End-stage kidney disease

Disease Description (Causes and Symptoms)

• Definition: End-stage renal disease (ESRD) is a condition in which kidney function falls to approximately 10% or less of normal, making independent life support difficult and requiring renal replacement therapy (dialysis or kidney transplantation).
• Causes: Mainly progression of chronic kidney failure (diabetic nephropathy, chronic glomerulonephritis, hypertensive kidney disease, etc.); rarely, irreversible acute kidney failure may progress directly to this stage.
• Summary of pathophysiology: Extensive loss of renal tubules and glomeruli → decreased glomerular filtration rate (GFR) → accumulation of waste products (uremic toxins), impaired electrolyte, acid-base, and fluid regulation, anemia (decreased erythropoietin), abnormal bone metabolism (renal osteodystrophy), and immune and hemostatic disorders, among others.
• Main symptoms: Anuria/decreased urine output, generalized edema (weight gain, shortness of breath), fatigue, loss of appetite, nausea, vomiting, itching (pruritus), bleeding tendency (uremic platelet dysfunction), bruising, bloody stool, coma/decreased consciousness (severe uremia), pericardial effusion, respiratory failure, etc.
• Indications for starting dialysis (clinical signs): If symptoms such as worsening loss of appetite and vomiting, generalized weakness, uremic bleeding, pericarditis/pericardial effusion, shortness of breath (pulmonary edema), or altered consciousness occur, dialysis should be considered immediately.

Treatment Methods

• Definitive treatment
  • Kidney transplantation: The most desirable treatment. Living-donor transplantation (usually from a family member) is considered first. ABO-incompatible transplantation is also possible, but the increased immunosuppression raises the risk of infection. For donations from brain-dead donors, the waiting period differs according to blood type (shorter for type AB and longer for type O).
• Renal replacement therapy
  • Hemodialysis: Widely performed in Korea (approximately 4:1 compared with peritoneal dialysis). Dialysis is performed through an arteriovenous fistula or synthetic vascular graft.
  • Peritoneal dialysis: Can be self-managed, but carries a high risk of infection, including peritonitis.
• Medication and supportive treatment
  • Anemia: Erythropoietin (ESA) preparations and iron supplementation.
  • Electrolyte and bone metabolism: Phosphate binders to control calcium/phosphate, active vitamin D (or analogues), and calcitriol when necessary.
  • Metabolic acidosis: Administration of sodium bicarbonate.
  • Hyperkalemia and hypertension: Dietary therapy and medication (when using ACE inhibitors/ARBs, residual kidney function and potassium levels require attention).
  • Immunosuppression (for transplantation): Calcineurin inhibitors (tacrolimus, cyclosporine), antimetabolites (mycophenolate), steroids, etc.
• Lifestyle management (self-management)
  • Diet: Restrict sodium, potassium, and phosphate; consume an appropriate amount of protein (the recommended amount varies depending on whether dialysis is being performed); restrict fluid intake (follow the doctor's instructions).
  • Medication precautions: Avoid or adjust the dosage of nephrotoxic medications such as NSAIDs, contrast media, and some antibiotics.
  • Vaccinations: Influenza, pneumococcal, and hepatitis B vaccines (similarly recommended).
  • Vascular access and peritoneal care: Prevent infection at the dialysis access site (maintain cleanliness); follow aseptic technique during peritoneal dialysis.
• Precautions and risk of complications
  • Complications: Cardiovascular disease (the leading cause of death), hyperkalemia, pulmonary edema due to fluid overload, infection (especially of the peritoneum and vascular access site), anemia, renal osteodystrophy, and dialysis-related hypotension and muscle cramps, among others.
  • Medication and dosage adjustments are required before and after dialysis, and monitoring of fluids and electrolytes is essential.
  • With transplantation, the risk of infection and malignancy increases due to immunosuppression.

Checkpoints Before an Outpatient Visit (Including Example Questions)

• Items to prepare (items that can help with the consultation and treatment planning)
  • A list of all medications currently being taken (including prescriptions, over-the-counter medications, and dietary supplements)
  • Recent test results (creatinine, eGFR, electrolytes, Hb, phosphate, calcium, albumin, etc.) and dialysis-related records (whether dialysis has started, frequency, and date of the last dialysis session)
  • Records of changes in blood pressure and weight, estimated daily urine output, and whether edema is present
  • Symptom records: the timing, frequency, and aggravating factors of nausea, vomiting, loss of appetite, itching, shortness of breath, changes in consciousness, etc.
  • History of dialysis access (arteriovenous fistula/catheter), surgeries, hospitalizations, and infections; whether kidney transplantation is desired; and information about potential donors (including blood type, if available)
• Key items the doctor will check during the outpatient visit
  • Trends in kidney function (whether the decrease has persisted for 3 months or longer), whether kidney imaging (ultrasound/CT) has been performed, and bone scan results (if necessary)
• Examples of frequently asked preparation questions during an outpatient visit
  • "May I bring all of my recent test results, including creatinine and eGFR?"
  • "Should I prepare a list of my current medications and supplements?"

Examples of General Questions to Ask the Doctor

• What are the main side effects of this medication (or treatment), and what risk factors apply to me?
• Is dialysis definitely necessary in my current condition, or can I prepare for transplantation first?
• What can I expect regarding my prognosis (expected duration of life and quality of life)?
• What precautions should I take in daily life (exercise, pregnancy and childbirth, returning to work, etc.)?
• Which vaccinations are recommended, and when should I receive them?

Examples of Disease-Specific Questions

• Based on my case (current test values and symptoms), please explain specifically when I should start dialysis. What symptoms indicate that dialysis should be started immediately?
• What tests and evaluations are needed to plan a kidney transplant, and what is the expected waiting period given my blood type and condition?