Renal Function Recovery in Chronic Dialysis Patients

Abstract

Renal function recovery (RFR) from acute kidney injury requiring dialysis occurs at a high frequency. RFR from chronic dialysis, on the other hand, is an uncommon but well-recognized phenomenon, occurring at a rate of 1.0-2.4% according to data from large observational studies. The underlying etiology of renal failure is the single most important predicting factor of RFR in chronic dialysis patients. The disease types with the highest RFR rates are atheroembolic renal disease, systemic autoimmune disease, renovascular diseases, and scleroderma. The disease types with the lowest RFR rates are diabetic nephropathy and cystic kidney disease. Initial dialysis modality does not appear to influence RFR. Careful observation and history taking are needed to recognize the often nonspecific clinical and laboratory signs of RFR. When RFR is suspected in a chronic dialysis patient, a 24-hour urine urea and creatinine clearance should be measured. Based on the renal clearance, along with other clinical factors, the dialysis prescription may be gradually reduced until a complete discontinuation of dialysis. After RFR from maintenance dialysis, patients require close follow-up in an office setting for chronic kidney disease management.

Promoting Kidney Function Recovery in Patients with AKI Requiring RRT

“…Unfortunately, symptoms and signs of recovery are nonspecific (Table 2), but they should still be assessed and considered for their potential value as early indicators. Those symptoms of recovery may also be conflicting; although some patients may develop an improved sense of well-being, other patients may begin to feel worse because of unnecessary fluid removal after gaining true body weight (88).…”

“…Indeed, methods to assess function recovery could reasonably be put in place for all patients initiating dialysis, as has been suggested by others (88), because approximately one in 20 of all patients with ESRD (AKI or non-AKI related) will achieve dialysis independence during the first year of dialysis initiation. Because most patients with ESRD who recover kidney function do so within the first 3 months of dialysis initiation, attention to recovery is especially important during this time period.…”

“…In patients with AKI-D who are considered to have ESRD, kidney function recovery has been reported to occur in approximately 1%-2% of patients (88 19.9% of all patients of renal recovery and 22% of those with sustained recovery. Among patients who were able to discontinue dialysis, most did so within the first 3 months: 69% for the entire cohort, and 81% for patients with a diagnosis of ATN.…”

“…Normalization of serum electrolytes, such as potassium and phosphorus, may also occur. In the ATN trial (9), dialysis was discontinued when the 6-hour creatinine clearance was .20 ml/min, but the most appropriate threshold for discontinuation is still uncertain (88). In the outpatient setting, a 24-hour urine collection for urea and creatinine is commonly used to calculate residual GFR.…”

Chronic Dialysis Discontinuation: A Systematic Narrative Review of the Literature in the New Millennium

“…The incidence of renal function recovery in patients who start dialysis is relatively low, but varies widely: a recent in-depth review, selecting registry data and large series published before 2010, reports an incidence range of 1% to 5.6% (average 1.6%). Definitions vary, however, and the time interval for defining "chronic dialysis" is not reported in some studies, while in the ones that do provide it, it ranges from 1 to 3 months (15). With this in mind, we performed a systematic search of the literature, which was carried out on Medline, Embase, and on the Cochrane collaboration; unlike the previously cited review, our analysis also takes into consideration case reports, and focuses on the period between 2000 and 2013, on account of the changes both in the dialysis modalities and in the approach towards early start of dialysis treatment that took place in the new millennium.…”