Intended for healthcare professionals

Practice ABC of Kidney Disease, 2nd Edition


BMJ 2014; 348 doi: (Published 23 January 2014) Cite this as: BMJ 2014;348:bmj.g2
  1. McIntyre Christopher W.1,
  2. Burton James O.2
  1. 1Department of Renal Medicine Derby City Hospital Derby, UK
  2. 2Department of Infection, Immunity & Inflammation, School of Medicine and Biological Sciences University of Leicester Leicester, UK

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  • Indications to commence dialysis are:

    • intractable hyperkalaemia;

    • acidosis;

    • uraemic symptoms (nausea, pruritus, malaise);

    • therapy-resistant fluid overload;

    • chronic kidney disease (CKD) stage 5.

  • There is considerable variation of the level of glomerular filtration rate (GFR) individuals may tolerate before becoming markedly uraemic.

  • ‘Crash-landing’ onto dialysis confers a reduction in patient survival that persists for at least the first three years of subsequent therapy.

  • Early identification and assiduous preparation mentally and physically are needed in the predialysis phase for those likely to need renal replacement therapy (RRT).

  • Haemodialysis (HD) involves circulating blood through a disposable dialyser. The vascular access of choice is the arteriovenous fistula (AVF). This, however, requires suitable peripheral veins and needs four to eight weeks for the fistula to mature. If there are no suitable veins, a graft can usually be inserted. Acute access with venous catheters has a high complication rate.

  • Peritoneal dialysis (PD) involves using the peritoneum as the dialysis membrane, with pre-packaged fluid being instilled into the peritoneal space via a Tenckhoff catheter. This is usually only inserted once the decision to start dialysis is made.

  • HD is usually performed in four-hour sessions, three times a week, in hospital-based dialysis units.

  • PD typically involves continuous ambulatory peritoneal dialysis (CAPD), which allows continuous dialysis using three to five exchanges of fluid per day via disposable bags.

  • Automated peritoneal dialysis (APD), whereby larger volumes of fluid are instilled and drained by the use of a small machine by the bedside, is used when either more intense dialysis is …

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