Nephrology Update: End-Stage Renal Disease and Renal Replacement Therapy

End-stage renal disease (ESRD) is associated with high rates of morbidity and mortality, and increased health care use. Optimal management of patients with ESRD requires close collaboration among primary care physicians, nephrology subspecialists, and other subspecialists. Critical issues for the family physician include helping patients transition from chronic kidney disease to ESRD, recognizing and managing common issues in patients receiving dialysis or after kidney transplantation, and understanding palliative care for patients with ESRD. Dialysis typically is initiated for patients with a glomerular filtration rate less than 15 mL/min/1.73 m(2) if they are symptomatic due to uremia or if medical management of metabolic conditions is unsuccessful. Kidney transplantation is the optimal form of renal replacement therapy in suitable patients. The choice between hemodialysis and peritoneal dialysis often is based on patient preference and coexisting conditions. Meticulous monitoring of volume status is necessary to achieve and maintain control of blood pressure. Sleep disorders and pruritus are common and can be managed by optimization of metabolic parameters, adequacy of dialysis, and drugs.