End-Stage Renal Disease: Treatment

In general, once CKD has degenerated to ESRD over the course of years, it is irreversible. Treatment is aimed at treating complications and replacing renal function via dialysis or transplantation.

Early identification of kidney replacement candidates so that adequate preparation and planning can be done to ensure a smooth transition to dialysis may reduce morbidity and mortality. Referral to a nephrologist should occur as early as possible in order to plan for long-term therapy. Kidney transplantation is the treatment of choice for appropriate candidates.

There are 2 options for maintenance dialysis. Hemodialysis involves the creation of an arterovenous fistula and dialysis graft, usually in the arm, and treatment at a dialysis center, typically 3 times weekly. Continuous peritoneal dialysis involves inserting the dialysate into the patient's abdomen and allowing dialysis to occur continuously or intermittently without requiring the patient to travel regularly to a dialysis center. Both methods have advantages and disadvantages, and outcomes are similar.

Complications

It is essential to treat ESRD complications that may arise. When remaining kidney function is markedly reduced, these treatments often are used in conjunction with dialysis therapy:

• Volume overload and hypertension (treated with a dietary sodium restriction).
• Hyperkalemia (treated with a low-potassium diet and, acutely, with kayexalate).
• Hypocalcemia (treated with calcitriol or other vitamin D analogues).
• Metabolic acidosis (treated with alkali therapy, such as sodium bicarbonate).
• Hyperphosphatemia (treated with dietary phosphate restriction and phosphate binders).
• Anemia (treated with erythropoietin).

Psychiatric Interventions

Psychiatric disorders are common and can interfere with treatment. Adherence to recommended diet and fluid restrictions increases life expectancy and can help to reduce medical complications, treatment side effects, and improve quality of life.¹ However, psychiatric disorders may interfere with treatment compliance, causing significantly higher interdialytic weight gain.² Depression is the most common psychiatric problem in ESRD patients and is associated with both mortality and morbidity.³ Antidepressant treatment (pharmacologic and psychotherapy combined) is not only effective in improving mood, but also improves biochemical indicators of nutritional status in hemodialysis patients.⁴ Psychological interventions have improved adherence to fluid restriction and related interdialytic weight gain.⁵

Exercise

Exercise should be encouraged in ESRD patients. Exercise training in patients with ESRD and hypertension reduces blood pressure and has other cardiovascular benefits, such as reducing the incidence of cardiac arrhythmias and improving left ventricular function and heart rate variability.^6,7 Exercise also reduces depression in ESRD patients.⁸