Content area
Full text
KEY WORDS: conservative care, haemodialysis, peritoneal dialysis, renal failure, renal transplantation
What is end-stage renal disease?
The two terms end-stage renal disease (ESRD) and failure (ESRF) are used to describe the irreversible loss of kidney function which, without treatment by dialysis or kidney transplantation, is likely to lead to fatal complications such as hyperkalaemia or pulmonary oedema over a period of days or weeks. Residual renal function in terms of glomerular filtration rate in such patients is generally below 10 ml/ min/1.73m2.
Early identification
It is important to:
* identify and refer patients with advanced and progressive renal failure as they will be at risk of developing ESRD
* look for reversible factors (eg obstructive uropathy, drug nephrotoxicity or renal vasculitis), and
* try to conserve renal function, principally by controlling hypertension.
Early recognition of patients destined for ESRF is also necessary to allow time for them to become fully informed about their treatment options and to institute therapy electively. However, ESRD may occur unpredictably, for example following acute kidney injury, and 20% of patients still present requiring urgent or emergency dialysis.1,2
Incidence and prevalence
All patients in the UK starting renal replacement therapy (RRT) (ie dialysis or renal transplantation) are registered by the UK Renal Registry and their subsequent progress recorded year on year. Approximately 110 adults per million population start RRT each year; in 2009 almost 50,000 patients were alive on RRT.2,3 The number of patients deemed unsuitable because of severe comorbidity or of those who decide not to receive RRT but receive conservative or palliative care is uncertain.
Survival and quality of life
Despite improvements in outcome, life expectancy remains significantly reduced for patients with ESRD undergoing RRT, principally due to increased cardiovascular and infection death rates.4 There is no convincing evidence of better survival with one type of dialysis compared with another. Increasing age, comorbidity and late presentation are adverse prognostic factors.4,5 Comparison of outcomes between patients wait-listed for transplantation but remaining on dialysis with those receiving transplants suggests a significant survival benefit from transplantation over dialysis.6 Anticipating when ESRD will occur and avoiding dialysis by undergoing pre-emptive renal transplantation is the optimum treatment for ESRD7 and also the most cost-effective. For suitable patients, successful transplantation offers better quality...