Dr Neha Bhandari
Sr. Consultant Pediatric Nephrology,
Sri Balaji Action Medical Institute, Paschim Vihar, Delhi

Initiation of Dialysis

The prevalence of end-stage renal disease (ESRD) is increasing, with an enormous financial burden on society. About 50 years ago, ESRD was invariably lethal. Although maintenance dialysis methods have now successfully prolonged the life of patients with terminal uremia, mortality remains high. The exact burden of CKD needing maintenance dialysis and/or renal transplantation is not known; however, from the existing published data prevalence of CKD ranges between 0.7 percent and 1.4 percent. The incidence of ESRD was estimated to be 180 to 200 per million populations.

Approximately 9–13 percent of patients on hemodialysis in India die within 1 year. The adjusted rates of all-cause mortality are 6.3–8.2 times greater for dialysis patients than for general population. Good quality of life and survival on maintenance dialysis depends on following major factors, namely: (i) The dose of dialysis delivered or solute removal achieved; (ii) time on dialysis; (iii) adequacy of nutrition; (iv) family and socio-economic support; (v) management of co-morbid illnesses; and (vi) prevention and management of infections.

Once a patient has reached stage-4, CKD with estimated GFR <30 mL/min/1.73 m2, counselling regarding initiation of dialysis should be started. One of the highest survival rates has been reported from Tassin, France, where patients are dialyzed 24 hours per week, much longer than in almost all other centers around the globe. This has led to a general increase in time in the dialysis prescription in all countries. In addition to increased duration of dialysis, it has been proposed that other factors also may improve patient outcome, such as frequency of the dialysis treatment and middle-molecule clearance.

Choice of modality

Patient education. Various treatment options available should be explained in the event of dialysis becoming necessary. Is dialysis most appropriate option or pre-emptive transplant or continued conservative management?

Options for renal replacement therapy like transplantation, home versus in-center dialysis. This will depend upon options available like hemodialysis or peritoneal dialysis. Multiple studies have found that peritoneal dialysis may provide relative short-term survival benefits but comparable or decreased survival after 1 to 2 years. An intention-to-treat analysis of 35,265 Canadian patients, who initiated dialysis between 1991 and 2004, demonstrated better survival associated with peritoneal dialysis for the first 18 months and with hemodialysis after 36 months. Analysis of patients who started dialysis between 2001 and 2004 showed better survival with peritoneal dialysis for two years and comparable survival thereafter.

A two-year prospective study was conducted at a tertiary care hospital in Bengaluru, India, to determine the factors influencing survival among patients on maintenance hemodialysis. Ninety-six patients with ESRD surviving more than 3 months on hemodialysis (8–12 h/week) were studied. This study revealed that mortality among hemodialysis patients remained high, mostly due to sepsis and ischemic heart disease. Patient survival was better with higher dialysis dose, increased frequency of dialysis, and adequate serum albumin level. Efforts at minimizing infectious complications, preventing cardiovascular events, and improving nutrition should increase survival among hemodialysis patients.

Short daily hemodialysis. Usually offered three times per week.

Peritoneal dialysis (PD). There are two types to consider continuous ambulatory peritoneal dialysis, where a patient performs four or five times exchanges per day, and continuous cycling peritoneal dialysis (CCPD) where automated PD is done with a machine

The gold standard of dialysis therapy is yet to be identified. Newer approaches are required to improve overall mortality rates and to achieve an acceptable level of survival and rehabilitation in hemodialysis patients.

Operational efficiency of hemodialysis demands lot of manual operations, though better machine design and easy operating structure permits easy handling as well as fast and intuitive programming of the treatment parameters. Important treatment values are represented graphically on the LCD monitor, which supports easy comprehension of the ongoing treatment, and provides a fast overview of the treatment history. The blood pressure monitor (BPM) is fully integrated with the machine, which further simplifies handling for therapy providers. In combination with the therapy data management system (TDMS), daily dialysis practice can be organized in a more effective and efficient manner taking full advantage of an online data acquisition and management tool.

Online monitoring of the effective in-vivo urea clearance (K). The accumulated cleared plasma (Kt) or the current dialysis dose administered (Kt/V). The non-invasive and precise Kt/V assessment is consistent with conventional blood sample-based methods, enabled by urea distribution volume V measured with the BCM (body composition monitor).

The quality and purity of the dialysis fluid are very important in any form of renal replacement therapy as large volumes of dialysis fluid come into contact with the patient’s bloodstream during each treatment. Endotoxins present in contaminated dialysis fluid may elicit undesirable acute reactions and influence the long-term outcome of patients on chronic hemodialysis. So, the need of the hour is ultrapure dialysis fluid.

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