End Stage Renal Disease

About this course

The development of chronic kidney disease (CKD) and its progression to end-stage renal disease remains a significant source of reduced quality of life and premature mortality. In end-stage renal disease (ESRD), an individual's kidneys permanently stop functioning, resulting in the necessity of long-term dialysis or a kidney transplant to survive. This course includes a complete overview of ESRD, its potential causes, and current treatments options for overall improved quality of life.

Learning objectives

• Identify causes of renal failure
• Review testing and assessments for renal failure
• Identify distinctions between acute renal failure and chronic kidney disease
• Recognize treatment modalities for hyperkalemia
• Summarize dialysis options, including peritoneal dialysis and hemodialysis

Course outline

23 sections · finish in any order across devices

1. 1

   Introduction

   End-stage renal disease, also called kidney failure, is a global health problem with a high prevalence rate, affecting around 10 to 12% of the population worldwide.1,3 In the United States, more than 500,000 people live with end-stage renal disease (ESRD).2 In this disease, an individual's kidneys p

   4 min

2. 2

   Physiology Chronic Kidney Disease

   The Kidney Disease Improving Global Outcomes (KDIGO) foundation guidelines define CKD using kidney damage markers that determine proteinuria and glomerular filtration rate.2 Each nephron in a normal kidney contributes to the total glomerular filtration rate (GFR).2 The decline of kidney function is

   4 min

3. 3

   Causes of Renal Failure

   There are two kinds of renal failure; acute and chronic.5 In acute renal failure (ARF), glomerular filtration declines abruptly (hours to days) and is usually reversible.5 It is further divided into 3 classifications, depending on the site; prerenal (caused by interference with renal perfusion), int

   4 min

4. 4

   Diabetes

   Diabetes mellitus (DM), especially type 2 diabetes mellitus, is the most frequent cause of ESRD.5,6 In DM, excess glucose in the body damages the kidney's filter system, resulting in the kidney’s inability to properly filter waste and extra fluid from the body.7

   4 min

5. 5

   High Blood Pressure

   High blood pressure is the second leading cause of kidney failure in the U.S. after diabetes.8 High blood pressure damages the kidney's blood vessels and affects their functionality.7 It narrows and constricts the blood vessels, reducing blood flow.8 As a result, the kidneys cannot remove all wastes

   4 min

6. 6

   Other Causes

   Other common causes of CKD and end-stage renal disease include:5,6,7

   4 min

7. 7

   Assessment and Diagnosis

   The first step in the evaluation of end-stage renal disease is establishing chronicity.6 Chronic kidney disease is diagnosed when there is evidence of kidney damage for at least three months or in any patient with a GFR of less than 60 mL/min for that same amount of time.2,6

   4 min

8. 8

   Acute Renal Failure

   In acute renal failure, the underlying cause is often reversible such as infection, drugs that reduce the GFR, hypotension caused by shock, and hypovolemia caused by vomiting and diarrhea.6

   4 min

9. 9

   Hyperkalemia - Medications to Reduce Potassium Levels

   Hyperkalemia is a common finding in patients with CKD.9 It is defined as an increase in potassium levels and is associated with decreased renal ion excretion, medications to reduce the progression of CKD, and control of associated diseases such as diabetes mellitus and heart failure.9 If not control

   4 min

10. 10

    Insulin and Dextrose

    Insulin and dextrose effectively decrease the serum potassium level through activation of Na+/K+ ATPase after insulin fixation to its receptor.10 Using insulin and dextrose decreases the potassium level by ∼0.5–1 mmol/L.10 The main side effects are glycemic variations, including hyperglycemia and hy

    4 min

11. 11

    Sodium Bicarbonate

    According to multiple studies, sodium bicarbonate is also efficient in decreasing potassium levels.10 In a recent randomized controlled trial (RCT), the authors observed a significant decrease in serum potassium levels in patients receiving sodium bicarbonate 4 h after the beginning of the perfusion

    4 min

12. 12

    Β2-agonists

    β2-agonists decrease the serum potassium level through two different pathways: first, by increased secretion of endogenous insulin and second, by the activation of Na+/K+ ATPase after stimulation of the β2-receptors in the muscle and liver.10 However, some patients may be resistant to β2-agonists.10

    4 min

13. 13

    Dialysis Types

    As ESRD progresses, based on health condition and in consultation with their healthcare provider, patients must discuss treatment options, including dialytic or non-dialytic treatment. If dialysis is the best option, dialysis modality selection and the preferred timing of dialysis initiation is cons

    4 min

14. 14

    Peritoneal Dialysis (PD)

    Peritoneal dialysis is a treatment for ESRD and is used to remove the waste products from the blood when the kidneys are unable to function adequately.12 It forces the abdomen's inner lining and peritoneum to act as a natural filter and uses dialysate fluid to cleanse the blood.12

    4 min

15. 15

    Types of Peritoneal Dialysis

    There are two types of peritoneal dialysis; continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis.12,13 Both differ in their administration and the schedule of exchanges.12,13 For instance, CAPD is a machine-free dialysis process in which the exchange is done by hand.12,

    4 min

16. 16

    Peritoneal Catheter Placement

    There are different techniques used for catheter placement, such as surgical or percutaneous.14 Determining one technique's advantages over another is difficult as the process depends on multiple factors and the patient's overall condition.14 However, research shows that there are multiple complicat

    4 min

17. 17

    Peritoneal Cavity Infection

    One of the most serious complications of peritoneal dialysis is infections. These can occur on the catheter site or in the abdominal cavity.14,15,16 Catheter-site infections cause pus-like drainage from the area and lead to redness, firmness, and tenderness of the skin around the catheter.16 These i

    4 min

18. 18

    Hemodialysis (HD)

    In the United States, there are currently 400,000 patients with ESRD on maintenance hemodialysis (HD).17 It is a form of renal replacement therapy that removes waste and extra fluid from the blood by using an external filter called a dialyzer, also known as an artificial kidney.18,19 The dialyzer co

    4 min

19. 19

    Complex Procedure

    Hemodialysis is usually conducted in a dialysis center. Thus, frequent visits can be burdensome for patients.20 Moreover, the hemodialysis procedure is long and complex. It only works when the right type of passageway is created through surgery, in which an artery and a vein are connected in the for

    4 min

20. 20

    Cardiovascular Complication

    Oxidative stress is developed in patients undergoing hemodialysis.19 During dialysis, the semipermeable membrane faces an immunological response and makes it permeable to granulocytes.19 The activated granulocytes in the blood stimulate the release of reactive oxygen species (ROS) and exaggerate oxi

    4 min

21. 21

    Vascular Access

    Vascular access is also a common complication in patients undergoing hemodialysis.18 The access site can become infected or be blocked by a blood clot and have poor blood flow.18 In the vascular access process, death may also occur from cardiac arrhythmias, pulmonary edema, or contrast medium reacti

    4 min

22. 22

    Dialyzer Reactions

    A dialyzer can cause allergic reactions in ESRD patients. There are two types of reactions, type A and type B.22 Type A reactions are more severe than type B and are mediated by preformed immunoglobulin E. Type A reactions are triggered after a few minutes to around 30 mins of dialysis initiation an

    4 min

23. 23

    Conclusion

    End-stage renal disease is a progressive disease, necessitating renal replacement therapy to survive.2 The disease is associated with frequent hospitalizations, high-cost treatments, and metabolic changes that increase mortality rates and lead to life-long lifestyle changes associated with dialysis

    4 min

This course satisfies

Requirement summaries come from our state requirement records. Always confirm details with your board before you renew.

References and resources

• Calderon-Margalit R, Golan E, Twig G, et al. History of Childhood Kidney Disease and Risk of Adult End-Stage Renal Disease. New England Journal of Medicine. 2018;378(5):428-438. doi:10.1056/nejmoa1700993
• Benjamin O, Lappin SL. End-Stage Renal Disease. Nih.gov. Published 2019. https://www.ncbi.nlm.nih.gov/books/NBK499861/
• Cobo G, Lindholm B, Stenvinkel P. Chronic inflammation in end-stage renal disease and dialysis. Nephrology, Dialysis, Transplantation: Official Publication of the European Dialysis and Transplant Association - European Renal Association. 2018;33(suppl_3):iii35-iii40. doi:10.1093/ndt/gfy175
• End-Stage Renal Disease (ESRD) | CMS. www.cms.gov. Published December 1, 2021. https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Coordination-of-Benefits-and-Recovery-Overview/End-Stage-Renal-Disease-ESRD/ESRD#:~:text=End%2DStage%20Renal%20Disease%20(ESRD)%20is%20a%20medical%20condition
• Bindroo S, Challa HJ. Renal Failure. PubMed. Published 2020. https://www.ncbi.nlm.nih.gov/books/NBK519012/
• Vaidya SR, Aeddula NR, Doerr C. Chronic Renal Failure (Nursing). PubMed. Published 2021. https://www.ncbi.nlm.nih.gov/books/NBK568778/
• NIDDK. Causes of Chronic Kidney Disease | NIDDK. National Institute of Diabetes and Digestive and Kidney Diseases. Published October 2016. https://www.niddk.nih.gov/health-information/kidney-disease/chronic-kidney-disease-ckd/causes
• High Blood Pressure & Kidney Disease | NIDDK. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/kidney-disease/high-blood-pressure#HBPKidneys
• Watanabe R. Hyperkalemia in chronic kidney disease. Revista da Associação Médica Brasileira. 2020;66(suppl 1):s31-s36. doi:10.1590/1806-9282.66.s1.31
• Coutrot M, Dépret F, Legrand M. Tailoring treatment of hyperkalemia. Nephrology Dialysis Transplantation. 2019;34(Supplement_3):iii62-iii68. doi:10.1093/ndt/gfz220
• Segall L, Nistor I, Van Biesen W, et al. Dialysis modality choice in elderly patients with end-stage renal disease: a narrative review of the available evidence: Table 1. Nephrology Dialysis Transplantation. Published online December 15, 2015:gfv411. doi:10.1093/ndt/gfv411
• NIDDK. Peritoneal Dialysis | NIDDK. National Institute of Diabetes and Digestive and Kidney Diseases. Published June 5, 2019. https://www.niddk.nih.gov/health-information/kidney-disease/kidney-failure/peritoneal-dialysis
• National Kidney Foundation. Peritoneal Dialysis: What You Need to Know. National Kidney Foundation. Published February 3, 2017. https://www.kidney.org/atoz/content/peritoneal
• Sachdeva B, Zulfiqar H, Aeddula NR. Peritoneal Dialysis. PubMed. Published 2022. https://www.ncbi.nlm.nih.gov/books/NBK532979/
• Roberts JR. InFocus: Diagnosing Peritoneal Dialysis Complications in the ED. Emergency Medicine News. 2022;44(2):12. doi:10.1097/01.EEM.0000820888.02744.b6
• UpToDate. Uptodate.com. Published 2019. https://www.uptodate.com/contents/peritoneal-dialysis-beyond-the-basics
• Saha M, Allon M. Diagnosis, Treatment, and Prevention of Hemodialysis Emergencies. Clinical Journal of the American Society of Nephrology. 2016;12(2):357-369. doi:10.2215/cjn.05260516
• NIDDK. Hemodialysis | NIDDK. National Institute of Diabetes and Digestive and Kidney Diseases. Published June 5, 2019. https://www.niddk.nih.gov/health-information/kidney-disease/kidney-failure/hemodialysis
• Vadakedath S, Kandi V. Dialysis: A review of the mechanisms underlying complications in the management of chronic renal failure. Cureus. 2017;9(8). doi:10.7759/cureus.1603
• Dialysis in chronic kidney disease. Nih.gov. Published March 8, 2018. https://www.ncbi.nlm.nih.gov/books/NBK492979/
• Murdeshwar HN, Anjum F. Hemodialysis. PubMed. Published 2020. https://www.ncbi.nlm.nih.gov/books/NBK563296/
• UpToDate. www.uptodate.com. Accessed January 20, 2023. https://www.uptodate.com/contents/reactions-to-the-hemodialysis-membrane#H3

Update history