Jennifer E. Flythe, MD, MPH, a dialysis expert from the University of North Carolina, joins Kristin L. Walter, MD, MS, JAMA's Deputy Editor. They delve into the crucial decision-making process behind choosing hemodialysis or peritoneal dialysis based on patient symptoms and preferences. The discussion highlights the ineffectiveness of statins and ICDs for cardiovascular prevention in dialysis patients. They also explore managing common symptoms like pruritus and depression, while shedding light on the high mortality risk within the first six months of treatment.
The selection and timing of dialysis methods are guided by patient symptoms, preferences, and shared decision-making to ensure optimal care.
Management of hypertension and anemia in dialysis patients is critical, requiring careful monitoring and timely intervention to improve health outcomes.
Deep dives
Understanding Kidney Failure and Treatment Options
Kidney failure is characterized by a significantly reduced glomerular filtration rate, typically defined as less than 15 mL per minute per 1.73 m². Treatment options for patients include kidney transplantation, hemodialysis, peritoneal dialysis, or supportive care, depending on individual circumstances. Common symptoms of uremia, which often accompanies chronic kidney failure, include nausea, fatigue, and potentially severe issues such as seizures or coma. The decision to initiate dialysis is complex and should be based on persistent uremic symptoms and other lab factors rather than a specific eGFR threshold.
Dialysis Modalities: Hemodialysis vs. Peritoneal Dialysis
In the U.S., approximately 86% of dialysis patients receive hemodialysis, while about 13% are treated with peritoneal dialysis, with a small fraction opting for home hemodialysis. Research indicates there are no significant survival differences between these modalities over a three to five-year period. Hemodialysis typically involves three weekly sessions at a clinic, lasting around four hours each, whereas home hemodialysis can be more flexible, with shorter daily treatments. Peritoneal dialysis facilities toxin removal by instilling a glucose-based solution in the abdomen, with variations such as continuous ambulatory or automated peritoneal dialysis available for patients.
Complications and Management in Dialysis Patients
Hypertension is a prevalent issue among dialysis patients, with estimates suggesting rates as high as 80% for those on peritoneal dialysis. Complications during hemodialysis sessions such as muscle cramps, headaches, and hemodynamic instability are common, highlighting the need for careful monitoring of blood pressure and fluid status. First-line treatments for hypertension are typically dietary salt restriction, followed by medications if necessary. Additionally, proper management of anemia is crucial, as over 85% of dialysis patients require treatment, with established guidelines indicating that interventions should commence if hemoglobin levels fall below 10.
Selection of hemodialysis or peritoneal dialysis and timing of dialysis initiation are influenced by patient symptoms, laboratory trajectories, patient preferences, and therapy cost and availability; shared decision-making is key. Jennifer E. Flythe, MD, MPH, from the University of North Carolina, discusses dialysis for chronic kidney failure with JAMA Deputy Editor Kristin L. Walter, MD, MS. Related Content: