TREATMENT OPTIONS FOR ESRD PATIENTS
Commonly accepted criteria for initiating patients on maintenance dialysis include the presence of uremic symptoms, th unresponsive to conservative measures, persistent extracellular volume expansion despite diuretic therapy, acidosis ref a bleeding diathesis, and a creatinine clearance or estimated glomerular filtration rate (GFR) below 10 mL/min per 1.73 estimating equations). Timely referral to a nephrologist for advanced planning and creation of a dialysis access, educati options, and management of the complications of advanced chronic kidney disease, including hypertension, anemia, aci hyperparathyroidism, is advisable.
In ESRD, treatment options include hemodialysis (in center or at home); peritoneal dialysis, as either continuous ambul (CAPD) or continuous cyclic peritoneal dialysis (CCPD); or transplantation (Chap. 276). Although there are geographic v remains the most common therapeutic modality for ESRD (>90% of patients) in the United States. In contrast to hemo is continuous, but much less efficient, in terms of solute clearance. While no large-scale clinical trials have been comple among patients randomized to either hemodialysis or peritoneal dialysis, outcomes associated with both therapies are s the decision of which modality to select is often based on personal preferences and quality-of-life considerations.
HEMODIALYSIS
Hemodialysis relies on the principles of solute diffusion across a semipermeable membrane. Movement of metabolic was down a concentration gradient from the circulation into the dialysate. The rate of diffusive transport increases in respon including the magnitude of the concentration gradient, the membrane surface area, and the mass transfer coefficient of is a function of the porosity and thickness of the membrane, the size of the solute molecule, and the conditions of flow o membrane. According to the laws of diffusion, the larger the molecule, the slower its rate of transfer across the membra as urea (60 Da), undergoes substantial clearance, whereas a larger molecule, such as creatinine (113 Da), is cleared les diffusive clearance, movement of waste products from the circulation into the dialysate may occur as a result of ultrafilt clearance occurs because of solvent drag, with solutes being swept along with water across the semipermeable dialysis .