Dialysis for Chronic Kidney Failure: A Review.

Jennifer E Flythe, Suzanne Watnick
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Abstract

Importance: More than 3.5 million people worldwide and 540 000 individuals in the US receive maintenance hemodialysis or peritoneal dialysis for the treatment of chronic kidney failure. The 5-year survival rate is approximately 40% after initiation of maintenance dialysis.

Observations: Hemodialysis and peritoneal dialysis remove metabolic waste and excess body water and rebalance electrolytes to sustain life. There is no recommended estimated glomerular filtration rate (eGFR) threshold for initiating dialysis, and patient-clinician shared decision-making should help determine when to initiate dialysis. Persistent signs and symptoms of uremia (eg, nausea, fatigue) and volume overload (eg, dyspnea, peripheral edema), worsening eGFR, metabolic acidosis, and hyperkalemia inform the timing of therapy initiation. A randomized clinical trial reported no mortality benefit to starting dialysis at higher eGFR (10-14 mL/min/1.73 m2) vs lower eGFR (5-7 mL/min/1.73 m2) levels. Observational data suggested no differences in 5-year mortality with use of hemodialysis vs peritoneal dialysis. Cardiovascular (eg, arrhythmias, cardiac arrest) and infection-related complications of maintenance dialysis are common. In the US, hemodialysis catheter-related bloodstream infections occur at a rate of 1.1 to 5.5 episodes per 1000 catheter-days and affect approximately 50% of patients within 6 months of catheter placement. Peritonitis occurs at a rate of 0.26 episodes per patient-year and affects about 30% of individuals in the first year of peritoneal dialysis therapy. Chronic kidney failure-related systemic complications, such as anemia, hyperphosphatemia, hypocalcemia, and hypertension, often require pharmacologic treatment. Hypotension during dialysis, refractory symptoms (eg, muscle cramps, itching), and malfunction of dialysis access can interfere with delivery of dialysis.

Conclusions and relevance: In 2021, more than 540 000 patients in the US received maintenance hemodialysis or peritoneal dialysis for treatment of chronic kidney failure. Five-year survival rate after initiation of maintenance dialysis is approximately 40%, and the mortality rate is similar with hemodialysis and peritoneal dialysis. Decisions about dialysis initiation timing and modality are influenced by patient symptoms, laboratory trajectories, patient preferences, and therapy cost and availability and should include shared decision-making.

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透析治疗慢性肾衰竭:回顾。
重要性:全球有 350 多万人和美国有 54 万人接受维持性血液透析或腹膜透析,以治疗慢性肾衰竭。开始维持性透析后,5 年存活率约为 40%:血液透析和腹膜透析可清除代谢废物和体内多余水分,并重新平衡电解质以维持生命。目前还没有推荐的启动透析的肾小球滤过率(eGFR)阈值,患者与医生共同决策应有助于确定何时启动透析。持续的尿毒症体征和症状(如恶心、乏力)、容量超负荷(如呼吸困难、外周水肿)、eGFR 恶化、代谢性酸中毒和高钾血症都有助于确定开始治疗的时机。一项随机临床试验报告显示,在较高的 eGFR(10-14 毫升/分钟/1.73 平方米)与较低的 eGFR(5-7 毫升/分钟/1.73 平方米)水平下开始透析对死亡率没有益处。观察数据表明,血液透析与腹膜透析的 5 年死亡率没有差异。维持性透析常见心血管(如心律失常、心脏骤停)和感染相关并发症。在美国,与血液透析导管相关的血流感染发生率为每 1000 个导管日 1.1 至 5.5 次,约 50%的患者在导管置入后 6 个月内会受到感染。腹膜炎的发病率为每名患者每年 0.26 次,在腹膜透析治疗的第一年中约有 30% 的患者会受到影响。慢性肾衰竭相关的全身并发症,如贫血、高磷血症、低钙血症和高血压,通常需要药物治疗。透析过程中的低血压、难治性症状(如肌肉痉挛、瘙痒)以及透析通路故障都会影响透析的进行:2021 年,美国有超过 54 万名患者接受维持性血液透析或腹膜透析治疗慢性肾衰竭。开始维持性透析后的五年存活率约为 40%,血液透析和腹膜透析的死亡率相似。透析启动时间和方式的决定受患者症状、实验室检查轨迹、患者偏好以及治疗成本和可用性的影响,应包括共同决策。
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期刊介绍: JAMA, published continuously since 1883, is an international peer-reviewed general medical journal. JAMA is a member of the JAMA Network, a consortium of peer-reviewed, general medical and specialty publications.
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