Renal replacement therapy Peritoneal dialysis

Patients who progress to ESRD require renal replacement therapy (RRT). The modalities that are used for RRT are dialysis, including HD and peritoneal dialysis (PD), and kidney transplantation. The United States Renal Data Service (USRDS) reported that the number of patients with ESRD was 452,957, with 102,567 new cases being diagnosed in 2003.2 The most common form of RRT is dialysis, accounting for 72% of all patients with ESRD. The principles and complications associated with dialysis are discussed below. Chapter 52 discusses the principles of kidney transplantation. 

Renal replacement therapy (RRT), such as hemodialysis and peritoneal dialysis, maintains fluid and electrolyte balance while removing waste products. See Table 75-4 for indications for RRT in ARF. Intermittent and continuous options have different advantages (and disadvantages) but, after correcting for severity of illness, have similar outcomes. Consequently, hybrid approaches (e.g., sustained low-efficiency dialysis and extended daily dialysis) are being developed to provide the advantages of both. 

Renal replacement therapies (RRTs) like hemodialysis, peritoneal dialysis, and other related treatments have been available for decades, but have not resulted in dramatic improvements in patient outcomes. RRT can help patient management by normalizing blood electrolyte values, augmenting waste product removal, and maintaining fluid balance. Despite the supportive care that RRT offers, development of ARF is frequently a catastrophic event. 

Renal replacement therapies are the most common nonpharma-cologic treatment that patients with ARF receive. Absolute indications for starting RRT in an ARF patient do not exist, but some general guidelines for therapy initiation do exist (Table 42-6). Renal replacement therapies come in two different forms, intermittent therapies like hemodialysis, and continuous RRTs like continuous hemofiltration or peritoneal dialysis. A more detailed explanation of these therapies appears in Chap. 45. The choice of whether continuous therapies or intermittent RRTs are used is a matter of debate and is usually determined by physician preference and the resources available at the hospital. 

Chap. 43). When patients reach Stage 4, progression to Stage 5 is almost inevitable, although the process may be slowed if appropriate therapy is initiated. It is during Stage 4 CKD that plans for renal replacement therapy (hemodialysis or peritoneal dialysis) need to be made, and patients educated on dialysis modalities and options for transplantation if they are good candidates. 

End-stage renal disease (ESRD) patients who present with severe hyperkalemia, or with cardiac manifestations of hyperkalemia, should undergo immediate hemodialysis. Dialysis is the most rapid means of lowering potassium compared to bicarbonate, epinephrine, or insulin plus glucose therapy. Other forms of dialysis can be performed (e.g., peritoneal dialysis or continuous renal replacement therapy), although they appear to be less effective means to acutely lower an elevated serum potassium. ... 

Advanced CKD may lead to end-stage renal failure that requires renal replacement therapy including hemodialysis, peritoneal dialysis and renal transplantation. 

Hemodialysis (HD) catheter-associated bloodstream infections (BSls) are a type of CLABSI due to a central venous catheter (CVC) specifically designed for HD. In 2002, it was estimated that 50,000 CLABSIs occur in dialysis patients in the US annually. A more recent surveillance study found the rate of access-related BSIs to be 0.73 events per 100 patient-months [5]. Aside from catheters, patients in need of renal replacement therapy should eventually use arteriovenous fistula (AVF) or arteriovenous grafts (AVG) for HD, or alternatively, may receive peritoneal dialysis. All renal replacement therapies are associated with a risk of infection however, this risk varies with the method selected. Data from a CDC surveillance program display nicely how the type of access influences the BSI rate per 100 patient-months 0.5 (for AVFs), 0.9 (AVG), 4.2 (permanent CVCs), and an impressive 27.1 for temporary CVCs [6]. Another, more practi-... 

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