1) chronic dialysis treatments (either hemodialysis or peritoneal dialysis),
2) renal transplantation, or 3) death. With renal failure of any cause, there are many physiologic derangements. Homeostasis of water and minerals (sodium, potassium, chloride, calcium, phosphorus, magnesium, sulfate), and excretion of the daily metabolic load of fixed hydrogen ions is no longer possible. Toxic end-products of nitrogen metabolism (urea, creatinine, uric acid, among others) accumulate in blood and tissue. Finally, the kidneys are no longer able to function as endocrine organs in the production of erythropoietin and 1,25-dihy-droxycholecalciferol (calcitriol).
Dialysis procedures remove nitrogenous end-products of catabo-lism and begin the correction of the salt, water, and acid-base derangements associated with renal failure. Dialysis is an imperfect treatment for the myriad abnormalities that occur in renal failure, as it does not correct the endocrine functions of the kidney.
Indications for starting dialysis for chronic renal failure are empiric and vary among physicians. Some begin dialysis when residual glomerular filtration rate (GFR) falls below 10 mL/min /1.73 m2 body surface area (15 mL/min/1.73 m2 in diabetics.) Others institute treatment when the patient loses the stamina to sustain normal daily work and activity. Most agree that, in the face of symptoms (nausea, vomiting, anorexia, fatigability, diminished sensorium) and signs (pericardial friction rub, refractory pulmonary edema, metabolic acidosis, foot or wrist drop, asterixis) of uremia, dialysis treatments are urgently indicated.
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