End-stage renal failure and renal replacement therapy
End stage renal failure (or disease; ESRF, ESRD) implies a level of renal function at which death is likely within weeks or months. Symptoms are those of severe chronic renal failure (see complications of CRF). It is not the same as CKD stage 5: the average GFR for commencing dialysis in the UK is below 10ml/min, but there is wide individual variation, and some may require renal replacement therapy (RRT) much earlier. There is no evidence of any benefit for starting dialysis earlier than currently. Treatment options include the three forms of renal replacement therapy, and conservative management:
Younger and ‘low risk’ patients are favoured for transplantation. For some patients who are at a high risk of dying on dialysis, conservative management may provide a higher quality of life than renal replacement therapy, with little shortening of life.
Risk is related to both age and co-existing diseases. Prognosis with renal replacement therapy tends to be very good in younger patients with no other serious diseases, especially after transplantation. However even in this group, mortality from cardiovascular disease is many times higher that of the general population. Infectious causes of death are the second major problem in patients on renal replacement therapy.
High risk patients are the very elderly (over 80 years) or those of any age with two major comorbid conditions (clear evidence of coronary, cerebrovascular or peripheral vascular disease; diabetes; non-skin malignancy); or those aged 70-80y with one major comorbid disease. The median survival of the high risk group defined this way is generally under 18 months, although up to a quarter may survive >4y.
Conservative management includes all usual measures to retard progression of renal disease and reduce symptoms, including particularly close attention to diet, and use of erythropoietin and other treatments to reduce symptoms.