Morbidity and mortality of dialysis.

The National Institutes of Health Consensus Development Conference on Morbidity and Mortality of Dialysis brought together experts in general medicine, nephrology, pediatrics, biostatistics, and nutrition as well as the public to address the following questions: (1) How does early medical intervention in predialysis patients influence morbidity and mortality? (2) What is the relationship between delivered dialysis dose and morbidity/mortality? (3) Can co-morbid conditions be altered by non-dialytic interventions to improve morbidity/mortality in dialysis patients? (4) How can dialysis-related complications be reduced? and (5) What are the future directions for research in dialysis? Following 1 1/2 days of presentations by experts and discussion by the audience, a consensus panel weighted the evidence and prepared their consensus statement. Among their findings, the consensus panel concluded that (1) patients in the predialysis phase, including children, should be referred to a renal team in an effort to reduce the morbidity and mortality incurred both during the predialysis period and when receiving subsequent dialysis therapy; (2) the social and psychological welfare and the quality of life of the dialysis patient are favorably influenced by the early predialytic and continued involvement of a multidisciplinary renal team; (3) attempts should be made to avoid a catastrophic onset of dialysis by instituting predialytic intervention and the appropriate initiation of dialysis access; (4) quantitative methods now available to objectively evaluate the relationship between delivered dose of dialysis and patient morbidity and mortality suggest that the dose of hemodialysis and peritoneal dialysis has been suboptimal for many patients in the United States; (5) factors contributing to underdialysis of some patients include problems with vascular and peritoneal access, nonadherence to dialysis prescription, and underprescription of the dialysis dose; (6) cardiovascular mortality accounts for approximately 50 percent of deaths in dialysis patients, and relative risk factors such as hypertension, smoking, and chronic anemia should be treated as soon as possible after diagnosis of chronic renal failure; (7) early detection and treatment of malnutrition contribute to improved survival of patients on dialysis; and (8) until prospective, randomized, controlled trials have been completed, a delivered hemodialysis dose at least equal to a measured fractional urea clearance of Kdrt/V of 1.2 (single pool) and a delivered peritoneal dialysis dose at least equal to a measured Kprt/V of 1.7 (weekly) are recommended.