Renal Replacement Therapy: Haemodialysis and Peritoneal Dialysis

The answer first

Renal replacement therapy is a portfolio, not a machine — transplantation, haemodialysis, peritoneal dialysis and conservative kidney management are the four options, and the consultant's job is to sequence them for each patient rather than default to the dialysis chair. Six rules carry the DWE and the long-case defence ^{[2] [3]}:

1. Transplant first, always. A functioning graft gives better survival and better life than any dialysis — transplantation is the treatment of choice for every eligible patient, and dialysis exists as a bridge to it or a destination when it is impossible ^{[3] [2]}.
2. Start on symptoms, not a number. The IDEAL trial proved that planned early start (eGFR 10–14) confers no survival benefit over late start (eGFR 5–7) — you start dialysis when uraemia or its complications declare themselves, typically somewhere in the eGFR 5–10 band, while planning starts many months earlier ^{[1] [2]}.
3. Modality is chosen by the patient, not by superiority. Haemodialysis and peritoneal dialysis deliver similar survival; the choice turns on lifestyle, residual kidney function, dexterity, home support and cardiac stability — independence versus intensity ^{[4] [2]}.
4. Access is the Achilles heel — fistula first, and early. An arteriovenous fistula needs 6–12 weeks to mature and a meaningful share fail to mature, so it is created months before the anticipated start; a tunneled catheter is a bridge, never a destination ^{[7] [25]}.
5. Cardiovascular disease is what kills dialysis patients. Volume and blood-pressure management, avoiding intradialytic myocardial stunning, and the holistic bundle (ESA, binders, vaccination, diet, advance care planning) matter as much as the membrane ^{[17] [16]}.
6. Conservative care is an active choice, not neglect. In the elderly, frail, multimorbid patient, structured conservative kidney management can preserve quality of life with little or no survival penalty — offering it honestly is consultant-level practice, not therapeutic nihilism ^{[18] [2]}.

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References27ShowHide

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