Management of end-stage renal failure

Abstract

10.2217/14750708.3.2.307 © part of Renal replacement therapy Conservative measures are only successful in nonterminal chronic renal failure (CRF) patients [1,2], and patients with end-stage renal failure (ESRF) and glomerular filtration rates less than 5% of the normal who cannot sustain life in the absence of renal replacement therapy (RRT), and either dialysis or transplantation is required [3]. RRT is widely available in industrialized countries. In developing countries it is not uniformly available, so patient management often relies on conservative measures and intermittent peritoneal dialysis (IPD) [4–7]. However, ESRF patients treated in such a way may die from uremia and complications of IPD [6–9]. In developed countries, well-functioning renal transplantation continues to result in the best quality of life for patients with ESRF, and therefore dialysis is used most often as a bridge to allow for the care of ESRF patients until such time that they can be transplanted [10–12]. However, all forms of RRT are associated with certain problems, complications and even deaths. Continuous ambulatory peritoneal dialysis, a common form of therapy in ESRF, is complicated by severe infections, such as peritonitis and exit-site and tunnel infections, which may result in peritoneal thickening and technique failure. An overall mortality rate of 5.7% was reported in a pediatric peritoneal dialysis population [14–16]. Hemodialysis requires the creation of a permanent vascular access, which may fail because of repeated needle punctures. The need for heparinization to prevent clotting in the extracorporeal circuit is an additional concern [13–18]. Lifelong immunosuppression is required for the functional life of the graft; with infection and malignancy being the most feared risks [19]. Nonadherence to medications post-transplant among pediatric patients range from 5 to greater than 50% [20–22] and may lead to enormous financial, physical and psychological costs, loss of graft, increased hospitalization and even death [23,24].