End-Stage Renal Disease: Medical Management

 

End-stage renal disease (ESRD) is diagnosed when kidney function is no longer adequate for long-term survival without kidney transplantation or dialysis. Primary care clinicians should refer people at risk of ESRD to nephrology to optimize disease management. Kidney transplantation typically yields the best patient outcomes, although most patients are treated with dialysis. The decision to initiate dialysis is best made through shared decision-making. Because most patients with ESRD elect to receive hemodialysis, the preservation of peripheral veins is important for those with stage III to V chronic kidney disease. A palliative approach to ESRD is a reasonable alternative to dialysis, particularly for individuals with limited life expectancy, with severe comorbid conditions, or who wish to avoid medical interventions. For patients with ESRD, vaccination against seasonal influenza, tetanus, hepatitis B, human papillomavirus (through 26 years of age), and Streptococcus pneumoniae is advised. Routine cancer screening for patients not receiving kidney transplantation is discouraged. Controlling blood pressure in patients receiving dialysis improves mortality. Volume control through adequate dialysis and sodium restriction can help optimize hypertension treatment in these patients. Insulin is the preferred treatment for patients with ESRD and diabetes mellitus requiring medication. Patients should be monitored for signs of protein-energy wasting and malnutrition. Clinicians must be aware of the many medical complications associated with ESRD.

End-stage renal disease (ESRD) is when kidney function is no longer adequate for long-term survival without kidney transplantation or dialysis.1,2 The estimated glomerular filtration rate (GFR) is usually less than 15 mL per minute per 1.73 m2 when this occurs.3 Kidney failure, a more concise term, may soon replace ESRD.4

 Enlarge     Print

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Refer people at increased risk of ESRD to nephrology (see Table 1 for indications).3,8

B

Cohort studies showing reduced mortality

Shared decision-making should be used when considering dialysis for patients with ESRD, including educating patients about the various dialysis modalities and the option of conservative management.3

C

Expert opinion and consensus guidelines, in the absence of clinical trials

To preserve peripheral venous access in patients with stage III to V chronic kidney disease, avoid excessive venipuncture, peripherally inserted venous catheters, and subclavian venous catheters.17

C

Expert opinion and consensus guidelines, in the absence of clinical trials

Avoid routine cancer screening for most patients with ESRD who are not candidates for kidney transplantation.17

C

Expert opinion and consensus guidelines, in the absence of clinical trials

Insulin is preferred for most patients with ESRD who have diabetes mellitus that requires medication.37

C

Expert opinion and consensus guidelines, in the absence of clinical trials


ESRD = end-stage renal disease.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Refer people at increased risk of ESRD to nephrology (see Table 1 for indications).3,8

B

Cohort studies showing reduced mortality

Shared decision-making should be used when considering dialysis for patients with ESRD, including educating patients about the various dialysis modalities and the option of conservative management.3

C

Expert opinion and consensus guidelines, in the absence of clinical trials

To preserve peripheral venous access in patients with stage III to V chronic kidney disease, avoid excessive venipuncture, peripherally inserted venous catheters, and subclavian venous catheters.17

C

Expert opinion and consensus guidelines, in the absence of clinical trials

Avoid routine cancer screening for most patients with ESRD who are not candidates for kidney transplantation.17

C

Expert opinion and consensus guidelines, in the absence of clinical trials

Insulin is preferred for most patients with ESRD who have diabetes mellitus that requires medication.37

C

Expert opinion and consensus guidelines, in the absence of clinical trials


ESRD = end-stage renal disease.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

 Enlarge     Print

BEST

The Author

NOAH WOUK, MD, is a provider with Piedmont Health Services, Prospect Hill, N.C.; an adjunct assistant professor in the Department of Family Medicine at the University of North Carolina School of Medicine, Chapel Hill; and an attending physician at Cone Health, Greensboro, N.C.

Address correspondence to Noah Wouk, MD, Piedmont Health Services, 322 Main St., Prospect Hill, NC 27314 (email: woukno@piedmonthealth.org). Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Agarwal R. Defining end-stage renal disease in clinical trials: a framework for adjudication. Nephrol Dial Transplant. 2016;31(6):864–867....

2. End-stage renal disease (ESRD). Centers for Medicare and Medicaid Services. Accessed December 18, 2020. https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Coordination-of-Benefits-and-Recovery-Overview/End-Stage-Renal-Disease-ESRD/ESRD

3. Levin A, Stevens PE, Bilous RW, et al. Kidney disease: improving global outcomes (KDIGO) CKD Work Group. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl. 2013;3(1):1–150.

4. Levey AS, Eckardt K-U, Dorman NM, et al. Nomenclature for kidney function and disease: report of a Kidney Disease: Improving Global Outcomes (KDIGO) Consensus Conference. Kidney Int. 2020;97(6):1117–1129.

5. U.S. Renal Data System. 2020 annual data report. Accessed July 9, 2021. https://adr.usrds.org/2020

6. Gaitonde DY, Cook DL, Rivera IM. Chronic kidney disease: detection and evaluation. Am Fam Physician. 2017;96(12):776–783. Accessed July 3, 2021. https://www.aafp.org/afp/2017/1215/p776.html

7. Smart NA, Dieberg G, Ladhani M, et al. Early referral to specialist nephrology services for preventing the progression to end-stage kidney disease. Cochrane Database Syst Rev. 2014;(6):CD007333.

8. Davison SN. End-of-life care preferences and needs: perceptions of patients with chronic kidney disease. Clin J Am Soc Nephrol. 2010;5(2):195–204.

9. U.S. Department of Veterans Affairs. VA/DoD clinical practice guidelines. Management of chronic kidney disease. 2019. Accessed July 9, 2021. https://www.healthquality.va.gov/guidelines/CD/ckd/

10. Chadban SJ, Ahn C, Axelrod DA, et al. KDIGO clinical practice guideline on the evaluation and management of candidates for kidney transplantation. Transplantation. 2020;104(4S1 suppl 1):S11–S103.

11. Ojo A, Wolfe RA, Agodoa LY, et al. Prognosis after primary renal transplant failure and the beneficial effects of repeat transplantation: multivariate analyses from the United States Renal Data System. Transplantation. 1998;66(12):1651–1659.

12. Verberne WR, Geers ABMT, Jellema WT, et al. Comparative survival among older adults with advanced kidney disease managed conservatively versus with dialysis. Clin J Am Soc Nephrol. 2016;11(4):633–640.

13. Kutner NG, Zhang R, Huang Y, et al. Patient awareness and initiation of peritoneal dialysis. Arch Intern Med. 2011;171(2):119–124.

14. National Kidney Foundation. KDOQI clinical practice guideline for hemodialysis adequacy: 2015 update [published correction appears in Am J Kidney Dis. 2016;67(3): 534]. Am J Kidney Dis. 2015;66(5):884–930.

15. Devoe DJ, Wong B, James MT, et al. Patient education and peritoneal dialysis modality selection: a systematic review and meta-analysis. Am J Kidney Dis. 2016;68(3):422–433.

16. Cooper BA, Branley P, Bulfone L, et al.; IDEAL Study. A randomized, controlled trial of early versus late initiation of dialysis. N Engl J Med. 2010;363(7):609–619.

17. Choosing Wisely five things physicians and patients should question. April 4, 2012. Accessed February 2, 2021. https://www.choosingwisely.org/choosing-wisely-five-things-physicians-and-patients-should-question-press-release-april-4-2012/

18. Lok CE, Huber TS, Lee T, et al.; National Kidney Foundation. KDOQI clinical practice guideline for vascular access: 2019 update [published correction appears in Am J Kidney Dis. 2021;77(4):551]. Am J Kidney Dis. 2020;75(4 suppl 2):S1–S164.

19. Wong SPY, Yu MK, Green PK, et al. End-of-life care for patients with advanced kidney disease in the US Veterans Affairs health care system, 2000–2011. Am J Kidney Dis. 2018;72(1):42–49.

20. Tam-Tham H, Ravani P, Zhang J, et al. Association of Initiation of Dialysis With Hospital Length of Stay and Intensity of Care in Older Adults With Kidney Failure. JAMA Netw Open. 2020;3(2):e200222.

21. O'Connor NR, Corcoran AM. End-stage renal disease: symptom management and advance care planning [published correction appears in Am Fam Physician. 2012;85(10):950]. Am Fam Physician. 2012;85(7):705–710. Accessed July 3, 2021. https://www.aafp.org/afp/2012/0401/p705.html

22. Schillie S, Vellozzi C, Reingold A, et al. Prevention of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2018;67(1):1–31.

23. Centers for Disease Control and Prevention. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine for adults with immunocompromising conditions: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2012;61(40):816–819.

24. Petrosky E, Bocchini JA Jr, Hariri S, et al. Centers for Disease Control and Prevention. Use of 9-valent human papillomavirus (HPV) vaccine: updated HPV vaccination recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2015;64(11):300–304.

25. Dooling K, Marin M, Wallace M, et al. The Advisory Committee on Immunization Practices' updated interim recommendation for allocation of COVID-19 vaccine - United States, December 2020. MMWR Morb Mortal Wkly Rep. 2021;69(5152):1657–1660.

26. Holley JL. Screening, diagnosis, and treatment of cancer in long-term dialysis patients. Clin J Am Soc Nephrol. 2007;2(3):604–610.

27. Kovesdy CP. Malnutrition in dialysis patients—the need for intervention despite uncertain benefits. Semin Dial. 2016;29(1):28–34.

28. Ikizler TA, Burrowes JD, Byham-Gray LD, et al. KDOQI clinical practice guideline for nutrition in CKD: 2020 update [published correction appears in Am J Kidney Dis. 2021; 77(2):308]. Am J Kidney Dis. 2020;76(3 suppl 1):S1–S107.

29. Oliveira EA, Zheng R, Carter CE, et al. Cachexia/protein energy wasting syndrome in CKD: causation and treatment. Semin Dial. 2019;32(6):493–499.

30. Agarwal R, Nissenson AR, Batlle D, et al. Prevalence, treatment, and control of hypertension in chronic hemodialysis patients in the United States. Am J Med. 2003;115(4):291–297.

31. Argilés A, Lorho R, Servel M-F, et al. Seasonal modifications in blood pressure are mainly related to interdialytic body weight gain in dialysis patients. Kidney Int. 2004;65(5):1795–1801.

32. Ahmad S. Dietary sodium restriction for hypertension in dialysis patients. Semin Dial. 2004;17(4):284–287.

33. Khan YH, Sarriff A, Adnan AS, et al. Blood pressure and mortality in hemodialysis patients: a systematic review of an ongoing debate. Ther Apher Dial. 2016;20(5):453–461.

34. Heerspink HJL, Ninomiya T, Zoungas S, et al. Effect of lowering blood pressure on cardiovascular events and mortality in patients on dialysis: a systematic review and meta-analysis of randomised controlled trials. Lancet. 2009;373(9668):1009–1015.

35. Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work Group. KDIGO 2020 clinical practice guideline for diabetes management in chronic kidney disease. Kidney Int. 2020;98(4S):S1–S115.

36. Rhee CM, Leung AM, Kovesdy CP, et al. Updates on the management of diabetes in dialysis patients. Semin Dial. 2014;27(2):135–145.

37. National Kidney Foundation. KDOQI clinical practice guideline for diabetes and CKD: 2012 update [published correction appears in Am J Kidney Dis. 2013;61(6):1049]. Am J Kidney Dis. 2012;60(5):850–886.

38. Sohal AS, Gangji AS, Crowther MA, et al. Uremic bleeding: pathophysiology and clinical risk factors. Thromb Res. 2006;118(3):417–422.

39. Mcmurray JJV, Parfrey PS, Adamson JW, et al.; Kidney Disease: Improving Global Outcomes (KDIGO) Anemia Work Group. KDIGO clinical practice guideline for anemia in chronic kidney disease. Kidney Int Suppl. 2012;2(4):279–335.

40. Ahmed J, Weisberg LS. Hyperkalemia in dialysis patients. Semin Dial. 2001;14(5):348–356.

41. Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Update Work Group. KDIGO 2017 clinical practice guideline update for the diagnosis, evaluation, prevention, and treatment of chronic kidney disease-mineral and bone disorder (CKD-MBD) [published correction appears in Kidney Int Suppl (2011). 2017;7(3):e1]. Kidney Int Suppl. 2017;7(1):1–59.

42. Nigwekar SU, Thadhani R, Brandenburg VM. Calciphylaxis. N Engl J Med. 2018;378(18):1704–1714.

43. Sarnak MJ, Levey AS, Schoolwerth AC, et al. Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention. Circulation. 2003;108(17):2154–2169.

44. Kidney Disease: Improving Global Outcomes (KDIGO) Lipid Work Group. KDIGO Clinical Practice Guideline for Lipid Management in Chronic Kidney Disease. Kidney Int Suppl. 2013;3(3):259–305.

45. Palmer SC, Di Micco LD, Razavian M, et al. Antiplatelet agents for chronic kidney disease. Cochrane Database Syst Rev. 2013;(2):CD008834.

46. K/DOQI Workgroup. K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients. Am J Kidney Dis. 2005;45(4 suppl 3):S1–S153.

47. Dad T, Sarnak MJ. Pericarditis and pericardial effusions in end-stage renal disease. Semin Dial. 2016;29(5):366–373.

 

 

Copyright © 2021 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP


Editor's Collections


Related Content


MOST RECENT ISSUE


Jan 2022

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article