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Dialysis management in endstage renal failure

William Plant
BSc MB MRCPI FRCP(Edin)
Consultant Renal Physician
Royal Infirmary of Edinburgh
Honorary Senior Lecturer
Department of Clinical and Surgical Sciences
Edinburgh University Medical School

About 1 in 2,000 individuals in the UK suffer from endstage renal failure (ESRF) and are alive because of renal replacement therapy. Slightly more than half have a renal transplant. The remainder are treated by haemodialysis or peritoneal dialysis. Many of these patients are older and suffer from other medical conditions. Typically, at least one-third have ischaemic heart disease, one-quarter have peripheral vascular disease and one-fifth have diabetes. The majority are hypertensive, and many of them are on multiple medications.
Patients on hospital-based haemodialysis usually have their care led by the medical staff of the renal unit. Those dialysing in the community (peritoneal dialysis and home haemodialysis) and those with renal transplants have more contact with the primary healthcare team.

Renal transplant recipients
Over 60% of renal transplant recipients are hypertensive and need regular blood pressure checks. The target BP is 130/85mmHg. Transplant recipients are at an increased risk of vascular disease (four times that of the normal population), so primary/secondary prevention and counselling (on topics such as body mass, smoking, lipids and aspirin) are very important. A total of 30% develop skin lesions (warts, keratoses and pityriasis), and 10% develop skin neoplasms - so regular surveillance and treatment is needed. Female patients need regular cervical smears.
These patients should have influenza vaccine each winter. They cannot have live vaccines (such as oral polio or yellow fever) if travelling abroad. They are susceptible to viral infections, especially chickenpox.
There is a potential for serious drug interactions, so it is very important that patients understand which drugs they are taking, and why.

Dialysis patients in general
Like transplant recipients, dialysis patients are often hypertensive and have an increased risk of vascular disease (16 times more than normal). Primary/secondary prevention and counselling are very important.
Many dialysis patients are anaemic and on erythropoietin. Poor response may indicate iron deficiency (best treated by intravenous iron therapy) or sepsis. Monitoring haemoglobin and BP is important.
Dialysis patients should have influenza vaccine each winter. Many have restrictions on dietary salt, protein, phosphate and fluid intake. It is important to help patients achieve this without becoming malnourished. Contact with the renal dietician is often helpful.

Haemodialysis patients
These patients have native arteriovenous access or indwelling venous catheters. They are at increased risk of Gram-positive infection. This should be suspected in any febrile dialysis patient, especially if there is inflammation at the AV-fistula site.
Dyspnoea and orthopnoea often reflect pulmonary oedema, especially if the patient has gained >2kg in weight since their most recent haemodialysis treatment. Urgent referral to the renal unit for ultrafiltration is required, and other therapies are unlikely to help.
All drugs have altered pharmacokinetics in haemodialysis patients and should be used cautiously. This includes over-the-counter preparations.

Peritoneal dialysis patients
These patients can develop catheter exit-site infections. These are often clinically innocuous but must be taken seriously as they may lead to catheter loss.
Peritoneal dialysis patients can develop peritonitis, which manifests as abdominal pain and cloudy dialysate. In this situation, referral to the renal unit is preferable to the general surgical service.

The psychological burden of ESRF
The psychological burden of ESRF is considerable - up to 25% of haemo-/peritoneal dialysis patients may be depressed - particularly at times of change, such as at the start of dialysis or after a failed transplant. Many older patients become increasingly dependent, particularly if other conditions deteriorate, and may need home nursing and an extensive social support package.

Resources
British Kidney Patient Association
T:01420 472 021
F:01420 475 831

Kidney Patient Guide
W:www.kidneypatientguide.org.uk

Further reading
Stein A, Wild J. Kidney failure explained. London: Class Publishing; 1999.

Tomson CRV, Plant WD. Key topics in renal medicine. Oxford: Bios Scientific Publishers; 1997.