Abstract

Decisions regarding the initiation of renal replacement therapy (RRT)—whether hemodialysis (HD), peritoneal dialysis, kidney transplantation, or palliative care is chosen—are critical when considering combined efforts among nephrologists, patients, family members, and nonphysician health care personnel. The transition from management of progressive chronic kidney disease (CKD) to that of end-stage renal disease (ESRD) requires the nephrologist to have a clear understanding of the disease trajectory in the individual patient and to function as a teacher for the patient and members of the patient's family, as well as for their professional and social networks. These functions involve an understanding of the patient both as an individual and as a member of a social milieu and require an appreciation of the patient's culture, spirit, and belief systems. Although all therapeutic choices facing patients with advanced CKD have advantages and disadvantages, many of the steps in the transition to ESRD care are common to all the choices. In particular, recent advances in clinical science (based on evidence derived from observational studies and clinical trials) allow the nephrologist to advise patients regarding appropriate timing of initiation of RRT and factors related to successful creation of vascular access, which will promote the best health outcomes. The nephrologist, while delivering complex care at the time of a crucial transition, plays a key role in determining whether the start of RRT with HD will be characterized by a “smooth landing” or a “crash landing,” ultimately by serving as a coordinator of education and multidisciplinary consultation.

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