End Stage Renal Failure (ESRD)

End stage renal disease (ESRD) is the last stage (stage five) of chronic kidney disease (CKD). This means kidneys are only functioning at 10 to 15 percent of their normal capacity. Kidneys are important organs that contribute to your overall well-being.  When kidney function is this low, they cannot effectively remove waste or excess fluid from your blood. Kidneys are also responsible for other functions that support the body, such as balancing electrolytes and producing certain hormones. When chronic kidney disease develops into ESRD, dialysis or a kidney transplant is necessary to stay alive.

Urine production

Fully functioning kidneys clean the blood of wastes and excess fluid. These items are eliminated through urine. Because kidneys with ESRD do a very poor job of removing these items, waste and fluid build up in the body to unhealthy levels. Accumulated waste in the bloodstream can make you feel sick. This is a condition called uremia. When fluid is not removed from the body, tissues will swell and lead to a condition called edema. Excess fluid in the bloodstream can also increase blood pressure.

Electrolytes

Electrolytes are minerals and salts such as magnesium, sodium and potassium. They are found in foods you eat and are essential to good health. However, too much or too little of these electrolytes can make you sick. Healthy kidneys make sure these levels are balanced. But kidneys affected with ESRD cannot regulate the levels of electrolytes. When this happens, changes in your body’s functions occur. Sodium can cause tissues to retain water. Excess potassium can cause an abnormal heart rhythm, which may lead to cardiac arrest. Too little magnesium can affect your heartbeat and cause changes in your mental state; too much can leave you feeling weak.

Hormones

Healthy kidneys make certain hormones. One is a parathyroid hormone (PTH) that activates vitamin D into a substance called calcitriol. Calcitriol helps your body absorb calcium. If your body cannot absorb calcium, your bones become weak and may break. Another hormone your kidneys manufacture is erythropoietin. Erythropoietin tells your body to make red blood cells, which carry oxygen to the cells throughout your body. If your red blood cell count is low, you may develop anemia, which will leave you feeling weak and fatigued.

Enzymes

Renin is an enzyme kidneys produce. Renin helps the body regulate sodium and potassium levels in the blood, as well as help regulate blood pressure. When blood pressure drops, renin is released and starts a chemical reaction in the body that will produce a substance called angiotensin. Angiotensin causes your blood vessels to narrow, or constrict. This helps raise blood pressure. Angiotensin also signals the adrenal glands (found at the top of your kidneys) to release a hormone called aldosterone. Aldosterone tells the kidneys to retain salt (sodium) and excrete potassium. By retaining salt, the body keeps more water in the system. This water raises the blood volume and blood pressure. Kidneys affected by ESRD sometimes make too much renin, which keeps blood pressure levels high. This kind of high blood pressure can be difficult to treat.

Regular dialysis treatment, following your renal diet and taking prescribed medications can go a long way in managing ESRD. If you have been diagnosed with end stage renal disease, it is important to follow your health care team’s advices regarding treatment. 

What are the symptoms of renal failure?

The symptoms for acute and chronic renal failure may be different. The following are the most common symptoms of acute and chronic renal failure. However, each individual may experience symptoms differently. Symptoms may include:

Acute: (Symptoms of acute renal failure depend largely on the underlying cause.)

·         Hemorrhage

·         Fever

·         Weakness

·         Fatigue

·         Rash

·         Diarrhea or bloody diarrhea

·         Poor appetite

·         Severe vomiting

·         Abdominal pain

·         Back pain

·         Muscle cramps

·         No urine output or high urine output

·         History of recent infection (a risk factor for acute renal failure)

·         Pale skin

·         Nosebleeds

·         History of taking certain medications (a risk factor for acute renal failure)

·         History of trauma (a risk factor for acute renal failure)

·         Swelling of the tissues

·         Inflammation of the eye

·         Detectable abdominal mass

·         Exposure to heavy metals or toxic solvents (a risk factor for acute renal failure)

Chronic:

·         Poor appetite

·         Vomiting

·         Bone pain

·         Headache

·         Insomnia

·         Itching

·         Dry skin

·         Malaise

·         Fatigue with light activity

·         Muscle cramps

·         High urine output or no urine output

·         Recurrent urinary tract infections

·         Urinary incontinence

·         Pale skin

·         Bad breath

·         Hearing deficit

·         Detectable abdominal mass

·         Tissue swelling

·         Irritability

·         Poor muscle tone

·         Change in mental alertness

·         Metallic taste in mouth

The symptoms of acute and chronic renal failure may resemble other conditions or medical problems. Always consult your doctor for a diagnosis.

How is renal failure diagnosed?

In addition to a physical examination and complete medical history, diagnostic procedures for renal failure may include the following:

·         Blood tests. Blood tests will determine blood cell counts, electrolyte levels, and kidney function

·         Urine tests

·         Renal ultrasound (also called sonography). A noninvasive test in which a transducer is passed over the kidney producing sound waves which bounce off the kidney, transmitting a picture of the organ on a video screen. The test is use to determine the size and shape of the kidney, and to detect a mass, kidney stone, cyst, or other obstruction or abnormalities.

·         Kidney biopsy. This procedure involves the removal of tissue samples (with a needle or during surgery) from the body for examination under a microscope; to determine if cancer or other abnormal cells are present.

·         Computed tomography scan (also called a CT or CAT scan). A diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce horizontal, or axial, images (often called slices) of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general X-rays. Contrast CT usually cannot be done when there is kidney failure. 

What is the treatment for acute and chronic renal failure?

Specific treatment for renal failure will be determined by your doctor based on:

·         Your age, overall health, and medical history

·         Extent of the disease

·         Type of disease (acute or chronic)

·         Underlying cause of the disease

·         Your tolerance for specific medications, procedures, or therapies

·         Expectations for the course of the disease

·         Your opinion or preference

Treatment may include:

·         Hospitalization

·         Administration of intravenous (IV) fluids in large volumes (to replace depleted blood volume)

·         Diuretic therapy or medications (to increase urine output)

·         Close monitoring of important electrolytes such as potassium, sodium, and calcium

·         Medications (to control blood pressure)

·         Specific diet requirements

In some cases, patients may develop severe electrolyte disturbances and toxic levels of certain waste products normally eliminated by the kidneys. Patients may also develop fluid overload. Dialysis may be indicated in these cases.

Treatment of chronic renal failure depends on the degree of kidney function that remains. Treatment may include:

·         Medications (to help with growth, prevent bone density loss, and/or to treat anemia)

·         Diuretic therapy or medications (to increase urine output)

·         Specific diet restrictions or modifications

·         Dialysis

·         Kidney transplantation

What is dialysis?

Dialysis is a procedure that is performed routinely on persons who suffer from acute or chronic renal failure, or who have ESRD. The process involves removing waste substances and fluid from the blood that are normally eliminated by the kidneys. Dialysis may also be used for individuals who have been exposed to or ingested toxic substances to prevent renal failure from occurring. There are two types of dialysis that may be performed, including the following:

·         Peritoneal dialysis. Peritoneal dialysis is performed by surgically placing a special, soft, hollow tube into the lower abdomen near the navel. After the tube is placed, a special solution called dialysate is instilled into the peritoneal cavity. The peritoneal cavity is the space in the abdomen that houses the organs and is lined by two special membrane layers called the peritoneum. The dialysate is left in the abdomen for a designated period of time which will be determined by your doctor. The dialysate fluid absorbs the waste products and toxins through the peritoneum. The fluid is then drained from the abdomen, measured, and discarded. There are three different types of peritoneal dialysis: continuous ambulatory peritoneal dialysis (CAPD), continuous cyclic peritoneal dialysis (CCPD), and intermittent peritoneal dialysis (IPD).

CAPD does not require a machine. Exchanges, often referred to as “passes,” can be done three to five times a day during waking hours. CCPD requires the use of a special dialysis machine that can be used in the home. This type of dialysis is done automatically, even while you are asleep. IPD uses the same type of machine as CCPD, but treatments take longer. IPD can be done at home, but usually is done in the hospital.

Possible complications of peritoneal dialysis include an infection of the peritoneum, or peritonitis, where the catheter enters the body. Peritonitis causes fever and stomach pain. Your diet for peritoneal dialysis will be planned with a dietitian, who can help you choose meals according to your doctor’s orders.
Generally:

o    You may have special protein, salt, and fluid needs.

o    You may have special potassium restrictions.

o    You may need to reduce your calorie intake, since the sugar in the dialysate may cause weight gain.

·         Hemodialysis. Hemodialysis can be performed at home or in a dialysis center or hospital by trained healthcare professionals. A special type of access, called an arteriovenous (AV) fistula, is placed surgically, usually in your arm. This involves joining an artery and a vein together. An external, central, intravenous (IV) catheter may also be inserted, but is less common for long-term dialysis. After access has been established, you will be connected to a large hemodialysis machine that drains the blood, bathes it in a special dialysate solution which removes waste substances and fluid, then returns it to your bloodstream.

Hemodialysis is usually performed several times a week and lasts for four to five hours. Because of the length of time hemodialysis takes, it may be helpful to bring reading material, in order to pass the time during this procedure. During treatment you can read, write, sleep, talk, or watch TV.

At home, hemodialysis is done with the help of a partner, often a family member or friend. If you choose to do home hemodialysis, you and your partner will receive special training.

Possible complications of hemodialysis include muscle cramps and hypotension (sudden drop in blood pressure). Hypotension may cause you to feel dizzy or weak, or sick to your stomach. Side effects are avoided by following the proper diet and taking medications, as prescribed by your doctor. A dietitian will work with you to plan your meals, according to your doctor’s orders.
Generally:

o    You may eat foods high in protein such as meat and chicken (animal proteins).

o    You may have potassium restrictions.

o    You may need to limit the amount you drink.

o    You may need to avoid salt.

o    You may need to limit foods containing mineral phosphorus (such as milk, cheese, nuts, dried beans, and soft drinks).

Long-term outlook for ESRD

People with ESRD are living longer than ever. Dialysis treatments (both hemodialysis and peritoneal dialysis) are not cures for ESRD, but will help you feel better and live longer. Over the years, ESRD can cause other problems such as bone disease, high blood pressure, nerve damage, and anemia (having too few red blood cells). You should discuss prevention methods and treatment options for these potential problems with your doctor.

 

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