Indications for renal replacement therapy

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Renal replacement therapy (RRT) is a treatment option for patients with end-stage kidney disease (ESKD) or acute kidney injury (AKI) when the kidneys are no longer able to perform their critical functions effectively. RRT includes methods like hemodialysis, peritoneal dialysis, and kidney transplantation. The decision to initiate RRT is based on a combination of clinical symptoms, laboratory results, and patient-specific factors.

Indications for Renal Replacement Therapy

1. Chronic Kidney Disease (CKD)

RRT is typically considered for patients with stage 5 CKD (glomerular filtration rate [GFR] < 15 mL/min/1.73 m²) or those who are experiencing progressive kidney failure. Specific indications include:

Uremic Symptoms: When the kidneys can no longer clear urea and other waste products from the blood, it leads to uremia, which causes symptoms such as:
- Fatigue, weakness, confusion, or drowsiness
- Pruritus (itching)
- Nausea and vomiting
- Anorexia and weight loss
- Pericarditis (inflammation of the lining around the heart)
- Bleeding tendencies (due to uremic toxins affecting platelet function)
Severe Fluid Overload: Persistent and severe fluid retention (edema) that cannot be controlled by diuretics (water pills), leading to:
- Pulmonary edema (fluid in the lungs, causing shortness of breath)
- Heart failure exacerbated by fluid overload
- Severe peripheral edema
Electrolyte Abnormalities: Severe imbalances in potassium, sodium, or calcium, especially if they cannot be corrected with medications or diet, such as:
- Hyperkalemia (high potassium) that is life-threatening and unresponsive to treatment
- Metabolic acidosis (low bicarbonate) that is severe and not responsive to treatment
Persistent Hyperphosphatemia: Very high levels of phosphate, leading to calcification in tissues, including blood vessels, which cannot be managed by diet, phosphate binders, or other treatments.
Intractable Hypertension: Severe hypertension that does not respond to medications, causing organ damage, such as heart failure, stroke, or further kidney injury.

2. Acute Kidney Injury (AKI)

For patients experiencing acute kidney injury (AKI), RRT may be necessary if the kidney damage is severe and persistent. Indications for RRT in AKI include:

Severe Volume Overload: Fluid overload that leads to pulmonary edema or cardiovascular collapse, especially when fluid removal is not achievable with diuretics.
Severe Electrolyte Imbalance:
- Life-threatening hyperkalemia (e.g., potassium > 6.5 mmol/L) that is unresponsive to medical management, such as medications or interventions like calcium gluconate, insulin, or sodium bicarbonate.
- Severe metabolic acidosis (pH < 7.1) that does not correct with medications.
- Severe hypercalcemia that cannot be corrected through other measures.
Uremic Symptoms: In AKI, uremic symptoms may develop quickly, and RRT is required if there are signs of toxicity, such as nausea, vomiting, confusion, pericarditis, or bleeding.
Poisoning or Drug Overdose: Certain toxins and medications that accumulate in the blood and are not easily cleared by the kidneys can be managed with RRT. Examples include:
- Lithium toxicity
- Methanol or ethylene glycol poisoning
- Salicylate toxicity

3. Indications in Dialysis-Dependent ESKD

For patients in the later stages of CKD, particularly stage 5 (ESKD), RRT is used to maintain life and manage symptoms, including:

Dialysis Initiation Criteria: In the absence of clear indications like uremic symptoms or fluid overload, the decision to start dialysis is often guided by GFR, creatinine levels, and the presence of symptoms (e.g., uremia, fluid overload, and electrolyte disturbances). A GFR below 15 mL/min/1.73 m² or symptomatic CKD often prompts the initiation of dialysis.
Patient Preferences and Quality of Life: The choice of starting dialysis or opting for conservative management also depends on the patient’s goals of care, quality of life considerations, and whether they want to pursue dialysis, a kidney transplant, or palliative care.

4. Chronic Dialysis Patients

In patients who are already on chronic dialysis, RRT may need to be intensified in certain circumstances, including:

Acute Complications: In cases of:
- Severe infections, like peritonitis or sepsis in dialysis patients
- Catheter-related complications, such as thrombosis or infection requiring the temporary use of a dialysis catheter or switch to another modality
Access Failure: If a patient’s dialysis access (e.g., AV fistula, graft, or catheter) fails and a new access cannot be created immediately, temporary dialysis options may be needed.
Post-transplant Period: After a kidney transplant, patients may require RRT temporarily if the transplanted kidney fails or if they experience a rejection episode or delayed graft function.

Types of Renal Replacement Therapy (RRT)

Hemodialysis (HD): Involves the use of a machine and a dialyzer (artificial kidney) to filter blood outside the body. This is typically done 3 times a week for most patients.
Peritoneal Dialysis (PD): Uses the peritoneal membrane as a filter, with dialysis fluid exchanged in the abdominal cavity. PD can be done at home, and patients can choose between continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD).
Kidney Transplant: The most ideal form of renal replacement for suitable candidates, where a donor kidney is transplanted into the patient. Transplantation eliminates the need for ongoing dialysis.
Conservative Care (No Dialysis): In certain cases, especially in elderly patients or those with multiple comorbidities, patients may opt for conservative care, which focuses on symptom management without initiating dialysis.

Conclusion

The decision to initiate renal replacement therapy depends on various clinical factors, including the severity of symptoms, laboratory abnormalities, the stage of kidney disease, and patient preferences. RRT may be required in cases of chronic kidney disease (CKD) when kidney function declines to end-stage, acute kidney injury (AKI) when kidney function deteriorates suddenly, or in specific circumstances like poisoning. Effective decision-making involves assessing both the medical indicators and the patient’s individual needs and goals, ensuring the appropriate therapy to maintain life and quality of life.

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