5. What I thought I learned?
Dialysis can restore health, improve
appetite, replaces kidney function, and has few
down sides, and since diabetics are overall
sicker, they should start dialysis earlier.
6. What Rosansky labels as CW
• Level of clearance is associated with survival and
morbidity, and clearance by dialysis is the same as
clearance by the native kidney
• Low albumin means bad nutrition
• Nutrition gets better after starting dialysis
• Diabetics should start at eGFR < 15, everyone else can
wait until 10
• Once you get to a GFR of < 15, it is rapidly downhill
from there
• It is dangerous to wait to an eGFR < 6 to start dialysis
7. Dialysis – Does and Doesn’ts
• Removes small • Remove middle and
molecular weight large MW molecules
solutes well well
(BUN, Cr, H20, Na, K, +/- • Modulate inflammation
P) • Balance Ca/Phos/Vit D
• Rapidly removes fluid axis
(3-4 hours instead of • Immediately benefit
48-72 hours) those without
• Provides lifesaving uremia, volume
therapy in AKI with overload, or
hyperkalemia, volume hyperkalemia
overload, uremia
8. Potential downsides to dialysis
• More rapid loss of RRF
• Possible myocardial ischemia hits
• Chronic inflammation and oxidative stress
• Dialysis access issues –
infection, thrombosis, procedures
• Heparin exposure
• Increased ESA dosing
• Protein and blood loss
9. What would be some criteria for
determining when to start dialysis?
Laboratory findings Symptoms/Signs
• Creatinine • Uremia?
• BUN (azotemia) • Pericarditis
• GFR • Cognitive decline
• Hyperkalemia • Volume overload
• Albumin • Nausea/loss of appetite
• Protein catabolism
10. KDOQI
• KDOQI, Canadian 1997 - - kT/V urea < 2 /wk
(equivalent to creatinine clearance 10.5 ml/min
• KDOQI 2001 essentially the same, changing
tone, still “It is paradoxical that nephrologists
have focused on optimizing urea clearance once
patients are started on dialysis, but have
accepted much lower levels of kidney urea
clearance during the pre-dialysis phase of patient
management.”
• KDOQI 2006 not much different, but more
change in tone
11. From early observational studies to
rethinking risk/benefit
• 1982 – urea reduction with HD predicts
mortality
• 1992 – serum albumin predicted survival
• 1997 – CANUSA suggests PD = endogenous
• 2003-5 – several studies show RRT is the
important fact, not urea reduction, and
additionally that albumin in dialysis patients
more of a marker of inflammation than
nutrition
14. IDEAL – Initiating Dialysis Early and
Late
• Randomized controlled trial
• 828 adults – Australia and New Zealand
• 355 with DM
• 65% male
• Mean age 60.4 years
• Early start GFR 10-14, Late start 5-7
15.
16.
17. When to initiate dialysis
( for the slowly progressive CKD patient)
eGFR 5-9 ml/min/1.73M2 and uremia related:
• Pericarditis
• Coagulopathy
• GI symptoms with N +/- V
• Anorexia/unexplained weight loss
• Diuretic refractory volume issues
• Resistant hyperkalemia
Rosansky -
18. But I would add other factors to
include
• Rate of kidney function decline – maybe
earlier if rapid decline to avoid acute start
• Cardiorenal syndrome can greatly increase
minimal tolerated eGFR
• Hepatorenal syndrome
• Certain metabolic issues (hyperoxaluria)
• Other co-morbidities, often age related
