Kidney disease, chronic renal replacement therapy

Dialysis (HD and PD) remains the most widely available and commonly nsed means of chronic renal replacement therapy. Despite con-tinnal advances in dialysis and transplantation, kidney failnre is associated with significant morbidity and mortahty. Both HD and PD are associated with comphcations and are burdensome to affected patients. Given the lack of a true cure for kidney failure, emphasis has recently been placed on the prevention and early detection of kidney disease. In light of the persistent increase in the incidence of ESKD, this approach deserves much effort and should remain a priority for the foreseeable future. 

Chronic kidney disease (CKD), as evidenced by the inability of the kidneys to excrete nitrogenous and other waste products, usually develops over months to years (see Chap. 43). Malnutrition secondary to reduced oral nutrient intake frequently is evident when the glomerular filtration rate (GFR) drops below 20 to 25 mL/min. Patients with CKD are considered to have ESKD when the GER falls below 15 mL/min (see Chap. 44). Malnutrition is also a common occurrence in ESKD, not only because of decreased oral intake, but also due to increased nutrient losses via the various renal replacement therapies. Because of its chronicity, malnutrition in these patients is treated most frequently in the ambulatory setting with EN. 

Anemia is also an independent risk factor for progression of chronic renal failure. The anemia of CKD is, in most patients, normocytic and normochromic, and is due primarily to reduced production of erythropoietin (EPO) by the kidney (a presumed reflection of the reduction in functioning renal mass), low iron stores and shortened red cell survival. In 40%, it could be corrected by iron replacement. Early initiation of EPO therapy in patients with CKD and mild to moderate anemia significantly slowed down the progression of renal disease and delayed the need for renal replacement therapy. The target level of hemoglobin is llOg/1 [10],... 

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