Handbook of dialysis therapy 6th edition 2023

Contributors Cahyani Gita Ambarsari, MD, FIPNA, FISPD Clinical Nephrology Fellow Princess Alexandra Hospital and Queensland Children’s Hospital, Brisbane, QLD, Australia Member of Medica

DIGITAL VERSION Included

2

HANDBOOK OF

DIALYSIS THERAPY

HANDBOOK OF

DIALYSIS THERAPY SIXTH EDITION

Allen R Nissenson, MD, FACP

Emeritus Professor of Medicine

David Geffen School of Medicine at UCLA

Los Angeles, CA, United States

Head, Division of Nephrology Department of Medicine University of Washington Seattle, WA, United States

Joshua Zaritsky, MD, PhD Chief Pediatric Nephrology

St Chris Hospital for Children Professor of Pediatrics

Drexel University College of Medicine Philadelphia, PA, United States

1600 John F Kennedy Blvd.

Ste 1800

Philadelphia, PA 19103-2899

HANDBOOK OF DIALYSIS THERAPY, SIXTH EDITION ISBN: 978-0-323-79135-9

Copyright © 2023 by Elsevier, Inc All rights reserved.

Ch 9, “Safety Monitors in Hemodialysis,” copyrighted by Joanne D Pittard

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations, such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found on our website: www.elsevier.com/permissions This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Previous editions copyrighted 2002, 2008, and 2017.

Senior Content Strategist: Nancy Anastasi Duffy

Senior Content Development Specialist: Priyadarshini Pandey

Publishing Services Manager: Deepthi Unni

Senior Project Manager: Manchu Mohan

Book Designer: Ryan Cook

Printed in The United States of America.

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Notice

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors,

or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

This book is dedicated to the heroic patients and care givers who showed courage and perseverance during the COVID-19 pandemic and inspired us all.

Allen R Nissenson, MD

I would like to dedicate this edition of Handbook of Dialysis to my wife of ALMOST

50 years, Shawney, whose encouragement, support, and advice have made the journey to facilitate access to ESRD care for children of all ages possible, as well as our 4 children, one of whom (Jeffrey) is no longer with us, 11 grandchildren, 2 of whom aspire to become physicians AND 3 GREAT-GRANDCHILDREN They have tolerated my conflicting priorities over the years I appreciate their continued understanding.

Richard N Fine, MD

This book is dedicated to my wife, Kushi Mehrotra, who has stood patiently by

my side for 29 years, to our two children, Kunaal and Ria, who have grown into amazing young adults in the blink of an eye, and to my parents, Trijugi and Kamini Mehrotra, who are no longer with us but forever in our hearts.

Rajnish Mehrotra, MD, MS

I would like to dedicate this book to my children, Sarah and Ella.

Joshua J Zaritsky, MD, PhD

Contributors

Cahyani Gita Ambarsari, MD, FIPNA, FISPD

Clinical Nephrology Fellow

Princess Alexandra Hospital and Queensland Children’s

Hospital, Brisbane, QLD, Australia

Member of Medical Technology Indonesia Medical

Education and Research Institute (IMERI)

Consultant Paediatric Nephrologist

Paediatric Nephrology Division

Department of Child Health

Faculty of Medicine, Universitas Indonesia

Cipto Mangunkusumo Hospital, Jakarta

Icahn School of Medicine at Mount Sinai, New York

NY, United States

Evamaria Anvari, MD

Assistant Professor of Medicine

Cleveland Clinic Lerner College of Medicine of Case

Western Reserve University

Department of Kidney Medicine

Glickman Urological & Kidney Institute

FL United StatesAssociate Professor Department of Pediatrics University of Central Florida, Orlando

FL United States

Rossella Attini, MD, PhD

Physician Department of Obstetrics and Gynecology Città della Salute e della Scienza, Ospedale Sant’Anna

Turin Italy

Rose Mary Ayoob, MD

Associate Professor of PediatricsDivision of Pediatric NephrologyHoops Family Children’s Hospital at CabellHuntington Hospital

Joan C Edwards School of Medicine at Marshall University

Huntington, WV, United States

Justine Bacchetta, MD, PhD

Professor of Pediatrics Pediatric Nephrology, Reference Center for Rare Renal Diseases

Hospices Civils de Lyon, Bron France

viii Contributors

Rossana Baracco, MD

Associate Professor

Pediatrics, Division of Pediatric Nephrology

Central Michigan University College of Medicine,

Peritoneal Dialysis Program

University Health Network, Toronto

Research, Innovation and Brand Reputation

Ospedale di Bergamo, ASST-Papa Giovanni XXIII,

Legacy Transplant Services

Legacy Health Systems, Portland

OR

United States

Professor of Medicine (Retired)

Oregon Health & Science University, Portland

Mei Lin Z Bissonnette, MD, PhD, FRCPC

Clinical Associate Professor Department of Pathology and Laboratory Medicine University of British Columbia, St Paul’s Hospital Vancouver

BC Canada

Brendan Bowman, MD

Associate Professor Department of Medicine University of Virginia School of Medicine, Charlottesville

VA United States

Patrick D Brophy, MD, MHCDS

Chairman Pediatrics University of Rochester, Rochester

NY United States

Steven Brunelli, MD, MSCE

Vice President for Research DaVita Clinical Research DaVita, Inc, Minneapolis

MN United States

Contributors

Jonathan Casavant, PharmD, BCPS

Antimicrobial Stewardship Pharmacist

Pharmacy Clinical Services

VA Puget Sound HealthCare System, Seattle

Deepa H Chand, MD, MHSA

Executive Medical Director

Global Patient Safety

Novartis Gene Therapies, Bannockburn

IL United States

NY United States

Joline L.T Chen, MD, MS

Health Sciences Associate Clinical Professor Division of Nephrology and Hypertension University of California, Irvine, Irvine

CA United States

Wei Chen, MD

Associate Professor Department of Medicine Albert Einstein College of Medicine, Bronx

NY United StatesAdjunct Professor Department of Medicine University of Rochester School of Medicine and Dentistry, Rochester

NY United States

Andrew I Chin, MD

Health Science Clinical Professor Division of Nephrology, Department of Internal Medicine

University of California, Davis School of Medicine, Sacramento

CA United States

x Contributors

Yeoungjee Cho, MBBS (Hons), FRACP, PhD

Consultant Nephrologist

Associate Professor of Medicine, University of Queensland

Clinical Trialist (Australian Kidney Trials Network)

Department of Nephrology

Division of Medicine

Metro South Health

Princess Alexandra Hospital

Brisbane, QLD

Australia

William R Clark, MD

Professor of Engineering Practice

Davidson School of Chemical Engineering

Purdue University, W Lafayette

IN

United States

John H Crabtree, MD

Visiting Clinical Faculty

Division of Nephrology and Hypertension

Harbor-University of California Los Angeles Medical

Lucia Del Vecchio, MD

Department of Nephrology and Dialysis, Sant’Anna

Hospital, ASST Lariana

Como

Italy

Alonso R Diaz, MD

Nephrology Fellow

Division of Nephrology, Department of Internal Medicine

University of California, Davis School of Medicine,

CA United States

Claire Dunphy, PhD

Postdoctoral FellowPediatrics

Icahn School of Medicine at Mount SinaiNew York, NY

United States

Mohamed Elbokl, MBBCH

Clinical FellowNova Scotia Health AuthorityNephrology

Dalhousie UniversityHalifax, NS

Canada

Fabrizio Fabrizi, MD

Staff Nephrologist Division of Nephrology Maggiore Policlinico Hospital and Ca’ Granda IRCCS Foundation, Milano

Italy

Mohammed K Faizan, MD

Associate Professor Department of Pediatrics The Warren Alpert Medical School of Brown University, Providence, RI, United States

Division Director Pediatric Nephrology Hasbro Children’s Hospital, Providence

RI, United States

Contributors

Steven Fishbane, MD

Chief

Division of Kidney Diseases & Hypertension

Zucker School of Medicine at Hofstra/Northwell,

Nephrology and Hypertension

Vanderbilt University Medical Center, Nashville

TN

United States

Jorge Ignacio Fonseca-Correa, MD

Geriatric Nephrology Fellow

Department of Nephrology and Mineral Metabolism

Instituto Nacional de Ciencias Médicas y Nutrición

Department of Pediatrics, Division of Nephrology

McGill University, Montreal

QC

Canada

Pediatric Nephrologist Pediatrics

Montreal Children’s Hospital, Montreal

QC Canada

Seth B Furgeson, MD

Associate Professor Medicine

University of Colorado, Aurora

CO United StatesStaff Nephrologist Medicine

Denver Health, Denver

CO United States

Ashley M Gefen, MD

FellowDepartment of Pediatrics, Division of NephrologyCohen Children’s Medical Center

New Hyde Park, NYUnited States

Guido Gembillo, MD

Department of Clinical and Experimental Medicine, Unit

of Nephrology and Dialysis Policlinic G Martino, Messina Italy

F John Gennari, MD

Professor Emeritus Medicine

University of Vermont College of Medicine, Burlington

VT United States

Marc Ghannoum, MD

Associate Professor Specialized Medicine University of Montreal, Verdun Hospital, Montreal

QC Canada

Griet Glorieux, PhD

Professor Internal Medicine and Pediatrics, Nephrology Division Ghent University Hospital, Ghent

Belgium

Pediatric Kidney, Liver and Metabolic Diseases

Hannover Medical School, Hannover

Lower Saxony

Germany

Rainer Himmele, MD, MSSH

Head of Global Medical Information & Education

Fresenius Medical Care

Charlotte

NC

United States

Jean L Holley, AB, MD

Clinical Professor of Medicine

Consultant Pediatric Nephrologist

Great Ormond Street Hospital for Children, London

United Kingdom

T Alp Ikizler, MD, FASN

Catherine McLaughlin Hakim Chair in Vascular Biology

ON CanadaProfessor Medicine University of Toronto, Toronto

ON Canada

Kirsten L Johansen, MD

Professor of MedicineDepartment of MedicineUniversity of Minnesota School of MedicineDirector

Division of NephrologyHennepin HealthcareMinneapolis, MNUnited Sates

David W Johnson, PSM MBBS, FRACP, DMed (Res), FASN, FAHMS, PhD

Director of Metro South Integrated Nephrology and Transplant Services (MINTS)

Medical Director, Queensland Kidney Transplant ServiceProfessor of Medicine (University of Queensland)Professor of Population Health (University of Queensland)

Co-Director of Centre for Kidney Disease Research, Translational Research Institute

NHMRC Leadership FellowDepartment of NephrologyDivision of MedicinePrincess Alexandra HospitalMetro South HealthBrisbane, QLDAustralia

Kamyar Kalantar-Zadeh, MD, MPH, PhD

Professor and Chief Nephrology University of California Irvine, Orange

CA United States

Contributors

Pranay Kathuria, MD, FACP, FASN

Director, Division of Nephrology and Professor of

Medicine

Division of Nephrology and Hypertension

University of Oklahoma School of Medicine, Tulsa

OK

United States

Irfan Khan, MD

Board Certified in Pediatrics and Pediatric Critical Care

Medical Director of PICU/CVICU/ECMO

Pediatrics

Presbyterian Hospital, Albuquerque

NM

United States

Paul L Kimmel, MD, MACP, FRCP, FASN

Clinical Professor of Medicine

Emeritus George Washington University

Nephrology and Hypertension

Vanderbilt University School of Medicine,

Profesor of Medicine Medicine/Nephrology Duke University Medical Center, Durham

NC United States

Robin A Kremsdorf, MD

Assistant Professor Department of Pediatrics The Warren Alpert Medical School of Brown University Providence, RI

United States

Martin Kreuzer, MD

Department of Pediatrics II Essen University Hospital, Essen North Rhine-Westphalia Germany

Mahesh Krishnan, MD, MPH, MBA, FASN

Group Vice President Research and Development DaVita Venture Group, Washington

DC United States

Martin K Kuhlmann, MD

Department of Internal Medicine—Nephrology Vivantes Klinikum im Friedrichshain, Berlin Germany

Danica Lam, BASc, MD

Division of Nephrology Humber River Hospital, Toronto

ON Canada

Department of Nephrology and Dialysis

A Manzoni Hospital ASST Lecco

Medical Director for Kidney Transplantaion

Department of Hospital and Specialty Medicine

Department of Medicine, Division of Nephrology

University of Toronto, Toronto

Nationwide Children’s Hospital/The Ohio

State University College of Medicine

Columbus, OH

United States

Harold J Manley, PharmD, FASN, FCCP

Senior Pharmacy Director Pharmacy

Dialysis Clinic Inc, Nashville

TN United States

Kevin J Martin, MB, BCh, FASN

Professor of Internal Medicine Division of Nephrology Saint Louis University, Saint Louis

MO United States

Nicola Matthews, FRCP(C)

Staff NephrologistDivision of NephrologyMackenzie HealthRichmond Hill, ONCanada

Juliet Mayes, BSc (Hons) Physiotherapy

Specialist Renal Physiotherapist Therapies Department

King’s College Hospital, London United Kingdom

Ian E McCoy, MD, MS

Assistant Professor Department of Medicine, Division of Nephrology University of California, San Francisco

San Francisco, CA United States

Christopher W Mcintyre, MD, PhD

Professor of Medicine, Medical Biophysics and Pediatrics

Department of Medicine University of Western Ontario, London

ON CanadaRobert Lindsay Chair of Dialysis Research and Innovation

University of Western Ontario, London, ON Canada

Division of Nephrology and Hypertension

Cincinnati Children’s Hospital Medical Center,

Department of Medicine, Division of Nephrology

Albert Einstein College of Medicine, Montefiore Medical

Liz Mooney, BA, MPA

Director of IT Strategy & Innovation

WV United StatesProfessor of Medicine Medicine, Sections of Nephrology and Geriatrics and Palliative Medicine

West Virginia University, Morgantown

WV United States

Vinay Narasimha Krishna, MBBS

Assistant Professor Department of Medicine, Division of Nephrology The University of Alabama at Birmingham, Birmingham

AL United States

Sharon J Nessim, MD, MSc

Nephrologist Department of Medicine, Division of Nephrology Jewish General Hospital, Montreal

QC CanadaAssociate Professor Medicine

McGill University, Montreal, QC Canada

Allen R Nissenson, MD, FACP

Emeritus Professor of Medicine David Geffen School of Medicine at UCLA, Los Angeles, CA

California United States

Vandana Dua Niyyar, MD

ProfessorDepartment of Medicine Division of Nephrology Emory UniversityAtlanta, GAUnited States

Unit Intensive Adult Care

National Institute of Perinatology, Mexico City

Mexico

Internal Medicine

Unit Intensive Adult Care

National Institute of Perinatology, Mexico City

Giorgina B Piccoli, MD

Néphrologie et Dialyse Centre Hospitalier Le Mans

Le Mans France

Connie M Rhee, MD, MSc

Associate Professor of Medicine Department of Medicine, Division of Nephrology, Hypertension and Kidney Transplantation University of California Irvine School of Medicine, Orange

CA United States

Ezequiel Ridruejo, MD

Chief Hepatology Section, Department of Medicine Centro de Educación Médica e Investigaciones Clínicas Norberto Quirno “CEMIC”, Ciudad Autónoma de Buenos Aires

Clinical Pharmacology and Toxicology

Royal Prince Alfred Hospital, Sydney

NSW

Australia

Medical Director

NSW Poisons Information Centre

Sydney Children’s Hospital Network, Sydney

NSW

Australia

Staff Specialist

Clinical Pharmacology and Toxicology

St Vincent’s Hospital, St Vincent’s

Nephrology, Hospital Universitario Reina Sofia

Maimonides Institute of Biomedical Research (IMIBIC)

MI United StatesChief Medical Officer Administration Children’s Hospital of Michigan, Detroit

MI United States

Claudio Ronco, MD

Full Professor of Nephrology School of Medicine, Department of Medicine Università degli Studi di Padova, Padova Italy

Director Department of Cardiovascular Medicine Division of Nephrology Dialysis & Transplantation International Renal Research Institute (IRRIV) San Bortolo Hospital, Vicenza

Italy

Mitchell H Rosner, MD

Professor of Medicine Medicine

University of Virginia Health System, Charlottesville

VA United States

John H Sadler, MD

Associate Professor (retired) Medicine-Nephrology University of Maryland, Baltimore

MD United StatesPresident & CEO Independent Dialysis Foundation, Baltimore

MD United States

Valeria Saglimbene, PhD

School of Public Health University of Sydney, Sydney NSW

Australia

xviii Contributors

Fabio R Salerno, MD

PhD Candidate

Department of Medical Biophysics

Western University, London

Internal Medicine—Unit of Nephrology and Dialysis

G Martino University Hospital, Messina

Department of Pediatrics, Division of Nephrology

Cohen Children’s Medical Center

New Hyde Park, NY

Institute of Molecular Medicine

Feinstein Institutes for Medical Research

Manhasset, NY

United States

Hitesh H Shah, MD

Director, Nephrology Fellowship Program

Division of Kidney Diseases and Hypertension,

Department of Medicine

Donald and Barbara Zucker School of Medicine at

Hofstra/Northwell, Great Neck

NY

United States

Professor of Medicine Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead

NY United States

Jenny I Shen, MD, MS

Assistant Professor Department of Medicine, Division of Nephrology and Hypertension

Harbor-UCLA Medical Center, Torrance

CA United States

NY United StatesMedical Director Hemodialysis New York-Presbyterian Hospital/Weill Cornell, New York

NY United States

New Hyde Park, NYUnited StatesAssistant ProfessorDepartment of PediatricsZucker School of Medicine at Hofstra/NorthwellUniondale, NY

United States

Paediatric Nephrology Center

Hong Kong Children’s Hospital, Kowloon

Division of Pediatric Nephrology

Nationwide Children’s Hospital/The Ohio State University

Italy

Cheuk-Chun Szeto, MD, FRCP

Professor Department of Medicine & Therapeutics The Chinese University of Hong Kong, Shatin Hong Kong

Isaac Teitelbaum, MD

Professor Medicine University of Colorado School of Medicine, Aurora

CO United StatesMedical Director Home Dialysis Program University of Colorado Hospital, Aurora

CO United States

Rebecca Thomas-Chen, MBBS, DM

Paediatric Nephrologist Nephrology

University Hospital of the West Indies, Kingston Jamaica

Associate Lecturer, Clerkship Coordinator Child and Adolescent Health

University of the West Indies, Kingston Jamaica

Ashita J Tolwani, MD

Professor Department of Medicine, Division of Nephrology University of Alabama at Birmingham, BirminghamAL

United States

Massimo Torreggiani, MD, PhD

Centre Hospitalier Le Mans Néphrologie et Dialyse Centre Hospitalier Le Mans, Le Mans France

Clinical Assistant Professor

Department of Medicine, Division of Allergy and

Cleveland Clinic Lerner College of Medicine of Case

Western Reserve University, Cleveland

OH

United States

Director of Interventional Nephrology

Department of Kidney Medicine

Glickman Urological & Kidney Institute, Cleveland

OH

United States

Director of Global Nephrology

Department of Kidney Medicine

Glickman Urological & Kidney Institute

OH

United States

Rudolph P Valentini, MD

Professor

Pediatrics, Division of Pediatric Nephrology

Central Michigan University College of Medicine, Detroit

Peter Noel Van Buren, MD

Associate Professor Internal Medicine, Division of Nephrology University of Texas Southwestern Medical Center, Dallas

TX United StatesChief Nephrology Section, Medical Service Dallas Veterans Affairs Medical Center, Dallas

TX United States

René G VanDeVoorde III, MD

Associate Professor Pediatrics

Vanderbilt University Medical Center, Nashville

TN United States

Raymond Vanholder, MD, PhD

Professor Internal Medicine and Pediatrics University Hospital Ghent, Ghent Select State

Belgium

Thanh-Mai Vo, MD

Training Program Director Division of Nephrology Saint Louis University, St Louis, MO United States

Bradley A Warady, MD

Professor of Pediatrics Department of Pediatrics University of Missouri-Kansas City School of Medicine, Kansas City

MO United StatesDirector, Division of Pediatric NephrologyDirector, Dialysis and Transplantation Department of Pediatrics

Children’s Mercy Kansas City, Kansas City

MO United States

Joslin Diabetes Center, Boston

MA United States

Jay B Wish, MD

Professor Department of Medicine, Division of Nephrology Indiana University School of Medicine, Indianapolis

IN United StatesChief Medical Officer for Outpatient Dialysis Division of Nephrology

Indiana University Health, Indianapolis

IN United States

Joshua J Zaritsky, MD, PhD

Chief Pediatric Nephrology

St Chris Hospital for ChildrenProfessor of Pediatrics

Drexel University College of MedicinePhiladelphia, PA

United States

xxiii

The delivery and financing of dialysis care have

contin-ued to evolve rapidly throughout the world The United

States has seen the continued consolidation of the dialysis

providers, with two large organizations now overseeing the

care of two-thirds of all patients In addition, younger as

well as older and sicker patients are now surviving multiple

chronic illnesses such as diabetes, hypertension, and

conges-tive heart failure and congenital diseases, and progressing

through chronic kidney disease (CKD) to end-stage kidney

disease (ESKD), entering dialysis, or seeking conservative

care In addition, in the United States, there has been a

major shift in government policy regarding kidney disease

with increased emphasis on kidney transplantation, home

dialysis, and the care of CKD patients prior to the

develop-ment of ESKD These have led to advances in care delivery

focusing on patient-centric, holistic care and emphasized

the need for care coordination and true integration of care

across providers and sites of care In such an integrated,

patient-centric world, an increasing number of providers

are taking a financial risk in ensuring quality outcomes

Elsewhere in the world, the rising middle class in countries

such as India, China, and throughout the Middle East has

seen the concomitant rise of “life-style” illnesses, including

obesity, hypertension, and diabetes, and ultimately CKD

and ESKD, putting pressure on care providers and

govern-ments to deliver and pay for the care of millions of patients

The increasing affluence has also facilitated the extension of

CKD and ESKD care to infancy and early childhood

The objective of the initial edition of Dialysis Therapy,

published in 1986, was to enlist the involvement of

preem-inent individuals in areas of clinical dialysis to address, in

a succinct fashion, the pertinent clinical problems

encoun-tered in adults and children undergoing dialysis The intent

was to provide a “how-to” approach to help the potential

reader solve specific patient problems Dialysis Therapy

was developed to help nephrologists (pediatric and adult), nurses, technicians, and other members of the health care team resolve the myriad problems confronting the patients undergoing dialysis

Over 30 years have passed since the first edition of this book was published, but the goals remain the same To pro-vide those who care for CKD and ESKD patients a simple, readily accessible resource to enable the highest quality care for patients

The current format has been substantially updated to enable easier access to information and searching for key topics New chapters and authors have been added, and we have again paid particular attention to the readability of the text, tables, and figures Resizing of the book to make it more portable and the abundant use of color are additional enhancements

We wish to thank all of our contributors for their standing work and hope that this book will be a useful reference for physicians, nurses, technicians, dieticians, social workers, and administrators, all of whom assidu-ously attempt to optimize the clinical care of the CKD and ESKD population The editors wish to thank Nancy Duffy, Meghan Andress, Priyadarshini Pandey, Ryan Cook, and Manchu Mohan, from Elsevier, whose invaluable assistance made the publication of this text possible

out-Allen R Nissenson, MD Richard N Fine, MD Rajnish Mehrotra, MD, MS Joshua J Zaritsky, MD, PhD

Editors

Contents

PART I: Dialysis Therapy for Adults

Section 1: Overview of ESKD

1 Demographics of the End-Stage Renal Disease

Patient, 3

James B Wetmore and Kirsten L Johansen

2 Uremic Toxicity, 16

Raymond Vanholder and Griet Glorieux

3 Initiation of Dialysis Therapy, 45

Matthew B Rivara

Section 2: Hemodialysis

4 Urea Kinetic Modeling for Guiding

Hemodialysis Therapy in Adults, 56

Alonso R Diaz and Andrew I Chin

5 The Dialysis Prescription, 67

Steven Brunelli

6 Selecting a Dialyzer: Technical and Clinical

Considerations, 72

William R Clark and Claudio Ronco

7 Water Treatment Equipment for In-Center

David I Ortiz-Melo and Eugene C Kovalik

11 Common Clinical Problems in Hemodialysis, 126

Brendan Bowman and Mitchell H Rosner

12 Hemofiltration and Hemodiafiltration, 135

Martin K Kuhlmann

13 Wearable and Implantable Renal Replacement Therapy, 141

William Henry Fissell IV

14 Home Preparation and Installation for Home Hemodialysis, 149

Timothy Koh Jee Kam and Christopher T Chan

15 Vascular Access, 154

Charmaine E Lok and Vandana Dua Niyyar

16 Cannulation of Arteriovenous Vascular Access: Science and Art, 165

xxvi Contents

18 Noninfectious Complications From Vascular

Access, 192

Tushar J Vachharajani and Evamaria Anvari

19 Infectious Complications From Vascular

Access, 198

Molly Fisher and Michele H Mokrzycki

Section 3: Peritoneal Dialysis

20 Determination of Continuous Ambulatory

Peritoneal Dialysis and Automated Peritoneal

Dialysis Prescriptions, 212

Seth B Furgeson and Isaac Teitelbaum

21 Peritoneal Dialysis Cyclers and Other

Mechanical Devices, 216

Rainer Himmele

22 Peritoneal Dialysis Solutions, 222

Cahyani Gita Ambarsari, Yeoungjee Cho,

and David W Johnson

23 Solute Management With Peritoneal

Dialysis, 230

Jenny I Shen

24 Volume Management With Peritoneal

Dialysis, 237

Jeffery Perl and Nicola Matthews

25 Peritoneal Access Devices, Placement

Techniques, and Maintenance, 254

Yu-Chi Lapid, Chaim Charytan, and Bruce Spinowitz

29 Dialysate Leaks with Peritoneal Dialysis, 284

Bogdan Momciu and Joanne M Bargman

30 Hydrothorax and Peritoneal Dialysis, 288

Mohamed Elbokl and Joanne M Bargman

31 Abdominal Catastrophes, Peritoneal Eosinophilia, and Other Unusual Events in Peritoneal

Dialysis, 292

Rajnish Mehrotra and Pranay Kathuria

32 Metabolic Complications of Peritoneal Dialysis, 296

Serpil Muge Deger, Berfu Korucu, and T Alp Ikizler

35 Intradialytic Parenteral Nutrition and Intraperitoneal Nutrition, 315

Ramanath Dukkipati, Annamarie Rodriguez, and Kamyar Kalantar-Zadeh

36 Nutritional Management in Peritoneal Dialysis, 332

Joline L.T Chen and Kamyar Kalantar-Zadeh

37 Anemia and Its Treatment in Patients With End-Stage Kidney Disease, 341

Hitesh H Shah and Steven Fishbane

38 Resistance to Erythropoiesis Stimulating Agent (ESA) Treatment, 351

Francesco Locatelli and Lucia Del Vecchio

39 Chronic Kidney Disease–Mineral and Bone Disorder, 363

Wei Chen and David Bushinsky

40 Phosphate Management in Patients with End-Stage Kidney Disease, 372

Antonio Bellasi and Geoffrey A Block

Contents

41 Use of Vitamin D Sterols and Calcimimetics

in Patients With End-Stage Renal

Disease, 378

Ezequiel Bellorin-Font, Thanh-Mai Vo, and Kevin J Martin

42 Parathyroidectomy, 381

Mariano Rodriguez

43 Acquired Cystic Kidney Disease, 389

Anthony Chang and Mei Lin Z Bissonnette

Section 5: Management of Co-Existing

Illnesses and Special Populations

44 The Challenges of Blood Pressure Control

in Hemodialysis Patients, 393

Peter Noel Van Buren

45 Arrhythmias in Hemodialysis

Patients, 406

Claudio Rigatto and Patrick S Parfrey

46 Management of Ischemic Heart Disease,

Heart Failure, and Pericarditis in Patients

Undergoing Long-Term Dialysis, 413

Ian E McCoy

47 Avoidance and Treatment of Cardiovascular

Disease in Dialysis, 421

Christopher W Mcintyre and Fabio R Salerno

48 Management of Dyslipidemia in Long-Term

Dialysis Patients, 430

Valeria Saglimbene, Suetonia C Palmer,

and Giovanni F.M Strippoli

49 End-Stage Kidney Failure in the Diabetic

Patient, 434

Mark E Williams

50 Care of Elderly Dialysis and End-Stage Kidney

Disease Patients, 452

Jorge Ignacio Fonseca-Correa, Danica Lam,

and Sarbjit Vanita Jassal

51 Liver Disease and Gastrointestinal

Disorders in Dialysis Patients, 460

Fabrizio Fabrizi, Roberta Cerutti, and Ezequiel Ridruejo

52 Abnormalities of Thyroid Function in Chronic Dialysis Patients, 466

Connie M Rhee

53 Care of the Human Immunodeficiency Virus–Infected End-Stage Kidney Disease Patient, 481

Luis G Tulloch-Palomino, Jonathan Casavant, and Rudolph A Rodriguez

54 COVID-19 and Dialysis Patients, 491

Jeffrey Silberzweig and Alan S Kliger

55 Psychosocial Issues in Patients Treated With Dialysis, 497

Daniel Cukor, Stephanie L Donahue, and Paul L Kimmel

56 Evaluation and Treatment of Sexual Dysfunction, 507

Biff F Palmer

57 Pregnancy in Dialysis Patients, 513

Giorgina B Piccoli, Rossella Attini, Massimo Torreggiani, and Alejandra Orozco-Guillén

58 Principles of Drug Usage in Dialysis Patients, 530

Joseph B Lockridge, William M Bennett, and Ali Olyaei

59 Medication Management, 574

Harold J Manley

60 Physical Activity, Function, and Exercise-Based Rehabilitation for People on Dialysis, 582

Juliet Mayes, Pelagia Koufaki, and Sharlene Anuska Greenwood

61 Physical, Psychosocial, and Vocational Rehabilitation of Patients Undergoing Long-Term Dialysis, 590

John H Sadler

62 Preventive Care in End-Stage Renal Disease, 596

Jean L Holley

xxviii Contents

Section 6: Systems Management for the Care

of Dialysis Patients

63 Ethical Considerations in the Care of

Dialysis Patients: The New

Paradigm, 606

Alvin H Moss

64 Improving Outcomes for End-Stage Renal

Disease Patients: Shifting the Quality

Liz Mooney, Adam Weinstein, and Mahesh Krishnan

Section 7: Acute Kidney Injury and

Poisonings

67 Continuous Renal Replacement Therapies for

Acute Kidney Injury, 637

Etienne Macedo and Ravindra L Mehta

68 Anticoagulation for Continuous Renal

Replacement Therapy, 653

Vinay Narasimha Krishna and Ashita J Tolwani

69 Treatment of Poisoning with Extracorporeal

Methods, 659

Marc Ghannoum and Darren M Roberts

PART II: Dialysis Therapy for Children

70 Vascular Access and Peritoneal

Dialysis Catheter Placement in

Children, 669

Rossana Baracco, Deepa H Chand, Bipan Chand,

and Rudolph P Valentini

71 Infant Hemodialysis, 680

Deborah Stein

72 Urea Kinetic Modeling for Hemodialysis Prescription in Children, 684

Avram Z Traum and Michael J.G Somers

73 Alternate Hemodialysis Prescriptions in Children, 689

Martin Kreuzer and Dieter Haffner

75 Prescribing Peritoneal Dialysis in Children, 700

René G VanDeVoorde III

76 Nutritional Management of Children Undergoing Peritoneal Dialysis, 705

Rebecca Thomas-Chen and Bethany J Foster

77 Peritoneal Dialysis in Neonates and Infants, 712

Joshua J Zaritsky and Bradley A Warady

78 Dialysis for Inborn Errors of Metabolism, 719

Euan Soo and Franz Schaefer

79 Neurocognitive Function in Pediatric Dialysis, 724

Mohammed K Faizan and Robin A Kremsdorf

80 Growth in Children With End-Stage Kidney Disease, 729

Emily Stonebrook, Rose Mary Ayoob, and John D Mahan

81 Adequacy of Peritoneal Dialysis/Assessing Peritoneal Function in Pediatric

Patients, 741

Vimal Chadha and Bradley A Warady

82 Continuous Renal Replacement Therapy in Pediatric Patients, 749

Irfan Khan and Patrick D Brophy

Contents

83 Prevention and Treatment of Bone Disease in

Pediatric Dialysis Patients, 768

Justine Bacchetta and Katherine Wesseling-Perry

84 Management of Anemia in Children

Undergoing Dialysis, 778

Carlos E Araya and Joshua J Zaritsky

85 Prevention and Treatment of Cardiovascular

Complications in Children Undergoing

Dialysis, 789

Mark M Mitsnefes

86 Infectious Complications in Children Undergoing Dialysis, 794

Ashley M Gefen, Pamela S Singer, and Christine B Sethna

87 Caring for the Teenager in an Adult Unit, 804

Claire Dunphy and Rachel A Annunziato Index, 809

HANDBOOK OF

DIALYSIS THERAPY

Dialysis Therapy for Adults

Overview of ESKD

End-stage kidney disease (ESKD) constitutes an ever-

increasing threat to public health Since the publication

of the last edition of this book in 2015, complex trends

have continued to evolve in the epidemiology of ESKD

and maintenance dialysis In this chapter, we highlight how

incidence rates of treated ESKD have increased globally, a

phenomenon that will almost certainly continue as low- and

middle-income countries undergo economic growth and

experience improvements in access to health care, including

dialysis In many developing countries, the challenge posed

by the growth of the incident ESKD population will

there-fore be to overcome the barriers hindering the creation of

an adequate dialysis infrastructure For many high-income

countries, the overall growth in the population receiving

dialysis has been fueled mainly by an increase in prevalent

patients receiving maintenance dialysis, although incidence

rates have also continued to increase in many such countries

Prevalent dialysis patients in the United States, for example,

are now living substantially longer than they did a decade

ago In developed countries, then, the struggle will be to

provide healthcare for ever-aging populations with ESKD

and multiple comorbid conditions In developing and

de-veloped countries, policy makers and public health officials

face major challenges in confronting the growth of ESKD

In this chapter, we review demographic data from the

United States and other counties to provide background

for subsequent chapters Most U.S data are derived from

the United States Renal Data System (USRDS) (

www.us-rds.org), which also collects data from some other countries

that contribute to this registry

Incidence and Prevalence of ESKD

International data on treated ESKD incidence and

prev-alence are published annually in the USRDS Annual

Data Report “Treated” ESKD refers to the provision of

life- sustaining maintenance dialysis (typically, in-center

hemodialysis, home hemodialysis, peritoneal dialysis) and kidney transplantation Note that the quality and complete-ness of international data are likely to vary substantially by country As such, the data presented should not be viewed

as definitive Nevertheless, they can provide the foundation for inferences about overarching trends

Worldwide, the incidence rate of treated ESKD varies tremendously (Fig. 1.1) Incidence rates reported by par-ticipating countries in 2018 are shown per million popu-lation (pmp) by country or region in Fig. 1.2 The Jalisco state in Mexico (594 pmp) and Taiwan (523 pmp) have the highest incidence rates, followed by Hungary (508 pmp) and the United States (395 pmp) Several developing coun-tries or areas, many of which have large populations, have extremely high incidence rates, such as the Mexican states

of Jalisco and Aguascalientes (372 pmp), Thailand (365 pmp), Malaysia (262 pmp), Indonesia (236), and Brazil (218 pmp)

The 10 countries with the largest growth in incidence rate between 2009–2010 and 2017–2018, plus the United States, are shown in Fig. 1.3 Growth over this period is par-ticularly striking in Asia, which contains 7 of the 10 coun-tries with the largest increases in incidence rates However,

6 of the 10 countries or regions with the largest growth in incidence rate are classified as lower- or middle-income areas Among developed countries, which generally pro-vide near-universal access to ESKD treatment (particularly maintenance dialysis), substantial differences exist: the an-nual growth in treated ESKD incidence rate between 2009 and 2018 remains very high in Hungary (39.9 pmp per annum), South Korea (19.4 pmp per annum), Singapore (12.8 pmp per annum), and Taiwan (11.1 pmp per an-num), and somewhat high in Greece (7.6 pmp per annum), Canada (4.4 pmp per annum), the United States (3.3 pmp per annum), and Hong Kong (an affluent part of China, 3.2 pmp per annum) Growth is more modest in Portugal (1.0 pmp per annum) and nonexistent in countries (Israel, Norway, Sweden, Italy, Bosnia and Herzegovina, Colombia, Chile, and Turkey)

1

4 PART I  Dialysis Therapy for Adults

2020 United States Renal Data System Annual Data Report Data source: Special analyses, USRDS ESRD Database Data presented only for countries from which relevant information was available All rates are unadjusted Data for Canada excludes Quebec Data for Italy representative of 38% of the ESRD patient population Data for Mexico includes Jalisco and Aguascalientes only Data for Japan includes dialysis patients only United Kingdom: England, Wales, Northern Ireland (Scotland data reported separately) Hungary data for incidence count include acute kidney injury NOTE: Data collection methods vary across countries, suggesting caution in making direct comparisons.

less than 100 100-200 201-300 301-400 401+

• Fig. 1.1 Geographic Variation in Incidence of Treated ESRD, by Country or Region, 2018.

ESRD incidence rate (per million population)

2020 United States Renal Data System Annual Data Report Data source: Special analyses, USRDS ESRD Database Data presented only for countries from which relevant information was available All rates are unadjusted Data for Canada excludes Quebec Data for Italy representative of 38% of the ESRD patient population Data for Japan includes dialysis patients only United Kingdom: England, Wales, Northern Ireland (Scotland data reported separately) Hungary data for incidence count include acute kidney injury NOTE: Data collection methods vary across countries, suggesting caution in making direct comparisons.

Jalisco (Mexico) Taiwan Hungary United States Aguascalientes (Mexico)

Thailand Singapore Rep of Korea Japan Greece Malaysia Portugal Indonesia Brazil Canada Israel Hong Kong Uruguay France Saudi Arabia Argentina Qatar Turkey Italy Albania Bosnia and Herzegovina United Kingdom Lithuania Kuwait Sweden Norway China Kazakhstan Finland Iceland Colombia Chile Bangladesh Ukraine South Africa

• Fig. 1.2 Incidence of Treated ESRD, by Country or Region, 2018.

CHAPTER 1 Demographics of the End-Stage Renal Disease Patient

The prevalence of treated ESKD, particularly the growth

in prevalence rates over the past several decades, is

prodi-gious Prevalence rates of treated ESKD are shown by

coun-try, pmp, in Fig.  1.4 Taiwan (3587 pmp), Japan (2653

pmp), the United States (2354 pmp), Singapore (2255

pmp), Thailand (2028 pmp), Portugal (2014 pmp), and South Korea (2006 pmp) all exceed a rate of 2000 pmp Average yearly change between 2009 and 2018 is shown in Fig. 1.5, which demonstrates the growth in the worldwide burden of treated ESKD over this period

ESRD incidence rate (per million population)

Bangladesh Thailand Hungary Rep of Korea Indonesia Brazil Singapore Malaysia Saudi Arabia Jalisco (Mexico) United States

0 100 200 300 400 500 600

Year

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

2020 United States Renal Data System Annual Data Report Data source: Special analyses, USRDS ESRD Database Data presented only for countries from which relevant information was available All rates are unadjusted (a) Ten countries having the highest percentage rise in 2017/18 versus 2009/10, plus the U.S NOTE: Data collection methods vary across countries, suggesting caution in making direct comparisons.

• Fig. 1.3 Countries or regions with the largest percentage increase in incidence of treated ESRD, plus the

United States, 2009–2010 versus 2017–2018.

Taiwan Japan United States Singapore Thailand Rep of Korea Jalisco (Mexico) Aguascalientes (Mexico)

Malaysia Canada Hong Kong Greece France Chile Israel Uruguay

Italy

Czech Republic Sweden United Kingdom Norway Turkey Brazil Finland Argentina Kuwait Saudi Arabia Lithuania Colombia Bosnia and Herzegovina

Iceland Hungary Qatar Indonesia Albania China Kazakhstan Ukraine South Africa Bangladesh

0 250 500 750 1000 1250 1500 1750 2000 2250 2500 2750 3000 3250 3500 3750

ESRD prevalence rate (per million population)

2020 United States Renal Data System Annual Data Report Data source: Special analyses, USRDS ESRD Database Data presented only for countries from which relevant information was available All rates are unadjusted Data for Canada excludes Quebec Data for Italy representative of 38% of the ESRD patient population

United Kingdom: England, Wales, Northern Ireland (Scotland data reported separately) NOTE: Data collection methods vary across countries, suggesting caution in making direct comparisons.

• Fig. 1.4 Prevalence of Treated ESRD, by Country or Region, 2018.

6 PART I  Dialysis Therapy for Adults

Particularly detailed information on the incidence and

prevalence of treated ESKD is available in the United

States Trends in the adjusted incidence of ESKD in the

United States are shown in Fig. 1.6 The annual number of

incident patients, shown by ESKD treatment modality in

Fig. 1.6A, reveals recent growth in the counts to 131,636

in 2018, representing a year-over-year increase of

approx-imately 2% (i.e., relative to 2017)—most of which is due

to growth in patients receiving maintenance

hemodialy-sis Adjusted incidence rate (accounting for growth in the

U.S population) was 374.8 pmp in 2018, however, a mere

0.2% increase from 2017 (Fig.  1.6B) This represents a

modest decrease from the incidence rates that characterized

the first decade of the millennium when rates routinely

ex-ceeded 400 pmp

Year-over-year changes in the prevalence of treated

ESKD in the United States are shown in Fig.  1.7 The

number of prevalent patients per year (Fig. 1.7A), shown

by ESKD treatment modality, demonstrates that the count

in 2018 was 785,883, roughly a 3% increase from 2017

Of these, 485,052 (61.7%) were receiving maintenance

in-center hemodialysis, 10,350 (1.3%) were receiving home

hemodialysis, 58,636 (7.5%) were receiving peritoneal

di-alysis, and 229,887 (29.3%) were living with a functioning

kidney transplant; 1958 (0.2%) were receiving a dialysis

modality that could not be determined from administrative

claims The year-over-year percentage growth has generally

declined since 2010 when the annual increase was 4%, but

the United States has continued to add > 20,000

individ-uals to the prevalent count annually since 2004 The

ad-justed prevalence rate (Fig. 1.7B) is 2242 pmp, representing

a 1.5% increase from the previous year Annual growth in

the prevalence rate has ranged between approximately 1%

and 2% since 2007, suggesting that the ESKD (and

there-fore the dialysis) population will continue to grow for the

foreseeable future

Incidence and prevalence rates are not evenly distributed geographically in the United States (Fig.  1.8) For exam-ple, adjusted ESKD incidence rates (Fig. 1.8A) are highest

in parts of the Ohio River Valley, southern Texas, southern and central inland California, and parts of the southeast Adjusted prevalence rates (Fig. 1.8B) reveal a similar, but not identical, pattern Prevalence also varies by demographic characteristics: adjusted rates of ESKD prevalence are grow-ing fastest in older populations (ages ≥ 65 years) and among Black Americans (Fig.  1.9A–B) The former finding sug-gests that older and possibly sicker patients are surviving longer on dialysis than in previous years The latter finding

is not surprising, as Black Americans receiving dialysis tend

to survive longer than members of other races (for reasons that remain uncertain)

Dialysis Initiation: Predialysis Care and Modality Selection

The transition from predialysis chronic kidney disease (CKD) to ESKD is an area of intense clinical and research interest In the United States, the percentage of patients with nephrology care in the year before the onset of treated ESKD varies substantially, as shown in Fig.  1.10, which illustrates this finding by Health Service Area Overall, in

2018 fewer than one-third of patients received nephrology care for more than a year prior to ESKD onset, and only about one-half received this care for more than 6 months, a situation that worsens with unemployment (Fig. 1.11) and other socioeconomic factors This is extremely disappoint-ing given the near-universal automated laboratory report-ing of estimated glomerular filtration rates (eGFR) in the United States If significant improvements in the care of CKD patients are to occur, overcoming barriers to nephrol-ogy care is imperative

500 1000 1500 2000 2500

2020 United States Renal Data System Annual Data Report Data source: Special analyses, USRDS ESRD Database Data presented only for countries from which relevant information was available All rates are unadjusted (a) Ten countries having the highest percentage rise in 2017/18 versus 2009/10, plus the U.S NOTE: Data collection methods vary across countries, suggesting caution in making direct comparisons.

• Fig. 1.5 Countries or regions with the largest percentage increase in prevalence of treated ESRD plus the

United States, 2009–2010 versus 2017–2018.

CHAPTER 1 Demographics of the End-Stage Renal Disease Patient

While the largest single group of individuals initiating

treatment for ESKD is those aged 45–64 (the vast

major-ity of whom initiate in-center hemodialysis), approximately

23% of the incident treated ESKD population is aged

≥ 75  years, a group that constitutes < 7% of the general

U.S population Likewise, African Americans, who

repre-sent approximately 12% of the general U.S population,

make up almost exactly one-quarter of the incident-treated

ESKD population (the vast majority of whom also initiate

in-center hemodialysis) Diabetes was the cause of incident

treated ESKD in approximately 47% of incident patients,

and hypertension was the cause in approximately 29%

Dialysis initiation at higher eGFR levels had been a

grow-ing trend in the United States between 2000 and 2010; this

trend began to reverse slightly in the last decade, but was

relatively unchanged between 2015 and 2018 (Fig. 1.12)

The slight decrease in eGFR levels at which patients are

ini-tiating may be the result of a seminal clinical trial

address-ing this issue The percentage of patients initiataddress-ing dialysis

with an eGFR of 5–10 mL/min/1.73 m2 has increased since

2011 However, efforts designed to promote initiation of

di-alysis at lower levels might allow more time for fistula

mat-uration, a potential benefit given that optimizing vascular access remains a vexing problem As shown in Fig. 1.13, the use of a catheter at hemodialysis initiation is the norm and, unfortunately, has decreased only slightly over time, from 82.4% in 2009 to 80.8% in 2018 Use of an arteriovenous fistula at hemodialysis initiation increased slightly over this period, from 14.4% to 16.2% Furthermore, most patients initiating hemodialysis in 2018 (65.2%) did so with a cath-

eter but without a maturing arteriovenous fistula or graft

Unfortunately, this represented an increase from 60.2% of patients in 2013 Although this failing is likely related to healthcare system issues and patient-level factors, nephrol-ogists and others involved in the care of patients with ad-vanced CKD must work to improve the rate of hemodialysis initiation with a fully developed arteriovenous access.Hemodialysis remains, by far, the most common di-alytic modality for the treatment of ESKD globally (Fig.  1.14), although in some countries transplantation

is used more commonly (as a percentage) than dialysis, including Norway, Finland, Sweden, the UK, several states in Mexico, and Hong Kong Countries and terri-tories with the largest total proportion of home-based,

Year

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

0 100 200 300 400 500

2020 United States Renal Data System Annual Data Report Data source: USRDS ESRD database.

B

• Fig.  1.6 (A) Number of Incident ESRD Patients, by Modality, 2000–2018 (B) Adjusted Incidence of

ESRD, 1990–2018.

8 PART I  Dialysis Therapy for Adults

compared to in-center based, therapies (that is,

perito-neal dialysis and home hemodialysis) are Hong Kong

(the only location where use exceeds 50%), the Mexican

states of Jalisco and Aguascalientes, Colombia, and, to a

lesser degree, Canada That some developing countries

have successfully implemented relatively high use of

peri-toneal dialysis is important, since the infrastructure

re-quirements for hemodialysis (the dialysis facility itself and

its expensive and complex reverse osmosis system) entail

substantial costs For developing countries, peritoneal

di-alysis may be the modality most suitable to the challenges

of a growing ESKD population

Home hemodialysis deserves particular comment In

the United States, use of home hemodialysis in prevalent

patients grew substantially over the past 10 years; between

2016 and 2018 alone, the prevalent population grew by

16% (Fig. 1.15) Patients receiving home hemodialysis

rep-resent a distinct clinical minority; if this therapy is to

be-come more widely utilized, studies examining the factors

associated with the adoption and, especially, sustainability

of home hemodialysis—and indeed of peritoneal dialysis as well—must be conducted

Comorbidity, Expected Survival, and Causes of Death

Mortality rates in patients receiving dialysis in the United States fell substantially between 2009 and 2018 As shown

in Fig. 1.16, adjusted mortality rates in patients receiving dialysis decreased from 190 pmp in 2009 to 161 pmp in

2018, a reduction of > 15% The improvement in ity among patients receiving peritoneal dialysis was approx-imately 20%, with the adjusted mortality rate decreasing from 164 pmp to 131 pmp It is important to note how-ever, that most of the decline in mortality rates occurred during the first half of this period, so future gains are far from assured

mortal-A decade of improvement in the annual mortality rate is particularly impressive given the burden of cardiovascular

Year

2020 United States Renal Data System Annual Data Report Data source: USRDS

Peritoneal Dialysis Transplant

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

0 100,000 200,000 300,000 400,000 500,000

Year

2020 United States Renal Data System Annual Data Report Data source: USRDS B

• Fig. 1.7 (A) Number of Prevalent ESRD Patients, by Modality, 2000–2018 (B) Adjusted Prevalence of

ESRD, 1990–2018.

CHAPTER 1 Demographics of the End-Stage Renal Disease Patient

disease (CVD) among patients receiving dialysis Percentages

of patients with key CVD diagnoses are shown in Fig. 1.17

The prevalence of CVD was 76.5% in patients receiving

hemodialysis and 65.0% in patients receiving peritoneal

dialysis The most common CVD diagnoses were: heart

failure (in 44.2% and 31.1% of patients receiving

hemodi-alysis and peritoneal dihemodi-alysis, respectively), coronary artery

disease (43.8% hemodialysis, 36.4% peritoneal dialysis),

and peripheral arterial disease (41.5% hemodialysis, 27.7%, peritoneal dialysis)

Despite improvement over time in mortality rates among patients receiving dialysis, the adjusted mortality rate in 2018

in patients receiving dialysis was far higher than for patients with other major medical conditions who were not receiving dialysis Adjusted mortality rates per thousand patient-years are shown in Fig. 1.18 for U.S Medicare beneficiaries aged

• Fig.  1.8 (A) ESRD Incidence Rate (Cases per Million People), by Health Service Area, 2017–2018

(B) ESRD Prevalence Rate (Cases per Million People), by Health Service Area, 2017–2018.

10 PART I  Dialysis Therapy for Adults

Year

0-17 18-44 45-64

65-74 75+

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

0 2000 4000 6000 8000

2020 United States Renal Data System Annual Data Report Data source: USRDS ESRD database

• Fig. 1.10 Prevalence (%) of > 12 Months of Pre–ESRD Nephrology Care Among Incident ESRD Patients,

by Health Service Area, 2017–2018.

Unemployed Other 0

2020 United States Renal Data System Annual Data Report Data source: USRDS ESRD database

and form CMS-2728 (ESRD Medical Evidence Report).

• Fig.  1.11 Duration of Pre–ESRD Nephrology Care Among Incident ESRD Patients, by Employment

2020 United States Renal Data System Annual Data Report Data source: USRDS ESRD database

and form CMS-2728 (ESRD Medical Evidence Report).

• Fig. 1.12 Estimated GFR (mL/min/1.73m²) Among Incident ESRD Patients, 2000–2018.

Catheter only Any Catheter

2020 United States Renal Data System Annual Data Report Data source: ESRD Medical Evidence

Report (CMS 2728) Incident patients with ESRD aged 18 years or older initiating hemodialysis between

January 1 and December 31 of each year.

• Fig. 1.13 Vascular Access Use at Hemodialysis Initiation, 2009–2018 AV, Arteriovenous.

2020 United States Renal Data System Annual Data Report Data source: Special analyses, USRDS ESRD Database

Data presented only for countries from which relevant information was available Denominator was calculated as the sum of patients receiving HD, PD, Home HD; does not include patients with other/unknown modality Data for

Canada excludes Quebec Data for Italy representative of 38% of the ESRD patient population United Kingdom: England, Wales, Northern Ireland (Scotland data reported separately) NOTE: Data collection methods vary across countries, suggesting caution in making direct comparisons.

CAPD/APD/IPD Home HD In-Center HD

• Fig. 1.14 Distribution of Dialysis Modality in Prevalent Patients with ESRD, by Country or Region, 2018.

Home Dialysis

Home Hemodialysis Peritoneal Dialysis

2020 United States Renal Data System Annual Data Report Data source: USRDS ESRD database

• Fig. 1.15 Number of Prevalent ESRD Patients Performing Home Dialysis, 2000–2018.

2020 United States Renal Data System Annual Data Report Data source: ESRD database Yearly period

prevalent ESRD patients 2009-2018 Age, sex, race, ethnicity, and ESRD cause were used in adjusted analyses.