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Continuous Renal Replacement Therapies for Acute Kidney Injury

Acute kidney injury (AKI) is a clinical syndrome characterized by an abrupt decrease in kidney function. It leads to the inability of the kidney to excrete waste products, manage electrolytes, regulate fluid balance, and maintain acid-base status. Based on the Kidney Disease: Improving Global Outcomes (KDIGO) definition, the most recent epidemiological studies estimate that AKI occurs in 21% of hospital admissions, and overall, 11% of patients…

Application of Telemedicine to Kidney Failure Patients

Telemedicine in Kidney Failure: Overview of the Opportunity and Issues Telemedicine is rapidly becoming a consistent part of health care delivery. While the term “telemedicine” includes any delivery or monitoring of care remotely, including telephonic care, the contemporary definition includes the use of video and the remote delivery of computer data. Telemedicine has historically seen a relatively low adoption rate, largely due to concerns around quality…

Quality, Safety, Accountability, and Medical Director Responsibilities

Introduction The challenges found in end-stage kidney disease (ESKD) facilities in the United States mirror fundamental shortcomings in the American health care system in general, as described in the Institute of Medicine (IOM) 2001 report Crossing the Quality Chasm: A New Health Care System for the 21st Century . The IOM concludes that “the American health care delivery system is in need of fundamental change.” The…

Ethical Considerations in the Care of Dialysis Patients: The New Paradigm

Ethics in the care of patients is about doing the right and good thing. Nephrologists want to do the right thing and treat their patients ethically, but unfortunately, most have not received formal training in the ethics of dialysis patient care. Historically, dialysis patient care has been disease oriented and focused on laboratory indicators and survival as measures of quality of care. There is a relatively…

Preventive Care in End-Stage Renal Disease

Preventive care of dialysis patients encompasses general medical care issues as well as dialysis-specific issues that are detailed in preceding chapters. In this chapter, aspects of general medical preventive care are discussed as they apply to maintenance dialysis patients. The transplant status of a patient will affect some of these issues. For example, recommendations for cancer screening and immunizations will in part depend on the patient's…

Physical, Psychosocial, and Vocational Rehabilitation of Patients Undergoing Long-Term Dialysis

Whatever the cause of kidney failure, for most patients, the effects are the same. The insidious progression of symptoms parallels the slow worsening of blood chemistries as glomerular filtration declines. Many patients fail to recognize the change in their vigor and well-being and simply adjust to serial changes. This allows marked losses in exercise capacity and endurance to occur as deconditioning proceeds. Similar slowing of mental…

Physical Activity, Function, and Exercise-Based Rehabilitation for People on Dialysis

Introduction The focus on increasing physical activity for those people with a high burden of cardiometabolic) conditions and complications (i.e., kidney failure, diabetes, cardiovascular comorbidities) for managing symptoms and maintaining physical well-being is at an all-time high. Rehabilitation, meaning recovering or restoring what is necessary to get on with living, has been a low priority in most dialysis facilities, and the inclusion of integrated rehabilitation programs…

Medication Management

Medication management is a patient-centered care process that optimizes safe, effective, and appropriate drug therapy. Medication management is a repeating process that involves patient assessment, creating and implementing a care plan, and follow-up and evaluation ( Fig. 59.1 ). Care is provided through collaboration with patients and their health care teams, including physicians, nurses, pharmacists, dietitians, social workers, and patient care technicians. Open full size image…

Principles of Drug Usage in Dialysis Patients

Introduction The evolution of the field of dialysis and the advances in surgical procedures and access placement have made it possible to treat patients with end-stage kidney disease (ESKD) with dialysis therapy for more than 60 years. Improvements in pharmacotherapy management prior to and after dialysis initiation have contributed to these remarkable advancements. However, uremia may directly or indirectly affect different aspects of drug pharmacokinetics or…

Pregnancy in Dialysis Patients

Introduction: A Historic Perspective When the first successful pregnancy in a woman on hemodialysis was reported in 1971 by Confortini and coworkers, the report elicited more skepticism than enthusiasm, and some nephrologists felt that emphasizing this exceptional occurrence could lead to the wrong expectations and might even be detrimental. In 1975, an editorial in The Lancet stated, “Children of women with renal disease used to be…

Evaluation and Treatment of Sexual Dysfunction

Introduction Sexual dysfunction is a common finding in both men and women with chronic kidney disease. Common disturbances include erectile dysfunction in men, menstrual abnormalities in women, and decreased libido and fertility in both sexes. These abnormalities are primarily organic in nature and are related to uremia as well as the other comorbid conditions that frequently occur in the chronic kidney disease patient. Fatigue and psychosocial…

Psychosocial Issues in Patients Treated With Dialysis

This chapter reviews the growing scientific literature on the psychosocial challenges patients with end-stage renal disease (ESRD) treated with hemodialysis (HD) confront, concentrating on psychopathology, sleep disturbances, quality of life (QOL), and barriers to adherence to the medical prescription. Patients' responses to the onset of ESRD and its continued treatment can alter their course, prognosis, and QOL. The psychological landscape shapes the patient's perception of his…

COVID-19 and Dialysis Patients

The Impact of COVID-19 on Outpatient Dialysis Facilities Introduction This is a point-in-time view of early pandemic. While the principles remain the same, the facts of COVID-19 care have evolved since 2020. Through August 2020, COVID-19 disease caused by the novel coronavirus SARS-CoV-2 has infected more than 30,500,000 people worldwide and caused nearly 1,000,000 deaths. The virus enters host cells via angiotensin-converting enzyme 2 (ACE-2) receptors,…

Care of the Human Immunodeficiency Virus–Infected End-Stage Kidney Disease Patient

Introduction The human immunodeficiency virus (HIV)–infected end-stage kidney disease (ESKD) patient presents specific clinical and logistical challenges to dialysis care providers. In this chapter, we discuss the shifting epidemiology and current management of ESKD in people living with HIV. Epidemiology Currently, the only nationally representative data regarding the incidence and prevalence of HIV infection among ESKD patients comes from United States Renal Database System (USRDS) surveillance…

Abnormalities of Thyroid Function in Chronic Dialysis Patients

Introduction Chronic kidney disease (CKD) patients, including those receiving dialysis, have a substantially higher prevalence of hypothyroidism compared to their non-CKD counterparts (i.e., 25% vs. 5%, respectively). However, there is often underrecognition of this metabolic disorder in dialysis patients, given that hypothyroid-related symptoms (i.e., fatigue, cold intolerance, impaired cognition, and depression) may overlap with uremia and coexisting comorbidities. Hypothyroidism is typically ascertained by biochemical tests, which…

Liver Disease and Gastrointestinal Disorders in Dialysis Patients

Introduction Patients with end-stage kidney disease on maintenance dialysis show a variety of acute and chronic diseases of the liver. Viral hepatitis continues to be the most frequently recognized cause of liver damage in patients on regular dialysis; the most important causes of hepatitis in this population remain chronic hepatitis B and C infection ( Table 51.1 ). The majority of the literature on liver disorders…

Care of Elderly Dialysis and End-Stage Kidney Disease Patients

Introduction Individuals aged 65 years or older comprise a significant proportion of those presenting with kidney failure and starting dialysis. In this chapter, we summarize data relating to key geriatric syndromes that are more commonly seen with kidney failure and discuss how these data can be integrated into advance care planning (ACP) discussions. Functional Changes, Social Functioning, and Quality of Life Large prevalence studies estimate that…

End-Stage Kidney Failure in the Diabetic Patient

Introduction: The Diabetic End-Stage Kidney Disease Population The prevalence of diabetes continues to increase in both developed and developing countries. End-stage kidney disease (ESKD) is the most recognizable result of diabetic chronic kidney disease (CKD). Patients with diabetes mellitus are at increased risk of ESKD. Diabetes mellitus continues to be a worldwide epidemic, and with it, diabetic CKD remains the single most important cause of ESKD.…

Management of Dyslipidemia in Long-Term Dialysis Patients

Introduction Dyslipidemia is commonly observed in adults treated with hemodialysis (HD) and peritoneal dialysis (PD). The most prevalent pattern is increased plasma triglyceride concentrations (linked to an accumulation of triglyceride-enriched apolipoprotein-B particles) and decreased plasma concentrations of high-density lipoprotein (HDL). In addition, PD patients usually have increased low-density lipoprotein (LDL) concentrations. Atherogenic changes in the composition of lipoproteins have also been documented in HD and PD…