Unperceived underdialysis

Chronic progressive renal disease is clinically manifested by an array of neurobehavioral symptoms and somatic wasting. When pre-end-stage patients were studied using objective measures in both domains, progressive and clinically unperceived deterioration was demonstrated at and below glomerular filtration rates (GFRs) of 40 ml/min/1.73 m2 (serum creatinine levels as low as 2 mg/dl). Reaching end-stage, patients' neurobehavioral measures objectively documented a favorable response to dialysis, to more dialysis versus less, and to successful renal transplantation. In a prospective study of reduced dialysis, patient's underdialysis remained clinically unperceived whereas the objective measures of the quantified electroencephalogram, psychometric measures, and patients' scored self-evaluations deteriorated, in that order. A graphic summary that quantifies progression from GFRs of 50 to 0 and compares various interventions by dialysis suggests that most, or all current, conventional dialysis prescriptions may actually impose unperceived underdialysis because they fail to achieve the GFR equivalent values that might prevent nutritional deterioration. Such optimal values may be accessible to daily hemodialysis treatments.