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Avoidance and Treatment of Cardiovascular Disease in Dialysis

Introduction The prevalence and severity of cardiovascular disease in the dialysis population are well appreciated and present one of the defining therapeutic challenges in nephrology. It is also one of the most difficult issues to approach—the unique pathophysiologic processes underpinning disease in the dialysis population require specialized care, aimed at optimizing dialysis therapy and preventing cardiovascular injury associated with dialysis, and also consider the unique response…

Management of Ischemic Heart Disease, Heart Failure, and Pericarditis in Patients Undergoing Long-Term Dialysis

Introduction Cardiovascular disease is exceedingly common in patients with kidney failure on maintenance dialysis and is the leading cause of death in this patient population. The rate of cardiovascular death in patients with kidney failure is substantially higher than that of the general population at all ages, but the disparity is particularly prominent within younger age groups. Cardiovascular disease is also a major contributor to the…

Arrhythmias in Hemodialysis Patients

Cardiac rhythm disturbances are common in dialysis. Multiple studies have shown a high prevalence of ventricular and atrial ectopy and conduction abnormalities in hemodialysis patients, reflecting both the proarrhythmic nature of the hemodialysis process itself and the high burden of structural heart disease in kidney failure populations. The prevalence of chronic or recurrent rhythm disturbances, especially atrial fibrillation, is several-fold higher than in the general population.…

The Challenges of Blood Pressure Control in Hemodialysis Patients

Introduction Hypertension is a risk factor for chronic kidney disease (CKD) that increases in prevalence as CKD progresses, and it is nearly universal in patients with kidney failure. The hemodialysis (HD) procedure itself induces hemodynamic changes throughout the course of treatment that warrant routine pre-, post-, and intradialytic blood pressure (BP) monitoring for safety purposes. Consequently, this generates an abundance of highly variable data between and…

Acquired Cystic Kidney Disease

There are many types of cystic diseases of the kidney, but a specific form often occurs in end-stage kidney disease (ESKD) patients. Acquired cystic kidney disease (ACKD) is defined by the presence of four or more renal cysts for both kidneys and the absence of any hereditary renal cystic disease. These cysts are associated with potential complications, including significant bleeding and malignant neoplasms. Epidemiology ACKD is…

Parathyroidectomy

The Development of Secondary Hyperparathyroidism in Chronic Kidney Disease Patients Mineral homeostasis requires precise regulation, and the kidney plays a crucial role. Deterioration of renal function causes an alteration in the regulation of calcium (Ca) and phosphate (P). There are a number of hormonal changes aiming to correct Ca and P disturbances. The term “chronic kidney disease-metabolic bone disease” (CKD-MBD) includes all abnormalities of mineral metabolism…

Phosphate Management in Patients with End-Stage Kidney Disease

Introduction Achieving adequate control of serum phosphate (P) is one of the most difficult challenges facing clinicians caring for patients with end-stage kidney disease. Despite the global acceptance of the consequences of elevated P and despite a large number of therapeutic options targeting this mineral disorder, almost no discernible progress has been made toward routinely achieving the international recommendation of a P level of < 4.6…

Chronic Kidney Disease–Mineral and Bone Disorder

Introduction Patients with CKD often have disturbances in divalent ion metabolism, including the dysregulation of calcium and phosphorus, bone disease, and extraosseous calcification. These disturbances were previously referred to as renal osteodystrophy. However, the term renal osteodystrophy is primarily a description of altered bone morphology in patients with CKD. In 2006, the Kidney Disease: Improving Global Outcomes (KDIGO) proposed a new term called CKD-MBD. CKD-MBD is…

Resistance to Erythropoiesis Stimulating Agent (ESA) Treatment

Anemia is a well-known complication of chronic kidney disease (CKD); its severity increases as renal function declines, with nearly 80% of patients on dialysis having a certain degree of anemia. Although the pathogenesis of anemia is multifactorial, it is primarily caused by an erythropoietic hypoproliferative state due to relative insufficiency of erythropoietin (EPO) production from the failing kidneys. This complex pathophysiological context forms the basis for…

Anemia and Its Treatment in Patients With End-Stage Kidney Disease

Introduction Anemia is an important clinical complication of chronic kidney disease (CKD). It is defined by the World Health Organization as serum hemoglobin level < 13 g/dL in adult men and postmenopausal women and < 12 g/dL in premenopausal women. Similar to anemia of chronic disease, anemia of CKD is generally normocytic and normochromic with bone marrow of normal cellularity. While several factors may play a…

Nutritional Management in Peritoneal Dialysis

Protein-Energy Wasting Patients with chronic kidney disease (CKD) are at risk for development of protein-energy malnutrition. The expert panels from the International Society of Renal Nutrition and Metabolism (ISRNM) first coined the term protein-energy wasting (PEW) to describe the malnutrition often seen among patients with CKD in 2007. PEW is specifically defined as the syndrome of depletion of systemic body protein and energy stores with specific…

Intradialytic Parenteral Nutrition and Intraperitoneal Nutrition

Introduction Protein-energy wasting (PEW) is common in patients undergoing dialysis and is associated with one of the strongest risk factors for death. The prevalence of PEW in observational studies ranges from 18% to 75%. PEW is indicated by decreased body mass index (BMI) and muscle mass, reduced serum levels of albumin and transthyretin, increased markers of inflammation, and decreased food intake and appetite. The Centers for…

Nutritional Management of Hemodialysis Patients

Introduction One of the most encountered complications of end-stage kidney disease (ESKD), especially for patients undergoing maintenance hemodialysis (MHD), is the subtle but clinically important progressive deterioration of nutritional status. Advanced chronic kidney disease (CKD) is associated with a unique state of metabolic and nutritional derangements, more aptly called protein-energy wasting (PEW). PEW is closely associated with major adverse clinical outcomes, such as increased rates of…

Acid–Base Homeostasis in Dialysis

When renal replacement therapy is initiated, regulation of acid-base balance by the kidneys is replaced by a new homeostatic process responding to the physical principles of diffusion and convection rather than to the pH of the body fluids. Consequently, blood HCO 3 _ concentration ([HCO 3 _ ]) in the steady state is dependent in large part on the kinetics of HCO 3 _ diffusion across…

Metabolic Complications of Peritoneal Dialysis

The removal of solute and water for the management of kidney failure with peritoneal dialysis (PD) is achieved by exposing the naturally occurring peritoneal lining of the abdomen to 6 to 15 L of dialysate every day. It is widely believed that the exposure of the peritoneum to large volumes of dialysate has significant and wide-ranging deleterious systemic effects. This chapter reviews the evidence for and…

Abdominal Catastrophes, Peritoneal Eosinophilia, and Other Unusual Events in Peritoneal Dialysis

Repeated instillation and drainage of dialysate during the course of peritoneal dialysis (PD) is a unique clinical situation, which infrequently draws attention to primary intra-abdominal events. These events are often unrelated to the PD treatment itself but are brought to attention because of an abnormal appearance of drained dialysate, with or without abdominal pain. They are important for two reasons—first, some conditions such as visceral perforation…

Hydrothorax and Peritoneal Dialysis

Introduction Peritoneal dialysis (PD) hydrothorax is a well-described, albeit uncommon, complication of PD. It results from movement of PD fluid from the peritoneal cavity to the pleural space across the diaphragm. It was first reported in 1967 by Edwards and Unger in a 69-year-old patient who developed acute severe respiratory distress with radiographic evidence of right-sided hydrothorax soon after the commencement of PD. It is reported…

Dialysate Leaks with Peritoneal Dialysis

Introduction Dialysis fluid leakage is a noninfectious complication of peritoneal dialysis, with reported incidence rates varying from 1% to 40%. Leaks are the result of egress of peritoneal dialysis fluid from the peritoneal cavity through defects created either during the catheter insertion process itself or through congenital or acquired defects in the peritoneal dialysis space. Peritoneal dialysis fluid leaks can result in patients needing corrective surgical…

Abdominal Hernias With Peritoneal Dialysis

Complications related to peritoneal dialysis (PD) can be categorized as infectious or noninfectious. Noninfectious complications, including abdominal hernias, catheter malfunction, and exit site leaks, occur in continuous ambulatory PD (CAPD), continuous cycling PD/automated PD (CCPD/APD), and intermittent PD (IPD). More serious complications, such as catheter erosion into the bowel, bladder, or vagina, are rare and related to the presence of a catheter irrespective of the form…