CASE STUDIES
Help me doctor, which renal replacement modality is best for me?
By W. Van Biesen
 |
Prof Dr W. Van Biesen Renal Divison, University Hospital Ghent Ghent, Belgium |
Patients suffering from end stage renal disease (ESRD) can be treated by different modalities of renal replacement therapy (RRT)1. These modalities include: peritoneal dialysis, haemodialysis and transplantation. In peritoneal dialysis, patients can be treated by rather “easy to perform” schedules like CAPD, or they can be placed on more complicated treatment regimens, using high dialysate volumes and cyclers (automated peritoneal dialysis: APD)2. For patients who opt for haemodialysis, a further modality choice can be made between home, hospital or low care dialysis, or for regular haemodailysis, haemofiltration or haemodiafiltration. Also alternative dialysis regimens, like daily dialysis, nightly dialysis, or long daily dialysis are available in selected centres3.
Different options are available for vascular access: native fistulas, PTFE grafts, or tunnelled catheters. Patients who are candidates for a renal transplant can either receive a cadaveric kidney, or a kidney from a living donor. In both cases, the option of pre-emptive transplantation before initiation of RRT may be offered.
Although all these choices have important consequences, both in terms of quantity and quality of life, and are thus very relevant for the patient, no hard, evidence based data that can guide or help the patient in the selection of these modalities are available at this moment. Initially, all studies comparing RRT modalities did this starting from the viewpoint that an ESRD patient should remain on his/her initial modality for the rest of his/her life. Only recently, attention was drawn to the observation that most patients will need more than one RRT modality during their life. The question is thus: which succession of different treatment modalities will result in the best long-term survival? This seemingly simple question breaks down in several other questions, including what is the best modality to start renal replacement therapy, how and when should a transfer to another modality be considered and monitored, and how can the usage of renal grafts be optimised both on the patient as on the society level.
CASE PRESENTATION
VS is a young girl of 18 years old when admitted in the emergency room of our hospital with fever, headache, neurological symptoms and petechiae which were distributed over her legs and arms. She has a blanco medical history and had just started university training in psychology. Her parents live in a town some 40 km from the university hospital. During the week, she remains in a student home of the university, and she spends the weekends at home. In the hour following her admission, the patient developed a septic shock, needing vasopressor therapy, and intubation. The diagnosis was made of meningococcal sepsis. The patient developed acute renal failure, and was dialysed at the intensive care unit (ICU). After 2 weeks of treatment, she can be dismissed from the ICU, but remains dialysis dependent because of a bilateral renal cortical necrosis. Until that time, she was treated with haemodialysis by means of a temporary catheter. It becomes however evident that she will need chronic renal replacement therapy.
