Renal Replacement Therapy in Female Patients

Introduction to Renal Replacement Therapy

The American College of Physicians recommends that kidney transplantation be considered the preferred treatment option for female patients with end-stage renal disease (ESRD), as it offers the best outcomes in terms of mortality and quality of life 1
The National Kidney Foundation recommends that living donor pre-emptive kidney transplantation be considered when the glomerular filtration rate (GFR) is <20 ml/min/1.73 m² with evidence of progressive and irreversible chronic kidney disease over 6-12 months 1

The American Journal of Kidney Diseases recommends a target Kt/V of 1.4 per hemodialysis session for patients treated three times a week, with a minimum delivered Kt/V of 1.2 2
The American Journal of Kidney Diseases recommends prescribing a minimum of 3 hours per session for patients with low residual renal function (<2 mL/min) 2
The American Journal of Kidney Diseases suggests considering additional sessions or longer treatment times for patients with large weight gains, high ultrafiltration rates, poorly controlled blood pressure, or inadequate metabolic control 2
Frequent hemodialysis (more than three times a week) should be offered as an alternative to conventional hemodialysis after considering individual preferences, potential benefits to quality of life and physiology, and risks 2

The American Journal of Kidney Diseases recommends that women with ESRD receive prolonged frequent hemodialysis during pregnancy, either in-center or at home, depending on convenience 2
There is a dose-response relationship between the intensity of dialysis and pregnancy outcomes, with birth rates of 48% in women dialyzed for 20 hours or less per week, 75% in women dialyzed for 30 hours per week, and 85% in women dialyzed for more than 36 hours per week 3
Women who received 48 ± 5 hours of hemodialysis per week for at least 6 nights per week carried their pregnancies to a mean of 36 weeks, with a live birth rate of 86% and mean birth weight of 2,118 ± 857 g 3

The decision to initiate maintenance dialysis should be based primarily on an assessment of signs and/or symptoms associated with uremia, evidence of protein-energy wasting, and the ability to safely manage metabolic abnormalities and/or volume overload with medical therapy, rather than a specific level of renal function in the absence of such signs and symptoms 2
Dialysis should be initiated when one or more of the following are present: symptoms/signs attributable to renal failure; inability to control volume status or blood pressure; progressive deterioration of nutritional status; or cognitive impairment 1

The American College of Surgeons recommends that arteriovenous fistulas (AVF) or arteriovenous grafts (AVG) be preferred over tunneled central venous catheters (CVC) 1
For patients using AVF with intensive hemodialysis, the ladder cannulation technique is recommended over the buttonhole technique, unless topical antimicrobial prophylaxis is used 1

An individualized ESRD Life Plan should be developed for each patient, considering their medical situation, life goals, preferences, social support, and functional status 1
This plan should be reviewed regularly, updated, and documented in the medical record, with comprehensive annual reviews and quarterly updates of vascular access functionality 1

Patients who reach stage 4 chronic kidney disease (GFR <30 mL/min/1.73 m²) should receive education on renal failure and treatment options, including kidney transplantation, peritoneal dialysis, home or in-center hemodialysis, and conservative management 2
Family members and caregivers of patients should also be educated about treatment options for renal failure 2

Do not initiate dialysis based solely on a level of GFR without symptoms of uremia present 2, 1
Do not offer only one modality of dialysis without discussing all available options, including transplantation and conservative management 2, 1
Do not continue with conventional hemodialysis three times a week in pregnant patients, as it is inadequate 3, 2