Other advanced imaging

  1. Consider CT or MRI of Kidneys and Liver
  2. Consider Voiding Cystourethrogram

XIX. Diagnosis: Renal Biopsy

  1. Indications
    1. Hematuria and low Creatinine Clearance or Proteinuria
    2. Nephrotic range Proteinuria
    3. Chronic Renal Failure with normal or large Kidneys
    4. Acute Renal Failure of unknown cause
  2. Contraindications
    1. Renal length <9 cm
    2. Severe Hypertension
    3. Multiple large Renal Cysts
    4. Uncorrected bleeding tendency
    5. Hydronephrosis
    6. Acute infection

XX. Management: Secondary Prevention

  1. Protocols
    1. See Prevention of Kidney Disease Progression
    2. See Drug Dosing in Chronic Kidney Disease
    3. See Renal Osteodystrophy
    4. See Nephrotoxic Drugs
    5. See Intravenous Contrast Related Acute Renal Failure
    6. See Gadolinium-Associated Nephrogenic Systemic Fibrosis (Nephrogenic Fibrosing Dermopathy)
  2. Proteinuria (Microalbuminuria or Macroalbuminuria)
    1. Start ACE Inhibitor or Angiotensin Receptor Blocker
  3. Coronary Artery Disease Prevention
    1. Aspirin 81 mg orally daily
    2. Statin for most patients
    3. Control Hypertension
  4. Hypertension (common in ESRD)
    1. Hypertension correlates with volume status
      1. Modify hemodilaysis to maintain normovolemia
    2. Sodium Restriction 2 g/day
    3. Antihypertensives
    4. Ambulatory or home Blood Pressure measurements are more preferred for BP monitoring over Dialysis center BPs
  5. Diabetes Mellitus
    1. Maintain careful Blood Glucose Monitoring in ESRD (higher risk for Hypoglycemia)
    2. Hemodialysis typically helps improve Hyperglycemia management
    3. Hemoglobin A1C may be inaccurate in ESRD (esp. on Hemodialysis)
      1. Glucose monitoring logs are preferred
    4. Insulin is preferred in ESRD or GFR <30 ml/min/1.73m2
      1. Many other diabetic medications (e.g. Metformin) are contraindicated in low GFR
      2. Alternatives include Glipizide (but risk of Hypoglycemia) and Repaglinide
  6. Medication limitations for GFR <30 ml/min
    1. Avoid Metformin and Flozins (SGLT2 Inhibitors) in Type II Diabetes
    2. Avoid Bisphosphonates
    3. Avoid Direct Oral Anticoagulants
    4. Avoid NSAIDs
    5. For Bowel Preparation, use Polyethylene glycol (PEG) instead of Magnesium or Phosphorus preparations
  7. Vaccination
    1. Influenza Vaccine
    2. Tetanus Vaccine
    3. Hepatitis B Vaccine
    4. Pneumococcal Vaccine (Pneumovax-23 and Prevnar 13)
    5. Covid-19 Vaccine
    6. Recombinant Shingles Vaccine (Shingrix) if indicated
  8. Cancer Screening is not recommended in End Stage Renal Disease (ESRD)
    1. Life Expectancy in ESRD is not sufficient to warrant longterm cancer screening

XXI. Management: Nephrology Referral

  1. Indications
    1. Chronic Kidney Disease Stage 4 (GFR <30 ml/minute)
      1. Consider initial evaluation when GFR <60 ml/minute
    2. Chronic Kidney Disease with rapid progression
      1. Unexplained decrease in GFR >30% over 4 months
      2. Annual GFR decline >5 ml/min/1.73m2
      3. Kidney Failure Risk Calculator estimates one year ESRD risk >10-20%
        1. https://www.mdcalc.com/kidney-failure-risk-calculator
    3. Acute failure complicating Chronic Kidney Disease
    4. Unclear etiology for Renal Failure
    5. Hereditary Kidney Disease
    6. Renal biopsy
    7. Nephrotic sediment (e.g. lipiduria)
    8. RBC Casts (indicates an urgent referral)
    9. Extensive or recurrent Nephrolithiasis
    10. Urine Eosinophils
    11. Refractory Hypertension despite at least 3 antihypertensives
    12. Significant Proteinuria
      1. 24 Hour Urine Protein > 1000 mg
      2. Protein to Creatinine ratio >500-1000 mg/g
      3. Albumin to Creatinine ratio >300 mg/g despite 6 months on ACE Inhibitor (or ARB)
    13. Acute Tubular Necrosis
    14. Significant comorbidity (e.g. cardiovascular disease)
    15. Complications of Chronic Kidney Disease
      1. Anemia of Chronic Kidney Disease
      2. Bone and mineral disorders of Chronic Kidney Disease
      3. Hyperkalemia (Potassium >5.5 meq despite modification of therapy)
  2. Goals of Nephrology Care
    1. Initiate disease specific management including complications and related comorbidity
    2. Intervene to slow Chronic Kidney Disease progression
    3. Planning for Hemodialysis, conservative management or Renal Transplantation
    4. Coordinate with multidisciplinary care

XXII. Management: End Stage Renal Disease

  1. Hemodialysis or Peritoneal Dialysis
    1. See Hemodialysis
    2. See Peritoneal Dialysis
    3. Absolute Dialysis Indications
      1. Uremic Symptoms
      2. Uremic Pericarditis
    4. Relative Dialysis Indications
      1. Hypervolemia
      2. Hyperkalemia or other Electrolyte abnormalities
      3. Severe Metabolic Acidosis
      4. Creatinine Clearance <10 ml/min (<15 ml/min in Diabetes Mellitus)
  2. Renal Transplantation
    1. Improves overall survival and quality of life in comparison to Dialysis and conservative management
    2. Refer to Renal Transplant when GFR <30 ml/min/1.73m2 to allow for adequate planning, preparation, wait list time
    3. As of 2020, the median time of Renal Transplant wait list is 4 years
    4. Less rejection if transplant before Dialysis started
      1. Mange (2001) N Engl J Med 344:726-31 [PubMed]
  3. Conservative management options (palliative approach)
    1. Optimizes quality of life over prolongation of life
      1. Survival benefit of Hemodialysis is reduced in elderly and comorbidity
      2. Uremia symptoms may not significantly improve with Hemodialysis
      3. Hemodialysis is associated with increased medical interventions
    2. More than half of chronic Hemodialysis patients regret their decision to undergo Hemodialysis
      1. Davison (2010) Clin J Am Soc Nephrol 5(2): 195-204 [PubMed]
    3. Non-Dialysis with Hospice care
    4. Delayed Dialysis until Creatinine Clearance <5 ml/min (similar morbidity and mortality)
      1. Cooper (2010) N Engl J Med 363(7):609-19 [PubMed]

XXIII. Management: Anemia

  1. Erythropoietin (EPO)
    1. Efficacy
      1. Initial studies showed benefit for Erythropoietin
        1. Renicki (1995) Am J Kidney Dis 25:548-54 [PubMed]
      2. Recent studies show no benefit and higher risk of Cerebrovascular Accident
        1. Outcomes are the same with and without normalized Hemoglobin via erythropoetin
        2. Morbidity and patient sense of well-being is not improved on erythropoetin
        3. Pfeffer (2009) N Engl J Med 361 [PubMed]
    2. Indications for Erythropoeitin
      1. Hemoglobin <9 mg/dl
    3. Adverse effects
      1. Increased risk of Cerebrovascular Accident
  2. Iron Supplementation
    1. Often indicated in Hemodialysis patients
    2. Parenteral replacement is often needed (decreased oral absorption)
      1. Non-Dextran IV Iron
        1. Indicated in significant Iron Deficiency refractory to oral replacement
        2. Options: Ferumoxytol (Feraheme), iron sucrose (venafer) or Sodium Ferric Gluconate (Ferrlecit)
      2. Ferric pyrophosphate (Triferic)
        1. Available in 2015 (U.S.)
        2. Indicated for maintenance iron infusion
        3. May be delivered inline with Hemodialysis
    3. References
      1. (2015) Presc Lett 22(4)

XXIV. Management: Anorexia and Protein Energy Wasting in ESRD

  1. Minimize Uremia with adequate Dialysis frequency
  2. Consider Major Depression, Gastroparesis, and Xerostomia
  3. Protein Energy Wasting Findings
    1. BMI < 23 kg/m2
    2. Unintentional Weight Loss (>5% over 3 months or >10% over 6 months)
    3. Serum Albumin <3.8 g/dl
  4. General Measures
    1. Dietician Consultation
    2. High Protein diet 1.0 to 1.2 g Protein/kg/day in ESRD
      1. Contrast with the limited Protein diet in Chronic Kidney Disease to prevent progression
      2. Consider dietary Protein Supplementation
  5. Medications
    1. Dronabinol 2.5 mg orally before meals
    2. Megestro 400 mg orally daily
    3. Prednisone 10 mg orally daily

XXV. Management: Symptomatic Management in ESRD

  1. Agitation
    1. Haloperidol 1 mg PO, IV or IM every 12 hours
  2. Dyspnea
    1. Regular Physical Activity to prevent deconditioning
    2. Fentanyl (Duragesic) 12.5 mg IV or SQ every two hours as needed for end-of-life
  3. Fatigue
    1. Treat Anemia if present
    2. Consider Depression Management with Fluoxetine 20 mg daily or Sertraline 50 mg daily
  4. Nausea and Vomiting
    1. Minimize Uremia with adequate Dialysis frequency
    2. Ondansetron 4 mg orally every 8 hours
    3. Metoclopramide (Reglan) 5 mg twice daily
    4. Haloperidol (Haloperidol) 0.5 mg orally every 8 hours
  5. Pruritus
    1. Minimize Uremia with adequate Dialysis frequency
    2. Phosphate Binders
    3. Standar Dry Skin therapy (e.g. barrier creams)
    4. Ondansetron 4 mg orally every 8 hours
    5. Hydroxyzine (Atarax or Vistaril), 25 mg orally every 6 hours
    6. Naltrexone (Revia) 50 mg orally daily
    7. Phototherapy (UV-B Light)
  6. Insomnia
    1. See Sleep Hygiene
    2. Treat Restless Leg Syndrome
    3. Treat Obstructive Sleep Apnea
    4. Zolpidem 5 mg orally at bedtime
    5. Temazepam (Restoril) 15 mg orally at bedtime

XXVI. Management: Advanced Directives in ESRD

  1. Cardiopulmonary Resuscitation (CPR)
    1. Survival in ESRD is only 8% at hospital discharge and 3% at six months
    2. Contrast with CPR in non-ESRD with survival of 12% at discharge and 9% at six months
    3. Discuss Do-Not-Reuscitate status at routine visits
  2. Hospice
    1. Criteria to qualify for Hospice services paid by medicare in End Stage Renal Disease
      1. ESRD on no-Dialysis management or
      2. ESRD on Dialysis and other Hospice qualifying condition (e.g. cancer)

XXVII. Complications

  1. Cardiovascular Disorders
    1. See Hypotension in the Dialysis Patient
    2. Coronary Artery Disease (21% of ESRD cases)
    3. Peripheral Vascular Disease
    4. Cardiac Arrhythmias
    5. Congestive Heart Failure
    6. Uremic Cardiomyopathy
    7. Erectile Dysfunction
    8. Uremic Pericarditis
    9. Severe Refractory Hypertension
    10. Pulmonary Edema
    11. High-output Heart Failure (secondary to Anemia or Arteriovenous Fistula)
    12. Calciphylaxis
      1. Life-threatening, small vessel Occlusion in skin and fatty tissue presenting with necrotic skin lesions
    13. Uremic Pericardial Effusion
      1. Consider in Chronic Renal Failure with Dyspnea
      2. Risk of Cardiac Tamponade (consider in any ill ESRD patient)
  2. Hematologic
    1. Pancytopenia
      1. Anemia (Normochromic, Normocytic)
      2. Thrombocytopenia
      3. Leukopenia
  3. Neurologic disorders
    1. Subdural Hematoma
      1. Consider in any altered LOC patient with ESRD
    2. Uremic encephalopathy (Memory Loss, slurred speech, asterixis)
    3. Dialysis Dementia
      1. Associated with >2 years on Dialysis
      2. Diagnosis of exclusion
    4. Peripheral Neuropathy (e.g. extremity Paresthesias)
    5. Restless Leg Syndrome
    6. Sleep Disorders
    7. Thiamine deficiency (and Wernicke's Encephalopathy)
      1. Hung (2001) Am J Kidney Dis 38(5):941-7 +PMID:11684545 [PubMed]
  4. Fluids, Electrolytes and Nutrition
    1. Metabolic Acidosis
      1. Associated with increased mortality and other adverse outcomes
      2. Improves with Dialysis
      3. Consider Bicarbonate Supplementation in persistently low serum bicarbonate
    2. Muscle wasting and Malnutrition
    3. Pseudogout
    4. Uremia (Nausea, Vomiting, Anorexia)
    5. Hyperphosphatemia (see Renal Osteodystrophy)
  5. Gastrointestinal disorders
    1. Chronic Constipation
    2. Gastritis
    3. Peptic Ulcers
    4. Uremic Gastroparesis
  6. Skin disorders
    1. Pruritus
    2. Calciphylaxis
    3. Uremic frost
      1. Occurs in end-stage renal disease with high BUN (untreated or missed Hemodialysis)
      2. Crystallized urea from sweat forms and deposits on the skin
      3. Uremic frost resembles Seborrhea
  7. Miscellaneous disorders
    1. Chronic Kidney Disease related Bone Disease (Renal Osteodystrophy)
    2. Amenorrhea
    3. Uremic Platelet disorder

XXVIII. Course

  1. Progression of Chronic Kidney Disease (<55 mmHg) is predictable
    1. Glomerular Filtration Rate (GFR) decreases -4 ml/min per year if no intervention
    2. Intensive management may halt GFR decline
      1. See Prevention of Kidney Disease Progression
  2. Major causes of death in ESRD
    1. Myocardial Infarction
    2. Cerebrovascular Accident

XXIX. Prognosis

  1. Annual mortality of ESRD: 24%
  2. Five Year survivalof ESRD
    1. All ages: 38%
    2. Age over 65 years: 18%

XXX. References

  1. (2018) Presc Lett 25(8)
  2. Golder (2003) AAFP Board Review, Seattle
  3. (2002) Am J Kidney Dis 39:s1-266 [PubMed]
  4. Baumgarten (2011) Am Fam Physician 84(10): 1138-48 [PubMed]
  5. Gaitonde (2017) Am Fam Physician 96(12): 776-83 [PubMed]
  6. Hood (1996) Postgrad Med 100(5):163-75 [PubMed]
  7. Snyder (2005) Am Fam Physician 72(9):1723-32 [PubMed]
  8. (2007) Am J Kidney Dis 49(2 suppl 2):S12-S154 [PubMed]
  9. O'Connor (2012) Am Fam Physician 85(7):705-10 [PubMed]
  10. Rivera (2012) Am Fam Physician 86(8): 749-54 [PubMed]
  11. Wouk (2021) Am Fam Physician 104(5): 493-99 [PubMed]

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