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  • Review Article
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Considerations in the optimal preparation of patients for dialysis

Nature Reviews Nephrology volume 8, pages 381–389 (2012)Cite this article

Subjects

Abstract

Every year, more than 110,000 Americans are newly diagnosed with end-stage renal disease and in the overwhelming majority, maintenance dialysis therapy is initiated. However, most patients, having received no predialysis nephrology care or dietary counseling, are inadequately prepared for starting treatment; furthermore, the majority of patients do not have a functioning permanent dialysis access. Annualized mortality in the USA in the first 3 months after starting dialysis treatment is approximately 45%; this high rate is possibly in part due to inadequate preparation for renal replacement therapy. Data from the Dialysis Outcomes and Practice Patterns study suggest that similar challenges exist in many parts of the world. Implementation of strategies that mitigate the risk of adverse consequences when starting dialysis are urgently needed. In this Review we present a step-by-step approach to tackling inadequate patient preparation, which includes identifying individuals with chronic kidney disease (CKD) who are most likely to need dialysis in the future, referring patients for education, timely placement of dialysis access and timely initiation of dialysis therapy. Treatment with dialysis might not be appropriate for some patients with progressive CKD; these individuals can be optimally managed with nondialytic, maximum conservative management.

Key Points

  • A large gap exists in care in transitioning patients with chronic kidney disease (CKD) to renal replacement therapy; a step-by-step approach is proposed to bridge this gap in care

  • Demographic and clinical criteria can help identify those individuals with CKD who would benefit from early preparation for renal replacement therapy

  • Iterative multidisciplinary patient education is the first step in preparing patients for dialysis and should offer decision support for selection of dialysis modality or maximum conservative care

  • Dialysis access should be placed sufficiently early to preclude the need for central venous catheters

  • The decision of when to start dialysis should be individualized based on uremic symptoms and/or the appearance of complications but should not be delayed until patient becomes too sick

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Figure 1: A proposed step-by-step approach to help prepare patients for dialysis.

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Acknowledgements

The following are the members of the Dialysis Advisory Group of the American Society of Nephrology (ASN) at the time of writing this Review: M. Allon, M. Chonchol, P. Eggers (National Institute of Diabetes and Digestive and Kidney Diseases liaison), J. Inrig, K. Kalantar-Zadeh, R. Mehrotra (Advisory Group Chair), S. Moe (ASN Council liaison), S. J. Saggi, R. Shaffer (ASN Staff), S. Watnick, D. Weiner and B. Young.

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Authors and Affiliations

  1. Renal Division, State University of New York Downstate Medical Center, 450 Clarkson Avenue, Box 52, Brooklyn, 11203, NY, USA

    Subodh J. Saggi

  2. Division of Nephrology, University of Alabama at Birmingham, 1530 Third Avenue S, Birmingham, 35294, AL, USA

    Michael Allon

  3. University of Pittsburgh, 128 Hastings Street, Pittsburgh, 15206, PA, USA

    Judith Bernardini

  4. Division of Nephrology and Hypertension, Harbor-UCLA Medical Center, 1124 W Carson Street, Torrance, 90502, CA, USA

    Kamyar Kalantar-Zadeh & Rajnish Mehrotra

  5. American Society of Nephrology, 1510 H Street, NW, Suite 800, Washington, 20005, DC, USA

    Rachel Shaffer

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on behalf of the Dialysis Advisory Group of the American Society of Nephrology

Contributions

S. J. Saggi, M. Allon, J. Bernardini, K. Kalantar-Zadeh and R. Mehrotra researched data for the article, provided substantial contribution to discussions of the content, contributed to writing the article and to review and/or editing of the manuscript before submission. R. Shaffer contributed to review and/or editing of the manuscript before submission.

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Correspondence to Rajnish Mehrotra.

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Competing interests

M. Allon serves as a consultant for CorMedix. J. Bernardini serves as a consultant for Baxter. K. Kalantar-Zadeh has received grant support from DaVita and serves as a Medical Director of a dialysis facility owned by DaVita. R. Shaffer is an employee of the American Society of Nephrology. R. Mehrotra has received grant support and/or honoraria from Amgen, Baxter, DaVita, Genzyme, Mitsubishi Tanabe Pharma, NovaShunt AG, Reata Pharmaceuticals, Shire and Vifor Pharma. S. J. Saggi declares no competing interests.

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Saggi, S., Allon, M., Bernardini, J. et al. Considerations in the optimal preparation of patients for dialysis. Nat Rev Nephrol 8, 381–389 (2012). https://doi.org/10.1038/nrneph.2012.66

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