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4.2 Preparation for Renal Replacement Therapy (RRT) 4.2.6 Timely Initiation of Dialysis The indications for dialysis are clear when patients present with life threatening problems such as severe hyperkalaemia (high potassium level), pulmonary oedema (fluid on the lung) and acidosis (too much circulating acid). The same is not true for 'planned' patients with slowly progressive renal failure. The point at which natural renal function becomes seriously inadequate is often difficult to define. Reliance has traditionally been placed on clinical features of renal failure or fluid overload and biochemical measurements (blood urea, creatinine). Blood urea and creatinine are poor indicators of adequacy in established dialysis patients. Low levels may indicate poor protein intake and wasting rather than adequate dialysis and predict poor survival (ref.71). Kinetic methods which measure the clearances (removal) of urea and creatinine are now the gold standard for the assessment of dialysis adequacy. The same may be true of low blood urea and creatinine, relative to renal function, in the period before dialysis is started and clearance measurements may similarly have a role in defining the optimum time to initiate dialysis treatment although the evidence base is still slim. Whatever the methodological details, the benefits of initiating dialysis in a timely fashion while patients are still healthy is self evident. To achieve this requires unimpeded access to all available dialysis modalities. There should be no 'waiting list' for dialysis.  |