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Definition of ESRD

CKD with the development of signs and symptoms of uremia

** most commonly occurs on eGFR <15, but need signs/symptoms of uremia



Build up metabolic toxins
- BUN, creatinine, urea, bilirubin, etc.

Signs/symptoms of uremia:
- anorexia/decreases appetite
- vomiting
- pericarditis
- peripheral neuropathy (burning feet or restless legs)
- metallic tastes
- CNS toxicity signs
- asterixis/AMS


Complications of ESRD


Uremic bleeding


Uremic neuropathy

Bacterial infections (especially pneumonia)


Treatment of ESRD

1) treat complications

2) kidney transplant list
- this is the treatment of choice
- **eligibility = eGFR <20 or on chronic dialysis
- if eligible, get them on the list ASAP

3) dialysis

**sometimes patients can want conservative management which is palatative care**


Absolute Contraindications to kidney transplant

Active infections or malignancy

Active substance abuse

Reversible kidney failure

Uncontrolled psychiatric disease

Documented inability to adhere to treatments

Life expectancy currently <1-5 years


How does dialysis work?

1) blood comes into the dialysis machine

2) machine is filled with dialysate fluid which makes a large osmotic gradient for toxins to move into the dialysate and out of blood
- Proteins DONT cross over since they are too big


Who should get dialysis in acute kidney injuries

Know your vowels “AEIOU”

A = acidosis w/ pH <7.1

E = Electrolytes are >6.5 (especially potassium)

I = intoxications are present
- Salicayltes, Lithium, Isopropanol, Methanol, Ethylene glycol

O = volume Overload and doesnt respond to diuretics

U = uremia is present
- uremic pericarditis and pleuritis
- uremic encephalopathy


Who should get dialysis in chronic kidney injury/disease

- uremic pericarditis/pruritus or encephalopathy
- GFR = <15

Relative (but pretty Much always)
-Declining nutritional status
-Fatigue and malaise
-Mild cognitive impairment
-Refractory acidosis
- hyperkalemia/hyperphosphatemia (especially if >6.5)



- blood is pumped out of patients and into a machine with an artificial membrane to move toxins out of the body
- requires access and this is usually done via initiation of a AV fistula or AV graft or central line catheter in the arm (vascular surgeon does this manually)
- can be done at home (less common but better outcomes if they can afford it) or dialysis center (most common but worse outcomes)


AV fistula vs AV graft vs Central venous catheter

AV fistula’s
- directly connection of an artery to a vein via surgery
- take 2-3 months to actual use though so is not used in very acute uremia
- need to see a sac like appearance in the arm that has bruit/thrill on auscultation
- DONT give BP checks or blood draws on the fistula arm

AV graft
- place artificial graft material between an artery and vein
- can be used within 24hrs-2 weeks option (quicker)
- Higher complication rates compared to fistula (especially clot rates go way up)

Central vascular catheter
- is usually done in conjunction with a fistula/graft in order to start dialysis immediately while waiting for the fistula/graft to form
- can use immediately and is preferred option in acute uremia**
- must be replaced frequently and very prone to complications (especially infections). Dont use for long term (this is why a fistula is often done at the same time)
- other complications = sepsis, venous stenosis which prevents use of that extremity for future AVF/G (from scarring due to central venous Cather placement)


Peritoneal dialysis

Dialysis fluid is injected into the peritoneal space and uses the patients peritoneal membrane as the membrane for toxins to cross through
- the dialysis fluid is then removed from the peritoneal space after a select amount of time
- requires placement of a peritoneal catheter and only has to wait 2 weeks to use (similar to AV graft)

Is done at home or work and allows independence

Complications includes infections/peritonitis
**cant use for significantly obese**


Two different types of peritoneal dialysis

1) continuous ambulatory peritoneal dialysis
- patients self-infuse dialysis fluid abdomen, leave it for 30-40 minutes than drain it.
- must be done 3-5x every day
- doesn’t require machine

2) automated peritoneal dialysis
- machine-driven infusion and draining of peritoneal dialysis fluid done once a day
- typically done every night while patient is sleeping
- must remain attached to the machine 9-12 hrs


When do doctors discuss dialysis?

If a patient reaches stage 4
- also discuss kidney transplantation ad an option and sign up for donor list


Nocturnal dialysis

Come into clinic at night and sleep at the clinic where the patient gets 2 4hrs sessions for a total 8 hrs


Words of wisdom for dialysis patinets

1) be the captain of your own ship

2) doctors are there to help you but you get the final decision

3) dont be afraid to ask questions and demand answers and get information about alternative options