Primary Care: Clinics in Office Practice 2008 pptx

Preface
Edgar V. Lerma, MD, FACP, FASN, FAHA
Guest Editor
Chronic kidney disease (CKD) is a major public health problem. Accord-
ing to the National Health and Nutrition Examination Survey (NHANES)
1999–2004, approximately 20 million Americans are diagnosed with CKD;
that is, 1 out of 9 adults in the US satisfy the criteria for the diagnosis of
CKD. Another 20 million are estimated to be at risk. This projection points
to the fact that patients with CKD will soon far outnumber trained nephrol-
ogists in the US.
This dilemma can be solved only by a collaborative approach between
primary care providers and nephrologists.
We, as nephrologists, are well aware that the primary care providers oc-
cupy a unique and vital role in this team approach (Table 1). Primary care
providers are at the forefront of this war against CKD. They are in a posi-
tion to be the first to identify and screen patients at risk for CKD, eg, those
with diabetes, hypertension, etc. They also are providers of long-term care
and management of these patients.
Nephrologists and nephrology teams contribute to this collaborative pro-
cess by being involved in the earlier stages of CKD, perhaps at the time of
diagnosis, and also by providing assessment s of patientsÕ conditions and
strategic guides to overall management [1]. An example of this is the admin-
istration of erythropoietin, a proven and effective treatment strategy that is
not available in many primary care establishments [1]. To be effective, how-
ever, our ultimate goal, as primary care providers and nephrologists alike, is
to be able to educate and empower patients so that they will be able to take
charge of their disease.
0095-4543/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.pop.2008.06.005 primarycare.theclinics.com
Prim Care Clin Office Pract

35 (2008) xi–xiii
As guest editor of two issues on ‘‘Kidney Diseases and Hypertension,’’
I feel privileged with a unique opportunity to contribute to this goal. I have
carefully chosen the different topics that I feel are of great interest to our
colleagues involved in primary care practice.
The first issue deals with the typical topics faced by primary care pro-
viders, such as common fluid and electrolyte disorders, as well as acid-base
problems. These articles discuss the diseases with predominant involve-
ment of renal pathophysiology, such as glomerular and tubulointerstitial
diseases, and common systemic diseases, such as diabetic nephropathy,
systemic lupus erythematosus, congestive heart failure, etc. The various
treatment modalities and approaches are also rendered towards the end
of each article.
An article discussing the new classification of chronic kidney disease and
the various complications that may arise secondary to it is also included.
The last two articles deal with common upper and lower urinary tract prob-
lems, such as infections and stones.
The second issue focuses on the various treatment stra tegies, namely re-
nal replacement therapy or dialysis and renal transplantation. Hypertension,
a common problem encountered in the outpatient setting and also the sec-
ond most common cause of CKD, is discussed in greater detail.
Over the past decades, with so many advances in technology, as shown by
our new understanding of the various disease processes and pathophysiol-
ogies, there has been a very noticeable increase in representation of the ge-
riatric population in those afflicted by renal disease processes, the so-called
‘‘gerontologizing of nephrology.’’ I believe that a discussion on this new
trend is appropriate, and so it is presented in the last article.
I would like to take this opportunity to thank my fellow authors who col-
laborated with me on this project. All of the authors were asked to give
a specific discussion related to kidney diseases and hypertension, while

taking into consideration that our target audience would be the primary care
providers whom we collaborate with on a regular basis.
Table 1
Team approach to the role of primary care physician and nephrologist in chronic kidney disease
What the primary care physician does What the nephrologist does
Identifies and screens for risk factors
of CKD, including:
Diagnoses and assesses patient
 Diabetes
 Cardiovascular disease
 Anemia
Provides ongoing management of patients
with CKD
Assists in developing strategic guidance
Provides role-specific patient education Recommends and implements patient care
Provides role-specific patient education
Abbreviation: CKD, chronic kidney disease.
Data from BeActive slide deck. Ortho Biotech, Bridgewater, NJ.
xii
PREFACE
I am hopeful that primary care providers will find the information pro-
vided in this text quite useful in their practice of daily medicine. As medicine
is ever-changing and developing, future studies will be published that may
either differ or provide updates to the recommendations presented herein.
I encourage readers to stay updated with the medical literature and to use
it in their practices as they deliver healthcare.
Edgar V. Lerma, MD, FACP, FASN, FAHA
Section of Nephrology
Department of Medicine
University of Illinois at Chicago

College of Medicine
820 S. Wood Street
Chicago, IL 60612-4325
Associates in Nephrology, SC
210 South Desplaines Street
Chicago, IL 60661
E-mail address:
Reference
[1] Schoolwerth A. The Scope of the cardio-CKD-anemia triad. Taking control of chronic kid-
ney disease: beyond the kidney. Presented at the ANNA Meeting. Orlando, May 25, 2002.
xiii
PREFACE
Treatment Options for End Stage
Renal Disease
Paul W. Crawford, MD, FACP
a,b,
*
,
Edgar V. Lerma, MD, FACP, FASN, FAHA
c,d
a
Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
b
Evergreen Park Dialysis Unit, 9730 S. Western Avenue, Suite 326,
Evergreen Park, IL 60805, USA
c
Section of Nephrology, Department of Medicine, University of Illinois at Chicago College
of Medicine, 820 S. Wood Street, Chicago, IL 60612-4325, USA
d
Associates in Nephrology, SC, 210 South Desplaines Street, Chicago, IL 60661, USA

Currently, more than 480,000 United States citizens are receiving dialysis
[1]. More than 314,000 are receiving hemodialysis, more than 25,000 are re-
ceiving peritoneal dialysis, and another 143,000 have had transplants [1].
Significantly, 16.8% of the population has chronic kidney disease (CKD)
[2]. The latest National Health and Nutrition Study revealed an increasing
incidence of kidney disease among aging baby boomers, as the incidence
of diabetes mellitus and hypertension rises. Because of this trend, a greater
proportion of a primary care physician’s practice will involve patients with
CKD, and consequently, end stage renal disease (ESRD) or CKD patients
receiving dialysis [3].
Unfortunately, far too many of these CKD patients are referred to
a nephrologist very late. More often than not, the opportunity for secondary
preventive intervention, with the goal of avoiding renal replacement ther-
apy, is lost [4].
When should a patient with CKD be referred to a nephrologist?
The National Kidney Foundation Kidney Disease Outcomes Quality Ini-
tiative (KDOQI) guidelines recommend a referral to a nephrologist when
the glome rular filtration rate (GFR) is less than 30 mL per minute per
1.73 m
2
[5]. A more aggressive approach is to encourage referral when the
* Corresponding author. Evergreen Park Dialysis Unit, 9730 S. Western Ave., Suite 326,
Evergreen Park, IL 60805.
E-mail address: (P.W. Crawford).
0095-4543/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.pop.2008.05.003 primarycare.theclinics.com
Prim Care Clin Office Pract
35 (2008) 407–432
GFR is less than 60 mL per minute per 1.73 m
2

. As a cautionary note, a con-
sultation when the GFR is greater than 60 is warranted in the presence of
rapidly declining GFR with or without hematuria or proteinuria.
Late referral to the nephrologist is considered by most clinicians to be
‘‘when management pf patients with chronic kidney disease could have been
significantly improved by earlier contact with the nephrology team,’’ and sur-
prisingly, it is extremely common in the United States. In most cases, it is when
one is referred within 3 months or less before start of dialysis therapy [6].
With an early referral, the patient and family are given the advantage of par-
ticipating in educational classes concerning CKD, as well as of receiving one-
on-one counseling with a multidisciplinary kidney care team, including a nurse
practitioner, physician, dietitian, and social worker. These team interventions
(informed selection of dialysis modality, timely placement of appropriate dial-
ysis access, as well as preemptive transplant) are paramount in helping the pa-
tient and family overcome many of the fears and myths associated with
dialysis, as well as to arm them with skills needed to cope with the CKD, its
complications, or ESRD diagnosis and treatment [7]. Similarly, other benefits
associated with early referral include nonemergent initiation of dialysis, lower
morbidity and improved rehabilitation, less frequent and shorter hospital
stays, lower cost, and improved survival [8]. Moreover, many CKD patients
are able to remain stable (within the same CKD stage), or improve CKD stage
with aggressive intervention. The National Kidney Foundation classifies
CKD stages into stages 1 through 5, as illustrated in Table 1.
Unfortunately, many patients with ESRD have been threatened with dial-
ysis by primary care providers or family members. Though well intentioned,
the use of the threat of dialysis as a tool for motivating compliance with pre-
scribed treatments and medications ultimately results in a patient who fears
the treatment (dialysis) more than the disease (ESRD), with all the accompa-
nying complications. All too often, this leads to patients with CKD Stage 5 re-
fusing renal replacement therapy for a prolonged time (more than a year in

some cases) or even never consenting to this life-saving treatment.
Table 1
National Kidney Foundation stages of chronic kidney disease
Stage Description GFR (mL/min/1.73 m
2
)
1 Kidney damage with normal or [ GFR R 90
2 Kidney damage with mild Y GFR 60–89
3 Moderate Y GFR 30–59
4 Severe Y GFR 15–29
5 Kidney failure !15 (or dialysis)
Chronic kidney disease is defined as either kidney damage or GFR less than 60 mL per minute
per 1.73 m
2
for greater than or equal to 3 months. Kidney damage is defined as pathologic abnor-
malities or markers of damage, including abnormalities in blood or urine tests or imaging studies.
From National Kidney Foundation. KDOQI clinical practice guidelines for chronic kidney
disease: evaluation, classification, and stratification. Am J Kidney Dis 2002;39(2 Suppl 1):S46;
with permission.
408
CRAWFORD & LERMA
It is ironic that, given our current armamentarium, our success in manag-
ing comorbidities associated with CKD Stage 5, such as anemia, hyperte n-
sion, metabolic acidosis, and secondary hyperparathyroidism with
hyperphosphatemia leads our patients to question whether dialysis can
improve their quality of life. With diligent management of these comorbi d-
ities, patients no longer need suffer from symptoms of fatigue, weakness,
loss of mental alertness, letha rgy, severe pruritus, recurrent chronic heart
failure, shortness of breath, and inability to perform activities of daily living
(ADLs). Instead, they are able to work, walk miles on a treadmill, golf,

bowl, swim, dance and perform all ADLs without difficulty, despite having
a GFR of less than 15 mL per minute.
Indications for renal replacement therapy
ESRD is always a diagnosis of exclusion; it is only after all exams have
ruled out all reversible causes for renal failure that a diagnosis of ESRD
should be made. No assumptions can be made in the work-up. A compre-
hensive, meticulous work-up includes an extensive history and physical,
laboratory exams, renal ultrasound, chest X-Ray, and CT scan and MRI
when indicated. Previous medic al records must be reviewed.
The National Kidney Foundation’s Kidney Disease Outcomes Quality
Initiative guidelines define CKD as:
1. Kidney damage for greater than or equal to 3 months, as defined by
structural or functional abnormalities of the kidney, with or without
decreased GFR an d manifest by either:
Pathologic abnormalities; or
Markers of kidney damage, including abnormalities in the composi-
tion of blood or urine, or abnormalities in imaging tests
2. GFR less than 60 mL per minute per 1.73 m
2
for greater than or equal
to 3 months, with or without kidney damage (Table 2) [9].
Table 2
KDOQI criteria for initiation of renal replacement therapy
Criteria for initiation of renal replacement therapy
Prior approach GFR
Diabetics !15 mL/min
Nondiabetics !10 mL/min
Transplant Not candidate until on dialysis
Current approach GFR
All patients !15 mL/min

Patients with symptomatic severe left ventricular
dysfunction, symptomatic uremia, uncontrollable
hyperkalemia or metabolic acidosis
15–20 mL/min
Transplant !20 mL/min
409
TREATMENT OPTIONS FOR END STAGE RENAL DISEASE
According to KDOQI guidelines, hemodialysis is also indicated when the
GFR has not yet decreased to or below 15 mL per minute per 1.73 m
2
, in the
presence of [9]:
Intractable extracellular fluid volume overload
Hyperkalemia
Hyperphosphatemia
Hypercalcemia or hypocalcemia
Metabolic acidosis
Anemia
Neurologic dysfunction (eg, neuropathy, encephalopathy)
Pleuritis or pericarditis
Otherwise unexplained decline in functioning or wellbeing
Gastrointestinal dysfunction (eg, nausea, vomiting, diarrhea,
gastroduodenitis)
Weight loss or other evidence of malnut rition
Hypertension
After the diagnosis of ESRD is determined, a decision concerning the
most appropriate mode of renal replacement for the patient must be
made. The various modes of dialysis must be very carefully discussed with
patients and families as a life saving treatment for those with ESRD who,
without this opportunity to receive treatment, will die prematurely of uremic

complications. If the primary care provider is unable to dedicate the time for
this often very lengthy, emotional discussion, then it is best left to the
nephrology team.
Options for renal replacement therapy for ESRD
Kidney Transplantation
a. Deceased donor
b. Living donor
Peritoneal Dialysis
a. Continuous ambulatory peritoneal dialysis (CAPD)
b. Continuous cycler peritoneal dialysis (CCPD)
c. Nocturnal intermittent peritoneal dialysis (NIPD)
d. NIPD-wet day
e. Tidal peritoneal dialysis
Hemodialysis (HD)
a. Conventional: 3 to 5 hours, 3 times per week
i. In-center HD
ii. Home HD
iii. Nocturnal home HD
iv. Nocturnal in-center HD (not widely available)
b. Daily home HD (day or nocturnal)
c. Day or nocturnal 8–10 hour HD
410 CRAWFORD & LERMA
Variations of the above referenced renal replacement therapies are being
attempted in an effort to improve outcomes, such as reduction of morbidity,
mortality, and hospitalization days, in accordance with current ongoing
demonstration projects.
Goals of renal replacement therapy include:
Prolongation of life
Reversal of symptoms of uremia
Return the patient to their prior lifestyle/activities of daily living

Maintenance of a positive nitrogen balance and an adequate energy
intake
Minimization of patient inconvenience
Maximization of quality of life
Selection of renal replacement therapy mode
The nephrologist has great influence over the patient’s selection of peri-
toneal versus hemodialysis. The nephrologist’s preferences are greatly
dependent upon their training, orientation, and practice location. A signif-
icant percentage of Nephrology Fellows come into practice with no prior
experience in peritoneal dialysis. Subsequentl y, these nephrologists are
much less likely influence a patient to choose peritoneal dialysis because
of a lack of confidence in their ability to successfully manage peritoneal
dialysis patients and staff.
Lack of experienced and adequately trained staff can be, and often is,
a major deterrent to a nephrologist recommending CAPD, even when
they believe this to be the best option for the patient. Fear of insecure,
inexperienced staff can also make an already apprehensive and fearful
new ESRD patient even more anxious and reluct ant to take on the respon-
sibility of self-care (Table 3).
Table 3
Considerations when determining mode of renal replacement therapy
Consideration Hemo CAPD CCPD
Access Desired: arteriovenous
(AV) fistula
Alternate: catheter
Tenckhoff catheter; no
AV access
Tenckhoff catheter; no
AV access
Frequency/duration 3 times per week/4 hrs

per session
Four exchanges daily Cycler at night
Patient manual
dexterity
Not a factor Partner is
recommended
Partner is
recommended
Patient intellectual
capacity
Not a factor Partner is
recommended
Partner is
recommended
Family support An advantage Necessary Necessary
411
TREATMENT OPTIONS FOR END STAGE RENAL DISEASE
Hemodialysis
History
Georg Haas performed the first human hemodialysis in 1924 in Giessen,
Germany. Using collodian tubes arranged in parallel cylinders, blood came
in contact with exchange fluid. Since that time, there have been num erous
breakthroughs with various membranes, including cellophane, cellulose ac-
etate, and cupraphane, all in the search for more biocompatible dialysis
membranes and ultimately, disposable kidneys.
In 1946, Gordon Murray created a dialyzerda coil design on steel framed
and used his invention on a patient in acute renal failure, performing the first
successful dialysis in North America.
Many patients start dialysis with the perception that their kidneys are
going to recover and that dialysis is ‘‘only temporary.’’ This is despite coun-

seling to the contrary by multiple care providers that their kidney disease is
irreversible and that they will need renal replacement therapy for the rest of
their life. Such denial is common in patients starting renal replacement ther-
apy and is to be expected for the first 6 to 12 months of dialysis. This is true
even for the patient who has received early, in depth education about the
need for renal replacement therapy.
Contraindications to hemodialysis
Hemodialysis contraindications include hemodynamic instability, hypo-
tension, unstable cardiac rhythm and patient refusal.
Vascular access
Vascular access has been called the Achilles heel of dialysis. Without
adequate access to the circulation, it is impossible to achieve adequate dial-
ysis results. Blood flow of between 200 mL to 500 mL per minute is required
for adults, depending on their size. For patients needing chronic hemodial-
ysis, creation of an arteriovenous (AV) fistula (connecting an artery to a vein
using a surgical anastomosis of the native vessels) in an upper extremity is
imperative.
Early identification of patients requiring AV access
Patients in CKD Stage 4 should have vein mapping with ultrasound. After
mapping has identified that the patient has adequate size vessels for the crea-
tion of a native AV fistula, a surgical referral for creation of an AV fistula
should be made. Only a native AV fistula should be placed. The decision to
place any other form of access should be reviewed with the nephrology
team, patient, and family. Some surgeons believe an AV graft using artificial
veins (PTFE) are also fistulas. However, the nephrologists must not relegate
the decision of appropriate AV access placement to the vascular surgeon.
412 CRAWFORD & LERMA
The selection and order of preference for placem ent of AV fistula are
a wrist (radial-cephalic) primary AV fistula or and elbow (brachial-cephalic)
primary AV fistula. If unable to establish AV access with the preceeding

methods, then use an artificial vein graft of synthetic material or a trans-
posed brachial-basilic vein fistula.
Typical longevity of an AV fistula is 80% over a 3-year period as com-
pared with 50% over 3 years for an AV-PTFE graft.
Location of an AV graft should be determined by the anatomic size of
vessels, as shown by vein mapping, the surgeon’s skills, and the anticipated
duration of dialysis, as noted in the KDOQI guidelines. After an AV fistula
is placed, a period of 4 to 16 weeks is required until adequate venous
enlargement and thickening of vessel walls results in a fistula suitable for
cannulation (Figs. 1 and 2).
The implications, potential complications, and risks associated with cath-
eter placement must be weighed carefully to avoid increased morbidity and
mortality. Unfortunately, there are instances wherein the patient may re-
quire hemodialysis on a rather emergent manner, such as in cases of acute
poinsonings or intoxications, acute renal failure with uremic signs and
symptoms at presentation, or in situations where the patient has not been
adequately prepared for hemodialysis, such that no AV access has been
placed. In these situations, the use of double lumen, noncuffed, nontun-
neled, short (9 cm–13 cm) hemodialysis catheters have been the preferred
method for vascular access. Such catheters can be inserted into the jugular,
subclavian, or femoral veins, via a modified Seldinger guidewire technique.
Because they are noncuffed, they are considered temporary and they can be
inserted at the bedside under sterile conditions. Radiologic imaging guid-
ance is not common ly required during their placements. The subclavian
route is discouraged because of increased risk of subclavian stenosis and
thrombosis. For femorally inserted catheters, a length of 18 cm or less is rec-
ommended to minimize recirculation.
Fig. 1. Primary radiocephalic arteriovenous fistula. A side-to-side anastomosis becomes a func-
tional artery side-to-venous-end anastomosis by ligation of the distal venous limb close to the
AV anastomosis (L1) or more distally (L2). Abbreviations: A, radial artery; V, cephalic antebra-

chial vein. (From Feehally J, Johnson R. Comprehensive Clinical Nephrology, 2nd Edition.
New York: Mosby, an imprint of Elsevier; 2003. p. 930; with permission.)
413
TREATMENT OPTIONS FOR END STAGE RENAL DISEASE
Internal jugular catheters can be left in place for 2 to 3 weeks, while fem-
oral catheters should be removed after one use in ambulatory patients, or
3 to 7 days in those who are bed-ridden. The most common complications
that arise from such catheters are infections.
At times, such temporary catheters have to be changed to the less thrombo-
genic, permanent, cuffed catheters that can be used for longer periods, such as
up to 6 months. For these purposes, the double lumen silastic/silicone, cuffed
catheters are used. Because of their larger size, fluoroscopy is usually required
for placement. The majority of such catheters are loss to bacteremia. Throm-
bosis, stenosis, and infection of the catheters are also common complications.
In comparing AV fistulas or grafts to catheters, the latter usually require
an increase in hemodialysis dur ation of treatment by approximately 20% to
achieve equivalent urea removal with the former [10]. In fact, using ultra-
sound dilution techniques, there is an estimated 20% to 30% decrease in
blood flow (based on blood pump reading) when using a catheter as
opposed to an AV access.
Hemodialysis basics
The basic unit of an artificial kidney is a semipermeable membrane made
up of several thousand hollow fibers with a surface area of from 0.5 m
2
to
Fig. 2. Arteriovenous polytetrafluoroethylene graft in the forearm. (From Feehally J, Johnson R.
Comprehensive Clinical Nephrology, 2nd Edition. New York: Mosby, an imprint of Elsevier;
2003. p. 931; with permission.)
414
CRAWFORD & LERMA

2.0 m
2
. Arranged in parallel, these fibers provide separation of the pa-
tient’s blood and dialysate fluid. Blood from the patient circulates through
the dialyser and is returned to the patient with the assistance of a pump
and tubing. Dialysate mak es just a single pass through the dialyzer
(Fig. 3A).
There are several types of extracorporeal therapy: hemodialysis, hemofil-
tration, hemodiafiltration, and hemoperfusion. For the purpose of manage-
ment of chronic renal failure in the outpatient setting, this discussion will be
limited to that of hemodialysis.
There are several variants of hemodialysis. These include:
Conventional hemodialysis, which uses a conventional low flux (small
pore size) membrane. The primary mechanism of solute removal is
diffusion.
High efficiency hemodialysis, which uses a low flux membrane with
higher efficiency for removal of small solutes (eg, use a large surface
area membrane).
High flux hemodialysis, which uses a high flux (large pore size) membrane
that is more efficient in removing large solutes.
Hemodialysis machines have several key components (Fig. 3B), such as:
Blood pumpddelivers blood to the artificial kidney at a constant rate of
approximately 500 mL per minute.
Monitorsdensures pressure inside blood circuit is not excessive.
Detectordmonitors leakage of red blood cells from the blood circuitry
component into the dialysate compartment.
Air detector/shut off devicedprevents air from entering the patient.
Dialysate pumpddelivers dialysate to the artificial kidney.
A proportioning systemdassures proper dilution of the dialysate
concentrate.

Heaterdwarms the dialysate to approximately body temperature.
Ultrafiltration controllerdprecis ely regulates fluid removal.
Conductivity monitordchecks dialysate ion concentrations (Fig. 4).
With all the above devices , the artificial kidney can safely and reliably
exchange water and solute in the physiologic ranges necessary to maintain
chemical homeostasis as well as hemodynamic stability.
Water transport and solute clearance
Ultrafiltration coefficients are used to measure effectiveness of water
transport across the dialysis membrane. Ultrafiltration coefficients are usu-
ally 2 mL to 5 mL per hour per mm Hg, with conventional membranes and
15 mL to 60 mL per hour per mm Hg with high flux membranes [11]. Stable
patients may tolerate 5-L ultrafiltration or fluid removal over the 4-hour
dialysis treatment, with close monitoring of vital signs.
415TREATMENT OPTIONS FOR END STAGE RENAL DISEASE
416 CRAWFORD & LERMA
Mass transfer coefficient (K
o
) and membrane surface area (A) determine
solute transport of dialysis membranes, expressed as mass transfer-area
coefficient K
o
A as molecular size increases and diffusive clearance of solutes
decreases. Therefore, small molecules, such as urea, are readily cleared at
rates much higher than normal glomerulus of the kidney. However, 4 hours
of dialysis 3 times per week cannot replace 24 hours, 7 days-a-week of clear-
ance at the rate of 168 hours per week.
Dialysate composition
Dialysate sodium at or above plasma sodium prevents hemolysis from
abrupt decrease in plasma sodium. Potassium often is kept low to decrease
plasma potassium. Bicarbonate concentrate is usually high to correct acido-

sis. Today, acetate is seldom used in the United States because of problems
with transient hypoxemia, metabolic acidosis, intradialytic hypotension, and
cardiac arrhythmia. Calcium concentration in dialysate may vary depending
on individual needs of the patient. Magnesium is usually low for ESRD
patients who tend to be hypermagnesemic. For all patients, to avoid hypo-
glycemia, the glucose in the bicarbonate bath is usually kept at 200 mg/dL.
Complications of hemodialysis
Hemodialysis today is a relatively safe procedure; however, complica-
tions do occur.
Hypotension
The most common complication of hemodialysis is hypotension. This can
be either intradialytic or after dialysis.
Etiology of hypotension
Dialysis-related hypotension is attributed to changes in body volume.
Both the amount of fluid removed and the rapidity of the removal from
the intravascular space can affect the development of hypotension, as can
Fig. 3A. Diagram of a hemodialysis circuit. Labels point to blood removed for cleansing,
arterial pressure monitor, blood pump, heparin pump to prevent clotting, dialyzer, inflow pres-
sure monitor, air detector clamp, venous pressure monitor, air trap and air detector, and clean
blood returned to body. (From the National Institute of Diabetes and Digestive and Kidney
Diseases (NIDDK). Treatment Methods for Kidney Failure Hemodialysis (KU-152). Available
at Fig. 3B. Blood
circuit for hemodialysis. (a) The blood circuit. (b) The pressure profile in the blood circuit
with an arteriovenous fistula as the vascular access. (From Feehally J, Johnson R. Comprehen-
sive Clinical Nephrology, 2nd Edition. New York: Mosby, an imprint of Elsevier; 2003. p. 955.
with permission.)
=
417TREATMENT OPTIONS FOR END STAGE RENAL DISEASE
changes in serum osmolality and sympathetic tone. Patients taking oral
antihypertensive medication before dialysis can experience intradialytic

hypotension. In addition, patien ts eating while being dialyzed can experi-
ence hypotension secondary to splanchnic pooling.
Management of intradialytic and post dialysis hypotension
Treatment of hyp otension may include:
Normal saline infusion
Recumbency
Discontinuing ultrafiltration
Increasing dry weight
Decreasing the temperature of the dialysate
Fig. 4. Design of a modern hollow-fiber dialyzer. (From Feehally J, Johnson R. Comprehensive
Clinical Nephrology, 2nd Edition. New York: Mosby, an imprint of Elsevier; 2003. p. 953; with
permission.)
418
CRAWFORD & LERMA
Sodium modeling dur ing hemodialysis
Isolated ultrafiltration
Withhold antihypertensive medications before dialysis
Midodrine, an oral selective a
1
-agonist has been used in some cases with
satisfactory results. The use of salt-poor albumin has been shown not to
demonstrate any advantage over normal saline infusion, and may actually
be more costly.
Hypertension
Hypertension during or immediately after dialysis is another common
complication, and it is primarily volume-dependent in its etiology. There
are patients, with so-called ‘‘dialysis-resistant hypertension,’’ whose blood
pressures remain elevated despite adequate fluid removal. Such patients
tend to have underlying long-standing hypertension and often have excessive
interdialytic weight gains. They may have a hyperactive renin angiotensin

system in response to fluid removal [12].
Use of erythropoietin has also been associated with a 20% to 30% inci-
dence of new onset of hypertension, or exacerbation.
Cardiac arrhythmia
Cardiac arrhythmias can occur in any patient, but are most often seen in
patients on multiple cardiac medications and when a low K bath is being
used. The numbers of patients with cardiovascular disease and arrhythmia
developing ESRD are continuing to rise and warrant close attention [13].
Arrhythmia prevention
Preventive measures may entail use of bicarbonate dialysate with close
monitoring of the potassium and calcium levels in the patient’s serum
and the dialysate. The use of zero potassium dialysate is arrhymogenic in
itself and should not be used, especially if the patient is on maintenance
digoxin.
Steal syndrome
Steal syndrome is commonly seen in patients with radiocephalic arterio-
venous fistulas or grafts, where blood flow to the involved hand is diverted
and diminished. These patients should be evaluated for signs and symptoms
of ischemia, such as subject ive coldness and paresthesia, objective reduction
in skin temperature, or intact sensory or motor functions. Neurologic
changes and muscle wasting tend to occur in severe cases.
Mild ischemia can be treated with analgesics or by wearing a glove. Those
that do not respond to conservative measures may require surgical interven-
tion with banding or access correction or even ligation.
419TREATMENT OPTIONS FOR END STAGE RENAL DISEASE
Muscle cramps
Muscle cramps are common when a patient drops below their dry weight
or when they undergo ultrafiltration that is too rapid. Periphera l arterial
disease (PAD) is common in kidney patients with CKD and can produce
muscle cramps [14]. As expected, they tend to occur toward the latter part

of the dialysis session, tending to involve the lower extremities, most
commonly. This is also the reason for a significant proportion of patients
discontinuing dialysis treatment session prematurely.
Muscle cramp management
Lar ge intradialytic weight gain can be avoided with flui d restrictions
of 1,000 cc to 1,500 cc plus urine volume per 24 hours, a task that
requires extreme self-discipline for some p atients whose thirst center is
overactive.
In the past, quinine sulfate, given 2-hours before dialysis, was favored by
many physicians. The United States Food and Drug Administration cur-
rently regards quinine sulfate as both unsafe and ineffective for prevent ion
of muscle cramps. Oxazepam has been used by some physicians with varying
rates of success. The value of sodium modeling in relieving muscle cramps
has been shown in at least one study [15] .
Evaluation for PAD with Ankle Brachial Index (ABI) may indicate pres-
ence of PAD that requires further treatment and evaluation.
Restless leg syndrome
Patients usually complain of crawli ng sensations on both lower extremi-
ties, which seem to occur during periods of inactivity (while the patient is
sleeping or seated). Sometimes it is perceived as pain. Prompt relief is usu-
ally obtained by moving the legs, hence, the term ‘‘restless legs.’’ Many
patients have difficulty sleeping and can have a poor quality of life. Use
of certain antidepressants (eg, tricyclic antidepressants, selective serotonin
reuptake inhibitors, and lithium) can exacerbate the symptom. Restless
leg syndrome has to be differentiated from peripheral neuropathy, which
tends to be more constant and is not relieved by movement.
Gabapentin has been shown to be effective and can also help with the
insomnia. Recently, ropinirole, a dopamine agonist approved for use in Par-
kinson’s disease, has shown to be a promising agent [16].
Disequilibrium syndrome

This syndrome may occur when too much fluid is removed over too short
a time period. Disequilibrium syndrome may manifest as a range of symp-
toms, including headache, nausea, vomiting, altered mental status, seizure,
coma, and death.
420 CRAWFORD & LERMA
Disequilibrium syndrome management
Fortunately, disequilibrium syndrome is much less common in patients
who are referred to a nephrologist for timely initiation of dialysis. Early
referral coupled with improved technology has made this syndrome much
rarer than in the past.
Anaphylaxis
Anaphylactic reactions may manifest with burning or heat over the access
site or throughout the body, chest or abdominal pain, difficulty breathing,
hypotension or hypertension, fever, chills, pruritis, emesis, urticaria, flush-
ing, and even cardiopulmonary arrest. The typical onset of symptoms is
usually within the first 5 minutes of initiating dialysis , although it may be
delayed by up to 20 minutes.
Fortunately, improved technology has decreased the incidence and
frequency of anaphylactic reactions to the dialysis membrane. Modern
membranes are much more biocompatible. Using bicarbonate dialysis
rather than acetate dialysis has also decreased the occurrence of anaphy-
laxis. Thorough rinsing of the dialyzer before use, helping to remove any
noxious materials or contaminants that became attached to the membr ane
during manufacturing, has also reduced the occurrence of anaphylaxis.
Eliminating the reuse of dialyzers prevents patient exposure to contami-
nation of membranes by chemicals used during sterilization and repro-
cessing and reduces the risk of anaphylaxis caused by sensitivity to these
chemicals.
Postdialysis syndrome
An ill-defined, washed-out feeling or malaise during or after hemodialysis

is seen in approximately one third of patients [17]. It has been attributed to
several factors: decreased cardiac output, peripheral vascular disease,
depression, deconditioning, electrolyte abnormalities, hypotension, and
myopathy, among others.
Infectious complications
Patients with ESRD primarily die from cardiovascular events. However,
infections are the second most common cause of death [18,19] Temporary
dialysis catheters are the source for most infections. AV fistulas carry the
least risk of infection. Staphylococcus aureus and Staphylococcus epidermidis
are the bacterial culprits most frequently found. Frequent infection control
in services and follow-up training to staff are required policy for all dialysis
units, whether hemodialysis or peritoneal dialysis units.
Hepatitis B was prevalent in the 1970s. Currently Hepatitis C is more
prevalent and increasing risk for liver failure and cirrhosis in ESRD
421TREATMENT OPTIONS FOR END STAGE RENAL DISEASE
patients. Unfortunately, the mode of transmission is not yet established.
Screening for Hepatitis B is mandatory and patients presenting or develop-
ing this condition require isolation.
Vaccination for Hepatitis B, Flu, and pneumonia are offered to appropri-
ate patients. Patients are considered candidates for the vaccines unless a spe-
cific contraindication, such as established antibody levels for Hepatitis B, is
present (Table 4).
Role of water treatment in hemodialysis complications
Water treatment is the most critical component of hemodialysis. Fortu-
nately, it is also the most monitored, regulated, and precisely accurate seg-
ment of dialysis. Purification of water from municipalities is critical because
of inherent levels of co ntaminants, as well as hardness that varies from
location and water source. Inadequate removal of calcium, aluminum, bac-
teria, chloramine, and other water components that may be either naturally
occurring or as a result of contamination can lead to deadly consequences.

There is no room for error in proportioning systems whose function is to
maintain proper osmolality, electrolyte content, and pH balance. Improper
Table 4
Vaccination table for patients with ESRD
Vaccine Recommended May use if otherwise indicated Contraindicated
Anthrax X
a
DTaP/Tdap/Td X
a
Hib X
a
Hepatitis A X
a
Hepatitis B X
Influenza (TIV) X
Influenza (LAIV) X
Japanese Encephalitis X
a
MMR X
a
Meningococcal X
a
Pneumococcal X
Polio (IPV) X
a
Rabies X
a
Rotavirus X
b
Smallpox X

a
Typhoid X
a
Varicella X
a
Yellow Fever X
a
a
No specific Advisory Committee on Immunization Practices recommendation for this
vaccine exists for renal dialysis patients and patients with chronic renal disease.
b
Children with primary immunodeficiency disorders and both children and adults who
have received hematopoietic, hepatic, or renal transplants are at risk for severe or prolonged
rotavirus gastroenteritis and can shed rotavirus for prolonged periods. (Data from Advisory
Committee on Immunization Practices, unpublished data.)
422
CRAWFORD & LERMA
temperature range can lead to hemo lysis. Air leak detectors ensure against
air embolism that can arise from a defective blood circuit.
Peritoneal dialysis
Peritoneal dialysis is the author’s first choice for renal replacement ther-
apy for a patient with ESRD if a kidney transplant is not possible or avail-
able. Peritoneal dialysis was initially used only to treat patients who were in
acute kidney failure. Typically used exclusively in intensive care units (ICU),
a hard plastic catheter was placed into the peritoneal cavity, allowing the
infusion of peritoneal dialysis fluid. The dialysis fluid was supplied in 2-liter
glass bottles. The ICU nurse would perform exchanges every 1 to 2 hours,
documenting hourly volume of intake and output, and calculating a positive
or negative fluid balance. This was a very laborious task for nursing staff,
often requiring a one-to-one patient-to-staff ratio (hardly available in

today’s nursing shortage era).
By the mid-1970s, continuous ambulatory peritoneal dialysis was intro-
duced. Currently, more than 25,000 patients with ESRD are on peritoneal
dialysis.
Fundamentals of peritoneal dialysis
Peritoneal dialysis involves an exchange of solutes and fluids across the
peritoneal membrane, which serves as the dialysis surface, via diffusion
and convective transport regulate solute movement. Urea, creatinine, and
potassium move into the peritoneal cavity dialysate across the peritoneal
membrane, while bicarbonate and calcium move in the opposite direction.
The concentration gradient between dialysate and blood facilitates small
molecule movement. Convection is also responsible for solute movement
across the peritoneal membrane. Patients perform the exchanges at home
on a daily basis and have follow-up at the dialysis center or home therapy
center twice monthly. Peritoneal dialysis patients are typically seen by the
nephrologist once a month and by the staff twice a month for social, dieta ry,
and financial needs. Mon thly laboratory work is required at a minimum;
more frequent laborat ory work may be requir ed (Fig. 5).
A high concentration of glucose in the peritoneal dialysis fluid is used as
solute driving fluid removal, creating an osmotic gradient for ultrafiltration
of fluid, and providing a dwell time that is not prolonged. Crucial to effec-
tive exchanges and fluid removal are peritoneal blood flow, dialysate
volume, and the integrity of the peritoneal membrane (Table 5).
The peritoneal dialysis cathet er is inserted by a surgeon or nephrologist
as an out-patient procedure. Most catheters are double-cuffed, curled tip
Tenckhoff catheters. Other types of catheters are available, but they are
infrequently used.
423TREATMENT OPTIONS FOR END STAGE RENAL DISEASE
Fig. 5. Diagram of a patient receiving peritoneal dialysis. Dialysis solution in a plastic bag drips
through the catheter into the abdominal cavity. CAPD is the most common form of peritoneal

dialysis. (From the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).
Kidney Failure: Choosing a Treatment That’s Right for You (KU-50). Available at: http://
kidney.niddk.nih.gov/kudiseases/pubs/choosingtreatment/index.htm.)
Table 5
Peritoneal dialysate fluid composition
Peritoneal dialysate fluid composition
Sodium 132 mEq/L
Potassium 0 mEq/L
Calcium 3.5 mEq/L
Lactate 40 mEq/L
Magnesium 0.5 mEq/L
Glucose 1.5 g/dL, 2.5 g/dL, or 4.25 g/dL
Osmolality 346, 396, 485
pH 5.2
424
CRAWFORD & LERMA
Continuous ambulatory peritoneal dialysis
CAPD uses 9 L to 10 L of peritoneal dialysis fluid per day, usually in 2-L
to 3-L bags. Four to six exchanges are typically performed over a period of
24 hours. The peritoneal dialysis fluid is infused into the peritoneal cavity
via catheter. The fluid remains in the cavity for 4 to 6 hours, is then drained
out, removing water and solutes, including urea and creatinine. The number
of exchanges and the volume of the peritoneal dialysis fluid bags are deter-
mined by patient size, peritoneal membrane permeability, and residual kid-
ney function (Fig. 6).
Automated continuous cycling peritoneal dialysis
While the mechanism of dialysis is the same, patients on CCPD use
a cycler. A cycler is a small bedside device that is programmed to set
volumes of infusion, dwell times and drain times. After programming, the
device automatically performs exchanges while the patient is either asleep

or resting. Because the process is automated, the patient is able to rest with-
out interruption, with the exception of an alarm that sounds as a result of
a problem detected by the cycler (Fig. 7).
Fig. 6. Flush-before-fill strategy used with Y transfer sets. (A) A small volume of fresh dialysis
solution is drained directly into the drainage container (either before or just after drainage of
the abdomen). This washes away any bacteria that may have been introduced in the limb of the
Y leading to the new bag at the time of connection. (B) Fresh solution is introduced through the
rinsed connector. (From NIH Publication No. 01-4688, May 2001. Available at: http://www.
intelihealth.com/IH/ihtIH/WSIHW000/23,847/25,944/273,441.html?d¼dmtContent#works.)
425
TREATMENT OPTIONS FOR END STAGE RENAL DISEASE
426 CRAWFORD & LERMA
Benefits of self care using CAPD or CCPD
Self discipline
Ownership of diseas e and self-management
Responsibility
Family involvement
Overcomes denial
Residual renal function preservation
Better quality of life
Lower morbidity and mortality
Adequacy of peritoneal dialysis is measured through determination of
KT/V where K equals urea clearance, T equals per unit time, and V equals
total body water. The combination of creatinine clearance of peritoneum
and residual renal function should reach a weekly KT/V of 2. Failure to
achieve the guideline level of 2 may result in uremic symptoms, decreased
protein intake, and increased mortality (Table 6).
Complications of peritoneal dialysis
Peritonitis is the most common complication of peritoneal dialysis. This
complication is usually discovered when the patient reports a cloudy drain-

age bag. A diagnosis of peritonitis is confirmed through a positive gram
stain, cell count, and sensitivity culture, as well as signs and symptoms of
peritoneal inflammation. Empiric treatment is started to treat gram-positive
or gram-negative organisms by instillation of intraperitoneal antibiotics.
Objective criteria for rationing dialysis?
In the early days of dialysis in the United States, dialysis was only offered
at univers ity teaching centers. It was considered a high risk, experimental,
but life saving procedure. Dialysis was only offered to those with ESRD
who were accepted by the ‘‘God Committees’’ as eligible for dialysis. Crite-
ria were very limiting; for example, patients had to be under the age of
55 and could not be diabetic. I will never forget having to inform a 55-
year-old father of two children that the committee voted he was not eligible
for dialysis. Never again do I wish to see a committee decide who may be
treated and who is essentially given a death sentence. Yet some 35 years
later, this pendulum of death appears to be resurfacing in the medical
Fig. 7. Example of a system used for cycler-assisted peritoneal dialysis. Solution is heated be-
fore use and weighed after use. The last bag of solution may have a different concentration to
last throughout the day. (From NIH Publication No. 01-4688, May 2001. Available at: http://
www.intelihealth.com/IH/ihtIH/WSI HW000/23,847/25,944/273, 441.html?d¼dmtContent#
works.)
=
427TREATMENT OPTIONS FOR END STAGE RENAL DISEASE