Renal Failure Stages, Treatment, and Outcomes

About

➀ Read and Learn

The following course content

Would it surprise you to know that 37 million adults in the United States are living with chronic kidney disease (CKD), and most don’t even know it (1)? Would it also surprise you to know that there currently is no cure for chronic kidney disease? How then do these 37 million adults living with this disease function in their daily lives? The answer is that most of the diagnosed are undergoing some type of renal replacement therapy. Renal replacement therapy (RRT) is an umbrella term that includes various treatment options for CKD patients. Even though this disease is so widespread, unless a person knows someone on dialysis or they have experienced it personally, they usually do not know anything about renal failure. This course offers an overview of renal failure and its’ causes, discusses the different options currently available to End-Stage Renal Disease (ESRD) patients, and discusses the pros and cons of each. 

Overview of Kidney Anatomy and Function 

We will begin with an overview of the kidneys. They are two bean-shaped organs, roughly the size of an adult fist, that lie in the retroperitoneal cavity. The right kidney is slightly lower than the left because of the liver placement. The adrenal glands sit right on top of each kidney. Blood carrying excess fluid and waste products enter the kidney through the renal artery. Within the kidney are millions of nephrons containing glomeruli that filter the blood and send waste, toxins, and excess fluid through the ureters, bladder, and urethra for excretion, or through the renal vein for recirculation back into the body. 

Relatively speaking, the kidneys are rather small; however, they hold a major role within the human body. The primary function is to balance the chemicals in the body so that homeostasis is maintained. They do this by releasing hormones to help regulate blood pressure, controlling sodium and fluid levels, stimulating the production of red blood cells, creating vitamin D to help the body absorb calcium, and balancing fluid and electrolytes. The filtered toxins and excess water, now urine, travel from the kidneys to the ureters, where they collect in the bladder and then empty out through the urethra when nerves in the bladder signal the brain that it is time for excretion. The kidneys receive approximately 25% of the body’s cardiac output and produce about 2 quarts of urine each day when working optimally (3). The body begins to lose kidney function when there are interruptions that limit the amount of blood flowing to the kidneys after exposure to nephrotoxic agents or trauma. 

Renal Failure Stages 

Kidney health is determined by testing blood and urine. Blood tests measure the glomerular filtration rate (GFR) in the blood, and urine tests calculate the albumin to creatinine ratio (ACR) in the urine. The presence of protein in the urine could mean that the kidneys are not filtering well.  

CKD is classified into five renal failure stages based on GFR. 

At Renal Failure Stage 5, the patient has developed end-stage renal disease, also called chronic kidney disease, and will require life-long renal replacement therapy (2). If CKD is detected in the earlier renal failure stages, treatments can slow the disease progression and keep the kidneys functioning longer.  

Early referral to a nephrologist at the onset of renal failure symptoms allows for treatments to begin sooner and allows the patient to prepare for the disease progression physically, mentally, and emotionally. Unfortunately, many patients delay medical attention when they are feeling poor, and the delayed treatment leads to an accumulation of toxins in the bloodstream, called uremia. Uremia can cause confusion, loss of appetite, nausea, and diarrhea. Some patients get a ‘uremic frost’ on their skin, which is a crystallization of the uremic toxins. Patient awareness is less than 10% for those with Renal Failure Stages 1-3. Awareness is much higher among people with Renal Failure Stage 4, who are beginning to experience obvious symptoms (7). When situations necessitate immediate action and adequate time is not available, individuals often begin dialysis without appropriate planning. “Approximately 50% of all dialysis initiations occur in a suboptimal manner, meaning that half of the patients starting dialysis do not have the opportunity to psychologically adjust to this treatment and its impact on their life (6).” These patients are at greater risk of developing stress, anxiety, and depression. 

Acute vs. Chronic Renal Failure 

Renal damage can be categorized as acute or chronic. In acute renal failure (ARF), damage to the kidneys happens suddenly, causing the kidneys to lose some or all function temporarily. Acute causes of renal failure include trauma, exposure to nephrotoxic substances, infection, and temporary interruption of blood flow to the kidneys. In Acute Renal Failure, the damage is sudden, but the expectation is that the kidneys will return to normal function once the cause is eliminated and the kidneys have healed.  

On the other hand, chronic renal failure (CRF) occurs slowly over time and is irreversible. Often, lifestyle choices can lead to CRF as uncontrolled diabetes and hypertension are the most prevalent causes. Hypertension is often referred to as the ‘silent killer because many people that have it are asymptomatic; therefore, diagnosis and treatment are delayed. Other causes include chronic use of certain drugs (nonsteroidal anti-inflammatory drugs (NSAIDs), heroin, and some antibiotics), chronic infections (i.e., urinary tract infections, glomerulonephritis), polycystic kidney disease, and kidney stones. Sometimes, an acute cause of renal failure can lead to permanent loss of kidney function. If the kidneys do not regain function after 90 days of acute renal failure, the patient is diagnosed with chronic renal failure. From 1999-2012, CKD was most prevalent in non-Hispanic, black individuals, followed closely by Mexican Americans (7). 

Types of Dialysis 

Dialysis is a form of renal replacement therapy. The two main types are hemodialysis and peritoneal dialysis. Both modalities utilize a semi-permeable membrane to eliminate waste, toxins, and excess fluid from the body. A semi-permeable membrane allows smaller molecules and fluid to pass through a porous surface; however, larger molecules are unable to pass through and are separated from the rest. In dialysis, molecules such as urea, toxins, and some electrolytes that are too concentrated in the blood pass through the semi-permeable membrane, while blood cells are too large to fit through, allowing them to remain in the bloodstream. Healthy kidneys function 24 hours a day and seven days a week. Dialysis treatments can only replace a fraction of this, no matter how frequently they are ordered or how effective it is. 

Hemodialysis 

Hemodialysis is the most prevalent type of treatment. It requires the use of a dialysis machine with a pump to mimic the heart’s pumping of blood through the body. The pump turns at an average rate of 400 ml/min. Different types of surgically placed accesses are used to enter the intravascular space, connecting an artery to a vein. There are three main types of accesses: an arteriovenous fistula (AVF), arteriovenous graft (AVG), and a central venous catheter (CVC). The fistula is the most preferred access because it uses the patient’s own artery and vein, whereas a graft uses a synthetic material to connect the artery to the vein. These are permanent accesses. The CVC is the least preferred access because of its higher rates of infection and clotting, and the tip of it sits in the right atrium of the heart. This is generally treated as a temporary access to be used while a patient is actively pursuing placement of a permanent access. However, for many patients, the CVC is the last resort option because they do not possess the vasculature needed to place a permanent access.  

AVFs and AVGs require two large-bore needles to be placed into the access, allowing entry into the patient’s bloodstream. One needle pulls the patient’s blood out of the body through the access and into a circuit on the machine that contains a dialyzer – often referred to as an artificial kidney. The inside of the dialyzer contains thousands of tiny hollow fibers that are semi-permeable. The blood travels inside the fibers in one direction, while a solution called dialysate (made of ultrapure water made through reverse osmosis (RO), sodium bicarbonate, and acid bath containing electrolytes such as sodium, potassium, calcium, and magnesium), travels in the opposite direction outside of the hollow fibers. This causes a pressure gradient that allows diffusion and osmosis to take place within the dialyzer, assisting the body to return to homeostasis by removing waste, toxins, and excess fluid. As the blood is filtered through the dialyzer, the waste product (effluent) travels down into a drain, while the second large-bore needle in the access returns the cleaned blood back into the body.  

Peritoneal Dialysis 

In peritoneal dialysis, the patient has a catheter surgically placed into the abdomen that allows fluid to flow in and out of the peritoneal cavity. The semi-permeable membrane is the peritoneal membrane, also called the peritoneum. In this modality, the dialysate, a solution with a high concentration of dextrose (which pulls the waste, toxins, and excess fluid through the semi-permeable membrane), is inserted into the peritoneal cavity. After a prescribed amount of time (dwell), the fluid is drained out through the catheter. This is the effluent. The cycle (exchange) is repeated a prescribed number of times, depending on the patient’s residual renal function and lab results, this often correlates with their renal failure stage. No intravascular access is needed; therefore, no needles are used. 

Treatment Goals 

No matter which modality is chosen, all dialysis treatments have the same goals: to replace lost kidney function and return the body to homeostasis. Because fluid balance is a crucial goal of dialysis, accurate patient weights are extremely important. Each patient is prescribed an estimated dry weight (EDW) by a nephrologist. This EDW is the weight the patient would be without excess fluid in their body. The machines are programmed to remove an amount of fluid during the dialysis treatment that will get the patient to their EDW by the end of treatment. Failure to remove the right amount of fluid or removal of fluid at the wrong rate could lead to undesired effects such as hypervolemia, leading to shortness of breath, pneumonia, pitting edema, congestive heart failure, pulmonary edema, and hypertension; or hypovolemia, which leads to cardiac stunning, hypotension, nausea, vomiting, muscle cramps, and dizziness. Fluid imbalances and infection are the primary reasons ESRD patients are hospitalized. 

Another goal of dialysis is the removal of waste and balancing of electrolytes. This is referred to as clearance or adequacy, and it lets the provider know if their orders are sufficiently cleansing the patient’s blood. Some factors that can affect clearance are: 

• The size of the semi-permeable membrane 
• The amount of time and frequency of the dialysis treatments 
• The exposure time to the semi-permeable membrane 
• The proper functioning of the access 
• The concentration of the dialysate 
• The efficacy of anticoagulant or thrombolytic used (because clotted blood leads to decreased surface area available for filtering) 

Generally, the more concentrated the dialysate, the better the clearance. However, there are consequences in using a dialysate that is highly concentrated, such as damaging the peritoneal membrane in a high dextrose concentration or exposing the patient’s blood to a hypertonic solution, which can lead to crenation of the red blood cells in hemodialysis. 

Medications can be given during dialysis treatments to mimic the kidney’s functions related to hormone stimulation and to protect against infection. 

• Erythropoietin stimulating agents (ESAs) and iron are given to stimulate the production of healthy red blood cells. 
• Vitamin D is given to help the body absorb calcium. 
• Protein supplements can be given to boost the body’s albumin to aid the body in shifting fluid to the intravascular space for removal. 
• Heparin is given to prevent coagulation and clotting. 
• Thrombolytics can be given to break up clots in a catheter. 
• IV antibiotics can be given to fight infections.  
• Vaccinations are given to protect against Hepatitis B, influenza, pneumonia, and now Covid-19.  
• Binders are often ordered for patients to take when eating to help limit their phosphorus absorption, which leads to better calcium absorption.

Dialysis Settings  

Both types of dialysis treatments can occur almost anywhere. Hemodialysis is generally performed in hospitals, outpatient clinics, or at a patient’s home. Electricity is required to operate the dialysis and RO machines and there needs to be a water source to make the RO water. Depending on the machine that is used, the patient may also travel with their supplies and conduct their treatments wherever they go. Peritoneal dialysis can be performed in the same places; however, electricity is not needed as there is a manual version of the procedure that only requires gravity. No matter the type of dialysis that is chosen or the setting that is chosen to complete it, infection control is of the utmost importance. Supplies are sterile when packaged and must remain clean when opened so as not to introduce microbes into the bloodstream or peritoneum. Aseptic technique must be utilized to minimize the risk of infection and/or cross-contamination.  

Incenter Hemodialysis 

The most common setting for dialysis in the U.S. is the outpatient hemodialysis clinic. There are thousands of them in the United States. Direct patient care is provided by patient care technicians (PCTs) and licensed practical nurses (LPNs) who operate under the license of a registered nurse. The clinics are typically run by a nurse manager or facility administrator and a medical director.  

Other staff present in the clinic could include: 

• Other attending physicians 
• Nurse practitioners 
• Physician assistants 
• Social workers 
• Dietitians 
• Biomedical staff 
• Administrative personnel 

These facilities vary in size, depending on how many stations they are licensed to have and operate. Each patient station has a specialized reclining chair or bed and a dialysis machine where the treatments are performed. The average hemodialysis treatment duration is between 3 ½ to 4 ½ hours, with constant monitoring by the direct patient care staff. Patients enter the facility, are weighed in and assessed by an RN, and then proceed to their station for their dialysis treatment and medications. Once the treatment is completed, the patient is again assessed by the RN, weighed out, and discharged back home.  

Most patients have treatments ordered three times per week on either a Monday, Wednesday, Friday or Tuesday, Thursday, Saturday schedule, but some patients can be ordered more frequent treatments because of fluid balance issues. The number and frequency of treatments can depend on the patients’ renal failure stage. A clinic typically runs two shifts of patients and then closes for the day. Some clinics offer a third shift or a nocturnal shift in which patients dialyze overnight. 

Many patients prefer to dialyze in this setting because of opportunities for socialization and a feeling of security in having a health care provider run the treatment. This modality has the strictest dietary and fluid limitations for the patients because it is only a three times-per-week treatment. Also, there is less schedule flexibility because of the daily operating schedule of the facility and the staff’s availability. 

Home Hemodialysis 

Hemodialysis can also be performed at home, even while the patient sleeps. The patient and care partner are trained to cannulate (insert needles) and facilitate the treatments. In the U.S., patients usually use either a NxStage machine or a Fresenius 2008K at home machine (often referred to as a Baby K because it is slightly smaller than the larger K machines utilized in the outpatient clinics and hospitals). Both machines have the same function and operate the same way. The patients receive a recliner for their home just like the incenter patients use. There are weekly or biweekly shipments of supplies, depending on how much storage space the patient has available. The supplies can be delivered virtually anywhere, which allows the patients to be able to travel easily without skipping their dialysis treatments. 

Transplant 

13.5% of dialysis patients in the U.S. (about 100,000 people) are currently listed as actively awaiting a kidney transplant (1). A kidney transplant is a surgical procedure in which the ESRD patient, with Renal Failure Stage 5, receives a kidney from either a living or deceased donor. This allows the patient to almost return to the life they lived prior to their renal failure. Unless there is a compelling reason to remove the old, nonfunctioning kidney, it is left in the patient, and the new kidney is placed in the abdomen. A kidney from a living donor usually works better and lasts longer than a cadaver kidney. 

There is an extensive workup required by the transplant center that the candidate must undergo to be listed on the transplant list, including a complete medical and psychosocial assessment. This is to mitigate the risk that the transplant will be unsuccessful and ensure that the kidney will be given to a person who is likely to take care of themselves after the transplant surgery. Any abnormalities should be treated prior to the transplant; risks to the transplant’s success should be addressed, such as weight loss or smoking cessation. Often, a patient must start or continue dialysis while awaiting a kidney transplant. Labs are collected and evaluated monthly, either by the dialysis clinic or transplant center, to maintain the patient on the list. The patient must be free of cancer and other serious illnesses that could jeopardize the kidney. The transplant center also assesses the transplant candidate’s compliance with their treatment prescription. A pattern of noncompliance prior to receiving a transplant could be a risk factor for an unsuccessful transplant.  

A patient’s financial situation is assessed as it could become an obstacle for some. Beginning in 1972, Medicare began providing coverage for ESRD patients who have sufficient work history and contributions to the Medicare fund. These recipients can claim Medicare benefits regardless of age. Medicare covers about 80% of the cost of the transplant and related expenses, however, after a kidney transplant, the number of years of coverage is limited, and the patient may no longer be eligible to receive these benefits as long as the new kidney is working until they meet the suitable age for Medicare benefits without ESRD (1). 

While on the active transplant list, the patient is responsible for making sure that they can be reached anytime and anywhere by the transplant center. They also must ensure that they can arrive at the transplant center in minimal time if called with a kidney match. 

Palliative Care 

A diagnosis of Renal Failure Stage 5 does not mean end-of-life unless the patient decides that it is. For the patients who decide that they do not want to begin or continue dialysis treatments or a transplant, palliative care keeps them comfortable during the end-of-life process. The patient experiences a smoother transition when treatment goals, substitute decision-makers, and power of attorney have been decided in advance. Patients that do choose to have dialysis treatments can also benefit from palliative care treatments that are received concurrently with their dialysis treatments. Many patients experience multiple symptoms during and after dialysis, which include fatigue, pruritus, diarrhea, and restless leg syndrome. Palliative care can help with the management of these symptoms.

Pros and Cons of Treatment Modalities 

Every patient diagnosed with chronic kidney disease must choose which treatment option(s) works best for them. Open and honest communication between the patient, family, caregivers, and the interdisciplinary team must take place to ensure that the patient is being treated in accordance with their wishes. Patients must be seen monthly, if not more frequently, by their nephrologist to ensure that they are enrolled in the safest and effective modality to help them reach their optimal health. Each patient is unique, and their needs can vary depending on their health, preferences, and lifestyle. Each treatment option discussed has its pros and cons, which must be weighed when trying to decide which to choose. 

As written above, the most prevalent option in the U.S. is the outpatient hemodialysis clinic. Many patients choose this option because they feel safer with the presence of direct patient care staff that provide and oversee their treatments. They also enjoy the social connections that are made in the clinic with other patients and staff. Cons of this modality include:  

• Having to travel back and forth to the clinic at least three days per week 
• Being at the mercy of the dialysis clinic’s schedule, which can be inflexible due to the number of patients admitted, clinic’s operating schedule, and staff scheduling 
• Being vulnerable to the staff’s level of competency and professionalism 
• An increased risk of infection due to the invasive nature of the procedure, exposure to microbes, and proximity to other patients 
• Cardiac complications due to the increased workload on the heart.  

The most preferred hemodialysis access is the AV fistula, followed by the AV graft, so a fear of needles would be another consideration of this modality, no matter the setting. 

Performing hemodialysis treatments at home is another option that is growing in popularity. There are three ways in which a patient can perform hemodialysis at home. Conventional “home hemo” is performed 3-4 days per week for 3-4 hours each time, just as with incenter. Short daily home hemo is completed 5-7 days per week for about 2 hours each time. Nocturnal home hemo treatments are done slowly (6-8 hours) while the patient sleeps. Treatments are either prescribed 6 nights per week or every other day. (1) 

Any dialysis treatment to be done at home requires an assessment of the home by a dialysis nurse. The nurse assesses if the patient will be able to aseptically perform their treatments in their home environment. A clean space in the home must be devoted to the patient’s dialysis treatments. If pets or plants are present, they must be kept out of the room to prevent infection risks. The patient and/or care partner is trained by the nurse to maintain aseptic technique when handling their supplies, equipment and initiating and terminating their treatment. They are also taught how to properly disinfect their equipment and household items utilized in the treatment.  

The positive benefits associated with home hemo are being able to perform dialysis treatments in the comfort of the patient’s own home; flexible scheduling, fewer trips to the dialysis clinic, and in the case of the conventional and nocturnal options, slightly more liberal diet and fluid allowance since treatments are performed more frequently. Patients are shown to thrive more when dialyzing at home. Generally, the more dialysis a patient receives, the more waste removal and balancing of electrolytes occurs; thus, these patients usually feel better and have a better quality of life. Patients tend to sleep better, with decreased restless leg syndrome and neuropathy. And they have more energy day to day. Less medication is required to control blood pressure, anemia, and phosphorus levels. Morbidity and mortality rates are also decreased (1). 

The cons of home hemodialysis treatments include: 

• The physical space that the machine and supplies take up in the patient’s home 
• The absence of trained staff to perform the treatments 
• Shifting the responsibility solely to the patient or care partner 
• There could be fear of putting in one’s own needles. 
• In the case of nocturnal hemodialysis, having a care partner is nonnegotiable for safety reasons. 

The training time to safely perform treatments at home requires a commitment of weeks to months, depending on the progress of the patient and/or care partner. They will not be released home until the training nurse is confident that the treatments can be performed safely at home. This may mean a leave of absence from work or school to meet the training time requirements. 

Peritoneal dialysis is the treatment that most nephrologists and nurses would choose if they were diagnosed with renal failure. It is considered to be gentler on the body than hemodialysis. Because it is performed every day, patients report feeling better and having a more liberal diet and fluid restrictions. There are no needles used in PD, and patients feel more comfortable dialyzing in their home environment, at whatever time they choose. Cons include: 

• Having to dialyze daily 
• Potential complications such as peritonitis 
• Drain pain (pain in the abdomen when fluid is being emptied by the catheter pulling the fluid out) 
• Intolerance of fluid in the belly during the dwell period 
• Dialyzing in the home environment requires ample storage space for the supplies that are needed. Delivery of supplies can be more frequent if the patient has limited storage space. 

The benefit of a kidney transplant is that the patient no longer has to undergo dialysis treatment, and so their lives can almost return to life as it was prior to their kidney failure. It is important to remember that a kidney transplant is not a cure. If the same circumstances exist that caused renal failure in the first place, the transplanted kidney may not last long. While eating and drinking can return to normal, it is advised that the patient follow a heart-healthy diet (1). Even if the patient does everything perfectly, there is always a chance that the new kidney will fail eventually, and the patient may find themselves having to decide which treatment option is best for them again. It is the hope that the kidney will last for years; however, many patients require more than one transplant in their lifetime. Kidney transplant recipients must take anti-rejection medications so that their body’s immune system does not attack the new kidney. These medications can be expensive, have side effects, and can leave the patient susceptible to illness. In any surgery, there are inherent risks, and the kidney transplant surgery is no different.

Future State of Patients with ESRD 

1 in 3 adults is at risk for kidney disease (1). Currently, there is a huge urgency to increase transplants and make home therapies the prevalent modality for ESRD patients. There will not be enough chairs available in clinics to treat the potential pipeline of dialysis patients incenter. 

In 2019, President Trump addressed this issue and set 3 goals in an executive order:  

1. Prioritize a reduction of new ESRD cases by 25% in 10 years. 
2. Increase home therapy and/or transplant utilization to 80% by 2025. 
3. Double kidneys available for transplant by 2030.  

In the meantime, there is ongoing research to strengthen the fight against kidney disease. Through the National Kidney Foundation, there are grants and clinical trials underway to find a cure or better treatment options for the CKD population. Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines were established about 20 years ago to improve the diagnosis and treatment of kidney disease, and that has had profound effects in the lives of thousands of patients.  

Conclusion 

In conclusion, there is a lot to know about renal failure and the renal failure stages. This course provided an overview of chronic renal failure stages, causes, treatments, and outcomes. Though a lot has been learned through research and advocacy efforts, there is much more to be learned about how to slow this disease’s prevalence and progression. 

➁ Complete Survey

Give us your thoughts and feedback

➂ Click Complete

To receive your certificate