Morbidity and Mortality of Renal Dialysis: An NIH Consensus Conference Statement

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 a representative of the public, to address the following questions: 1) How does early medical intervention in predialysis patients influence morbidity/mortality? 2) What is the relationship between delivered dialysis dose and morbidity/mortality? 3) Can comorbid conditions be altered by nondialytic 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? After one and a half days of presentations by experts and discussion by the audience, a consensus panel weighed the evidence and prepared their consensus statement. Among their findings, the consensus panel concluded the following: 1) During the period before dialysis therapy begins, patients, including children, should be referred to a renal team to reduce the morbidity and mortality incurred during this period and during subsequent dialysis therapy; 2) the social and psychological welfare and the quality of life of the patient receiving dialysis are favorably influenced by the early and continued involvement of a multidisciplinary renal team; 3) to avoid a catastrophic onset of dialysis, attempts should be made to institute intervention before dialysis therapy begins and to appropriately initiate dialysis access; 4) quantitative methods now available to objectively evaluate the relation between the 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 the 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% of deaths in patients receiving dialysis, and relative risk factors such as hypertension, smoking, and chronic anemia should be treated as soon as possible after the diagnosis of chronic renal failure; 7) early detection and treatment of malnutrition contribute to the improved survival of patients receiving dialysis; and 8) until randomized, controlled trials have been completed, a delivered hemodialysis dose at least equal to a measured fractional urea clearance Kdr t/V value of 1.2 (single pool) and a delivered peritoneal dialysis dose at least equal to a measured Kpr t/V value of 1.7 (weekly) are recommended.