Core Objectives of Treatment in Renal Disease

1. Identification of potentially treatable causes of renal disease. There must be a concerted initial evaluation of the etiology of disease and for identification of potentially treatable aspects.
2. An intervention aimed at delaying disease progression. All appropriate means should be used to preserve renal function. This requires the presence of renal disease be appreciated at an early point, occasionally when the serum creatinine is still grossly normal.
3. Early identification and treatment of anemia to ensure that treatment is initiated to maintain the serum hemoglobin between 10-12 g/dl. The heart’s response to anemia is the development of left ventricular hypertrophy. This maladaptive response is an independent risk factor for mortality.
4. Adequate treatment of hypertension. This links closely with objective No. 2 above-intervention aimed at delaying disease progression. Renal disease often makes it difficult to control hypertension, so blood pressure control often develops into a major focus of therapy.
5. Early identification and treatment of renal osteodystrophy. Secondary hyperparathyroidism must be identified before severe renal disease develops, and then treated appropriately. Early treatment with vitamin D analogs may have an important salutary effect on bone pathology.
6. Maintaining good nutrition. Patients should receive comprehensive education and counseling regarding nutritional aspects of their disease. Usually this requires consultation with a dietitian with expertise in renal disease.
7. Identification and treatment of electrolyte and acid-base disturbances. A variety of metabolic derangements develop in the course of renal disease, requiring ongoing management.
8. Ensuring that the patient’s comorbid conditions are being intensively treated. This applies, as discussed above, for cardiac disease and diabetes, but also for any other important coexistent disease state.
9. Identification and intervention for psychosocial risk. Psychosocial factors greatly affect quality of life and may adversely impact medical outcomes. There must be a formal attempt to identify patients at increased psychosocial risk.
10. Appropriate disease education. A staged approach should be used to gradually help the patient understand kidney disease and its related problems. This is vitally important for reducing patient anxiety, improving compliance, and making the patient a partner in the care plan.
11. Early modality selection and vascular access placement. The patient with progressive renal disease needs to be directed on the need to choose an ESRD treatment modality well in advance of reaching ESRD. If renal transplantation is an appropriate option, then this option should be fully explained to the patient and early preparation initiated. If hemodialysis is to be the modality selection, then an arm should be protected, and an arteriovenous fistula should be placed 3—12 months prior to intended use.

 

Treatment Options

Dialysis and transplantation are life-prolonging therapies for many patients with renal insufficiency. Initially, patients with ESRD are managed with conservative therapy, but eventually, they require hemodialysis, peritoneal dialysis, and/or transplantation.

The correlation of uraemic symptoms with renal function varies from patient to patient depending on the cause of renal disease (earlier onset of symptoms in subjects with diabetes mellitus), muscle mass (large, muscular patients tolerate high levels of azotemia), diet, nutritional status, and coexisting conditions.

Dialysis and/or transplantation

Selection of patients to receive dialysis and/or transplantation is a matter of some debate. Because of the reversible nature of the acute renal failure, all patients with this diagnosis should be supported with dialysis, at least for some period of time, to allow the return of renal function.

The recipient should be free of life-threatening extrarenal complications such as cancer, severe coronary artery disease, and cerebrovascular disease. Provided that diffuse vascular involvement is not present, diabetes mellitus is not a contraindication. Oxalosis may recur in relatively short order in a transplanted kidney and is generally a contraindication for transplantation.

Criteria for treatment with hemodialysis or peritoneal dialysis are more liberal because dialysis has less morbidity than transplantation in older patients with the aforementioned medical complications.

Preparation for Therapy of End-stage Renal Disease

While conservative measures are being carried out in patients with chronic renal failure, it is important to prepare them with an intensive educational program, explaining the likelihood and timing of complete renal failure and the various forms of therapy available. The more knowledgeable patients are concerning hemodialysis, peritoneal dialysis, and transplantation, the easier and more appropriate.

Dialysis

Hemodialysis

Hemodialysis employs the process of diffusion across a semipermeable membrane to remove unwanted substances from the blood while adding desirable components. A constant flow of blood on one side of the membrane and a cleansing solution (dialysate).

Hemodialysis equipment consists of three components: the blood delivery system, the composition and delivery system of the dialysate, and the dialyzer itself. Blood is pumped to the dialyzer by a roller pump through lines with appropriate equipment to measure flow and pressures within the system; blood flow should be approximately 300 to 450 mL/min.

Peritoneal dialysis

Peritoneal dialysis, like hemodialysis, may be performed in various settings and with several techniques. In patients with acute renal failure, intermittent peritoneal dialysis(IPD) has largely been replaced by CAVHD (Continuous arteriovenous hemodialysis). Chronic peritoneal dialysis was attempted in the late 1940s but was impractical until the development of a permanent peritoneal catheter, the Tenckhoff catheter.

Transplantation

Transplantation of the human kidney is frequently the most effective treatment of advanced chronic renal failure. Worldwide, tens of thousands of such procedures have been performed. When azathioprine and prednisone were initially used as immunosuppressive drugs, the results with properly matched familial donors were superior to those with organs from cadaveric donors, namely, 75 to 90 percent compared with 50 to 60 percent graft survival rates at 1 year. During the 1970s and 1980s, the success rate at the 1-year mark for cadaveric transplants rose progressively.

Donor selection

Donors can be cadavers or volunteer living donors. The latter are usually family members selected to have at least partial compatibility for HLA antigens.

Tissue Typing and Clinical Immunogenetics

Matching for antigens of the HLA major histocompatibility gene complex is the ideal criterion for selection of donors for renal allografts.

Living Donors: When first-degree relatives are donors, graft survival rates at 1 year are slightly greater than those for cadaver grafts, with the exception of HLA-identical donors