Evidence-Based Nephrology

Symptom Management of the Patient with CKD: The

Role of Dialysis
Valerie Jorge Cabrera,* Joni Hansson,* Alan S. Kliger,† and Fredric O. Finkelstein*

Abstract
As kidney disease progresses, patients often experience a variety of symptoms. A challenge for the nephrologist is
to help determine if these symptoms are related to advancing CKD or the effect of various comorbidities and/or
*Department of
medications prescribed. The clinician also must decide the timing of dialysis initiation. The initiation of dialysis Medicine, Section of
can have a variable effect on quality of life measures and the alleviation of uremic signs and symptoms, such as Nephrology, Yale
anorexia, fatigue, cognitive impairment, depressive symptoms, pruritus, and sleep disturbances. Thus, the University, New
initiation of dialysis should be a shared decision–making process among the patient, the family and the nephrology Haven, Connecticut;
and †Yale New Haven
team; information should be provided, in an ongoing dialogue, to patients and their families concerning the Health System–
benefits, risks, and effect of dialysis therapies on their lives. Performance
Clin J Am Soc Nephrol 12: 687–693, 2017. doi: https://doi.org/10.2215/CJN.01650216 Management, New
Haven, Connecticut

Introduction
Patients with CKD often experience a wide variety of
symptoms as disease progresses. These same patients
may have symptoms related to the effects of aging, the
various comorbidities common to this population, or
one or more of the medications prescribed for them
(1,2). A challenge for the nephrologist is to consider if
initiating dialysis will alleviate these symptoms. This
becomes particularly important as patients approach
ESRD, because the clinician must help decide with
the patient and his/her family if and how the patient
will benefit from starting dialysis. This review will
focus on the timing of dialysis initiation and the effect
of dialysis on health–related quality of life (HRQOL)
and uremic symptoms.
Initiation of Dialysis
What is the best advice to provide to patients
concerning the optimal time to initiate dialysis? Life
ceases when the GFR reaches zero unless RRT is started.
Patients will likely develop life-threatening complica-
tions of uremia, such as pericarditis, pulmonary edema,
neurologic problems, and/or metabolic abnormalities
(such as severe hyperkalemia), as kidney function be-
comes marginal. Common practice has been to initiate
dialysis at some point after stage 5 CKD develops but
before renal function ceases to avoid these complica-
tions. In addition to life-threatening complications of
ESRD, patients often report various clinical symptoms
as GFR declines. Dialysis is sometimes initiated rela-
tively early in stage 5 CKD after initial symptoms appear
or in an effort to avoid these symptoms completely.
Early start of dialysis was defined in the Initiating
Dialysis Early and Late (IDEAL) Trial as starting dialysis
with an eGFR of $10 ml/min per 1.73 m2 (3). In the
United States, these early-start dialyses have become
very common. Over 40% of patients who start dialysis
Correspondence:
do so when the eGFR is .10 ml/min per 1.73 m2, al- Dr. Fredric O.
though there seems to be a slight decrease in this per- Finkelstein, 136
centage from 2010 to 2013 (4). Sherman Avenue,
Do patients benefit from the early initiation of di- New Haven, CT
alysis? Does early-start dialysis improve survival, re- 06511. Email:
fof@comcast.net
duce the likelihood of uremic complications, or reduce
the frequency and/or intensity of uremic symptoms?
Recent studies of early dialysis initiation do not
show improved outcomes. The IDEAL Trial random-
ized patients to an early (eGFR of 10.0–14.0 ml/min
per 1.73 m2 estimated by the Cockcroft–Gault equa-
tion) versus late initiation of dialysis (eGFR of 5.0–
7.0 ml/min per 1.73 m2) (3). The actual mean eGFR at
initiation of dialysis was 12.0 ml/min per 1.73 m2 in
the early-start group compared with 9.8 ml/min per
1.73 m2 in the late-start group. In this trial, the early
initiation of dialysis did not result in significant im-
provements in mortality rates, cardiovascular or in-
fectious events, or quality of life measures. However,
interpretation of this study is complicated by the fact
that 76% of the patients in the late-start group started
dialysis when the eGFR was above the target of
7.0 ml/min per 1.73 m2 due to development of symp-
toms attributed by clinicians to renal failure.
Similar findings were observed in two other data
registries: the US Renal Data System and the Canadian
Registry (5,6). Scialla et al. (5) reported outcomes in
89,547 United States patients starting dialysis in 2008
with eGFR between 5 and 20 ml/min per 1.73 m2.
They found no associated harm or benefit with early
dialysis initiation. However, Clark et al. (6) examined
the Canadian Registry and noted that early initiation
of dialysis (mean6SD eGFR of 15.567.7 ml/min per
1.73 m2) compared with late initiation (mean6SD
eGFR of 7.162 ml/min per 1.73 m2) was actually as-
sociated with a higher mortality rate, which was not
fully explained by differences in baseline patient

www.cjasn.org Vol 12 April, 2017 Copyright © 2017 by the American Society of Nephrology 687
688 Clinical Journal of the American Society of Nephrology
characteristics. Notably, this study based renal function on
an eGFR; a lower creatinine in malnourished patients
could lead to a falsely high eGFR, which can confound
the data on mortality rates.
It is important to keep in mind that dialysis initiation at any
level of GFR can be associated with an increase in cardiovascular
events; a recent review of data from over 300 dialysis centers
found increased cardiovascular events after hemodialysis (HD)
initiation from the first week to the fifth month (7). The imme-
diate period after dialysis initiation was noted to be associated
with a particularly high risk of cardiovascular events (7).
Given the evidence that dialysis initiation may at times
be associated with adverse outcomes or increased mortal-
ity, it is important to examine carefully the evidence that
does exist suggesting that dialysis reduces or avoids the
symptoms associated with advancing kidney failure. We
might hypothesize that early-start dialysis prevents or de-
lays the development, frequency, or intensity of uremic
symptoms. However, the hypothesis that dialysis reduces
uremic symptoms has not been tested rigorously and in
fact, is not well supported by the literature. The interpre-
tation of the literature is challenging, because the symp-
toms associated with uremia are often vague, difficult to
quantify objectively, and difficult to distinguish from symp-
toms that can be attributed to conditions coexisting with
advanced CKD or side effects of medications used to man-
age these conditions. Patients with stage 4 or 5 CKD are
prescribed a mean of eight different medications (8,9).
Many patients without comorbidities remain surprisingly
asymptomatic until eGFRs are well below 10 ml/min per
1.73 m2. Some patients may have symptoms but adapt to
and downplay these symptoms, reporting an acceptable
sense of wellbeing, although family members may have
noticed a change in level of functioning. Importantly, health
care providers are often not aware of patients’ symptom bur-
den, thus complicating their advice about when to start di-
alysis (10). This can make the decision to initiate dialysis for
symptom relief challenging and difficult to clearly articulate
in a formal guideline. In fact, in a questionnaire distributed to
Canadian nephrologists, only 3% indicated that their institu-
tion had a formal policy for the initiation of dialysis (11).
Traditionally, the indications for initiating dialysis have
been divided into two broad categories: absolute and relative
indications (1,2). The 2015 Kidney Dialysis Outcome Quality
Improvement (KDOQI) guidelines (“KDOQI clinical practice
guideline for hemodialysis adequacy: 2015 Update”) recom-
mend initiation of dialysis “based upon an assessment of
signs and/or symptoms associated with uremia, evidence
of protein-energy wasting, ability to safely manage meta-
bolic abnormalities and/or volume overload rather than
based on a specific level of kidney function if these symp-
toms or signs are absent” (2). Absolute indications that are
generally agreed on include the presence of uremic pericar-
ditis, uremic encephalopathy, intractable fluid overload,
and/or electrolyte abnormalities that cannot be managed
without dialysis. Relative indications include the presence
of a constellation of symptoms that are attributable to ad-
vanced renal failure. These signs and symptoms were noted
in the updated KDOQI 2015 guidelines and are adapted in
Table 1 (2). What makes the interpretation of these symp-
toms so challenging is that their etiology is often multi-
factorial and can be related, at least in part, to various
Table 1. Signs and symptoms of patients with CKD
attributable to advanced renal failure
Fatigue
Lethargy
Cognitive dysfunction
Symptoms of neuropathy
Uremic pruritus
Sleep disturbances
Anorexia, nausea
Restless legs
Depressive symptoms
Modified from Kidney Dialysis Outcome Quality Improvement
clinical practice guidelines (2).
comorbidities, medications, or other complications of renal
failure, such as anemia, volume overload, hyperparathy-
roidism, cardiovascular disease, hypertension, psychoso-
cial stressors, etc.
Effect of Dialysis Initiation on HRQOL
Assessments of HRQOL for patients with CKD not on
dialysis using standardized instruments have generally
shown lower scores (indicating worse patient perception of
their quality of life) compared with the general population,
particularly for the physical compared with the mental
domain (12,13). HRQOL scores for patients with CKD not
on dialysis are generally higher than scores reported for pa-
tients on dialysis (12,13). These scores decline progressively
with decreasing renal function (12). Many variables correlate
with the HRQOL scores, including age, sex, presence of di-
abetes, cardiovascular comorbidities, and stage of CKD (12).
Several tools to assess symptoms of patients on dialysis
have been validated, including the Dialysis Symptom In-
dex, the Choice Health Experience Questionnaire (CHEQ),
and the Kidney Disease Quality of Life instrument (14–16).
The initiation of dialysis has been reported to have a vari-
able effect on these HRQOL measures. This was carefully
studied in a national prospective cohort of patients initiat-
ing dialysis—the Choices for Healthy Outcomes in Caring
for ESRD (CHOICE) Study. This study looked at the qual-
ity of life at the time of dialysis initiation and 1 year later
using the CHEQ (15). This questionnaire includes the 36–
Item Short–Form Health Survey (SF-36) as well as ques-
tions examining 14 dialysis-specific domains. Changes in
the SF-36 domains were examined over time and catego-
rized as worsened, no change, or improved; 20%–31% of
patients had worsening, 42%–60% had no change, and
19%–28% had improvement in the eight domains of this
instrument. In the dialysis-specific domains, 19%–30% had
worsening, 50%–65% had no change, and 16%–24% had
improvement after 1 year of dialysis therapy. It, therefore,
seemed that dialysis treatment showed no consistent rela-
tionship to quality of life measures or dialysis-specific
symptoms. There were no statistically significant differ-
ences between HD and peritoneal dialysis (PD) on the ef-
fect of therapy on any of the SF-36 or dialysis-specific
domains. The CHOICE Study has some important
Clin J Am Soc Nephrol 12: 687–693, April, 2017
limitations. There was no control group (that is, patients
with advanced CKD not starting dialysis); 928 patients
completed a baseline CHEQ, but only 525 completed the
questionnaire 1 year later. In total, 101 of the initial 928
patients died, which highlights the high mortality in the
ESRD population and could have contributed to an under-
estimation of the negative effect of dialysis initiation on
quality of life. In addition, it should be noted that the ini-
tial CHEQs were completed shortly after the initiation of
dialysis (not before the start), thus perhaps missing an
improvement in HRQOL during that initial period of RRT.
Similarly, in the IDEAL Trial (3), which looked at the tim-
ing of dialysis initiation and survival, HRQOL was also ex-
amined using two measures: the SF-36 and the Assessment
of Quality of Life. The Assessment of Quality of Life is a
generic instrument that measures quality of life for health
interventions across five dimensions (illness, independent
living, social relationships, physical senses, and psychologic
wellbeing). Importantly, there were no differences with ei-
ther instrument comparing early- with late-start patients on
dialysis during the period of the study (17).
Effect of Dialysis on Uremic Symptoms
Looking at the effect of dialysis on various symptoms
associated with advanced renal failure, much attention has
been focused on worsening nutritional status and the de-
velopment of cachexia that occurs as renal failure prog-
resses (18). By the time that dialysis is started, patients can
be significantly malnourished. It has been recommended
that dialysis be initiated to prevent a worsening of the
malnutrition that occurs with advancing CKD (19). In an
international survey on initiation of dialysis, 72% of re-
spondents selected malnourishment as a reason to start
dialysis early (20).
Nutritional parameters clearly improve in the first
12 months after the initiation of dialysis, with the most
striking improvements occurring in younger patients and
those with the lowest serum albumin levels (21,22). How-
ever, it is important to note that malnutrition is highly
prevalent in the dialysis population, is associated with
poor outcomes, increases with dialysis vintage, and does
not improve with increasing dose of dialysis. In the analy-
sis of the nutritional status of the first 1000 patients ran-
domized in the Hemodialysis Study, the majority had
protein and energy intakes below the 2002 National Kidney
Foundation–KDOQI guidelines at the time of enrollment
(23). Only those patients who had been on dialysis for at
least 3 months were included, and those with serum albu-
min levels ,2.6 g/dl were excluded. In a 3-year follow-up
period, nutrition parameters, such as serum albumin levels
and postdialysis weights, were not affected by intensity of
dialysis therapy (24). In a cohort study of 3009 patients, di-
alysis vintage had a significant inverse relationship with al-
bumin, prealbumin, and cholesterol (25). This data suggest
that initiating dialysis in patients with CKD may not affect
nutritional status. However, other factors, such as dietary
restrictions, inflammation from systemic illness, comorbidi-
ties, and the catabolic effect of dialysis, may complicate
analysis as confounding variables.
Fatigue is a common symptom of patients with CKD and
has been reported to be present in up to 89% of patients
Initiation of Dialysis for Symptom Management, Cabrera et al. 689
with advanced renal failure (26). It is multifactorial in eti-
ology with CKD associations, including anemia, depres-
sion, low albumin levels, sleep disturbances, and restless
legs syndrome (RLS) (27). In the CHOICE Study, patients
with CKD reported vitality scores (a measure of fatigue)
on the SF-36 of about 40 compared with 100 in the general
population (15). One year after dialysis initiation, only 24%
of patients reported improvement, and 27% reported
worsened vitality (15). Other possible measures related
to fatigue on SF-36, such as the domains of physical func-
tion and physical role, showed similar results (15). The HD
procedure itself may cause patients to feel tired or washed
out. Moreover, a mean of 4 hours of recovery time after
each HD session to resume normal activities may contrib-
ute to the perception of fatigue (28).
Patients with progressive CKD develop cognitive im-
pairment related to a variety of factors, including cere-
brovascular disease, systemic inflammation, comorbidities,
and exposure to uremic toxins (29–32). In a cross-sectional
study that evaluated cognitive function with multiple stan-
dardized tests among patients with stages 3–5 CKD on
HD, a graded decline in function with progression of
CKD was noted (33). Similarly, in a cohort of 119 patients
with stages 3–5 CKD (mean eGFR of 35616 ml/min per
1.73 m2), there were significant cognitive deficits when
memory, information processing speed, and executive
function were compared with control patients (30). Cogni-
tive impairment in patients on dialysis is also well docu-
mented (31,32).
There is no good evidence to support the idea that early
initiation of dialysis will alter the severity of cognitive dif-
ficulties. In fact, in the CHOICE Study, only 17% of patients
had an improvement in self-reported symptoms of cognitive
functioning 1 year after dialysis initiation, whereas 26% had a
worsening; cognitive performance function tests were not
performed in this study (15). Interestingly, a recent study of 28
patients with ESRD showed improvements in various cogni-
tive function tests (including measuring memory, attention,
and executive functions) several hours later after a single HD
session (32). This could suggest a reversible component to the
impaired cognitive performance in this population. However,
increasing the dose of dialysis does not improve cognitive
function; in the Frequent Hemodialysis Network Trial, more
frequent HD was not associated with any improvement in the
primary cognitive outcome (34).
Neuropathy, which frequently develops in advanced
stages of CKD, is characterized by a slowly progressive
distal symmetrical polyneuropathy. Its clinical features
include paresthesias, weakness, muscle wasting, and de-
creased deep tendon reflexes and vibration sensation (35).
In a cross-sectional study of 100 adult patients with CKD
and mean eGFR of 19.368.1 ml/min per 1.73 m2 who
were evaluated with motor nerve conduction studies,
70% had evidence of polyneuropathy, which was asymp-
tomatic in 6%, symptomatic and nondisabling in 51%, and
disabling in 13% (36). The mean conduction nerve veloc-
ities decreased with increases in serum creatinine levels
(36). The effect of dialysis on preventing further deterio-
ration on uremic neuropathy was reported as early as
1967, when dialysis provided for .1 year resulted in a
significant increase in mean motor nerve conduction ve-
locities (37). Subsequent studies have shown that uremic
690 Clinical Journal of the American Society of Nephrology
neuropathy remains unchanged during up to 5 years of
HD treatment (38).
Pruritus can be a distressing symptom that affects patients
with CKD. A recent study showed that the prevalence of
pruritus was 19% in patients with CKD, independent of the
stage of CKD (39). However, in patients maintained on
chronic HD, up to 84% of the patients reported pruritus
occurring almost daily, and 42% reported that the pruritus
was moderate to extreme (40,41). Pruritus was associated
with poor sleep quality, reduced physical and mental com-
posite scores on the SF-36, and depression (41).
Sleep disturbances are commonly reported by patients
with CKD and often unrecognized by renal providers.
These are well documented by polysomnography and asso-
ciated with lower cognitive function scores, poorer patient–
reported quality of life, and depressive symptoms
(10,42,43). Interestingly, these sleep disturbances are inde-
pendent of GFR but associated with age, sex, comorbidi-
ties, and medications (12,44). Sleep disturbances are more
common and of greater severity in patients on HD com-
pared with patients with CKD not on dialysis (44). Formal
sleep testing shows that patients on HD have more sleep
problems than patients with CKD not on dialysis, with less
total sleep time and rapid eye movement sleep and higher
brief arousal index, respiratory disturbance index, and
numbers of sleep apneas (43,44). After the initiation of di-
alysis in the CHOICE Study, only 19% reported an im-
provement in sleep symptoms, and 24% reported a
worsening of symptoms (15).
Sleep in CKD can also be affected by other factors, such
as RLS, which has a prevalence of up to 25% in patients on
dialysis (45,46). RLS has also been associated with higher
cardiovascular mortality, decreased quality of life, and in-
creased morbidity in these patients (46). The prevalence of
RLS in patients with CKD not on dialysis is variable, with
some authors reporting a prevalence similar to that in the
general population, whereas others report a prevalence up
to 26% (47–49). In a study of 110 patients with stages 2–4
CKD, 21 patients were classified as having probable RLS
with self-administered questionnaires, but only in five pa-
tients was the diagnosis confirmed after careful questioning
by a trained investigator. This suggests that self-administered
questionnaires can overestimate the frequency of RLS and
that the leg discomfort could be secondary to other disorders
mimicking RLS (49).
Clinical depression diagnosed with a structured interview
as well as depressive symptoms are commonly noted in
both patients with CKD and patients with ESRD. Patients
Table 2. Selected dialysis-related issues that affect health-related quality of life of patients on dialysis
Peritoneal Dialysis
Weight gain (60)
Glucose control (62)
Peritoneal access issues (63)
Peritonitis (65)
Daily dialysis routine (67)
Visits to dialysis facility (67)
Exit site infections (65)
Ultrafiltration problems (69)
Encapsulating peritoneal sclerosis (71)
on dialysis, however, consistently have higher depression
scores than patients with CKD not on dialysis. Clinical de-
pression diagnosed by a structured interview affects about
20%–25% of patients with CKD and 25%–30% of patients on
maintenance dialysis (50). Depressive symptoms are associ-
ated with an increased risk of death and a lower quality of
life in both patients with CKD and patients with ESRD (51).
The initiation of dialysis is associated with an increased in-
cidence of depressive symptoms, with 44% of patients who
recently initiated dialysis having Beck Depression Inventory
scores above the validated cutoff value for clinical depres-
sion in patients with ESRD (52).
Challenge for the Nephrologist
Thus, the symptom burden and high level of disability in
patients with advanced CKD are not necessarily improved
by dialysis. Patients need to be informed that dialysis may
or may not result in an improvement in their quality of life
and functional status (53). It is difficult to accurately iden-
tify those individuals who are unlikely to benefit from
dialysis. However, it is important to keep in mind that
the dialysis procedure itself, both PD and HD, can have
an effect on patients’ HRQOL. This relates to the burden
and frequency of the procedure itself as well as the com-
plications of treatment. Some of these concerns are out-
lined in Table 2. When health care providers discuss
RRT with patients and their families, the potential benefits
are usually emphasized, and the negative aspects of treat-
ment are often not discussed or minimized.
One of the challenges for nephrologists after symptom
screening information has been obtained is what health
care providers should do to address these symptoms. This
requires a discussion among the clinician, the patient, and
the patient’s family to set up realistic expectations by try-
ing to sort out the effect of the symptoms on the patient’s
quality of life and the risks and benefits of potential treat-
ments. The executive summary of the Kidney Disease
Improving Global Outcomes (KDIGO) Controversies Con-
ference on Supportive Care in CKD (53) emphasized the
difficulties in the development of treatment strategies
given the significant variation in level of evidence for
symptom management and the complexity of patients
with CKD. Patients with CKD have a variety of symptoms
that affect their perception of their quality of life, work,
and social life. These symptoms can significantly add con-
straints to patients’ lives, particularly when combined with
complex treatment regimens, medications and their side
Hemodialysis
Myocardial stunning (61)
Postdialysis recovery time (28)
Vascular access issues (64)
Sepsis (66)
Three or more times per week treatment (67)
Transportation to hemodialysis unit (67)
Endotoxemia (68)
Cerebral ischemia (70)
Recurrent hypotension (72)
Clin J Am Soc Nephrol 12: 687–693, April, 2017
effects, and dietary restrictions (54). The multiplicity of
symptoms that patients with CKD experience and the com-
plexity of the patients can make the development of treat-
ment strategies challenging and difficult. Nonpharmacologic
and pharmacologic interventions can be potentially effective
for managing these symptoms. The executive summary of
the KDIGO Controversies Conference on Supportive Care in
CKD (53) provides a list of symptoms experienced by pa-
tients with CKD and a high-level synthesis of the literature
summarizing treatment strategies.
A time-limited trial of dialysis is a reasonable option
when a patient has an uncertain prognosis, it is not clear if
the individual will benefit from dialysis, or there is a lack of
consensus from the patient/family about proceeding with
RRT. This trial allows the patient and the family to evaluate
the effect of dialysis and permits the clinician to evaluate
the clinical response of symptoms to the treatment. In such
circumstances, it is important to establish clear parameters
delineating the decision to continue with dialysis (55). The
duration of such a trial needs to be assessed on an ongoing
basis taking into account the patient’s response to treat-
ment. According to the clinical practice guidelines on
shared decision making from the Renal Physicians Associ-
ation and the American Society of Nephrology, it is appro-
priate to discontinue dialysis in the following situations:
those patients who request to discontinue dialysis, those
without capacity who previously indicated refusal of di-
alysis in oral or written advanced directive, and those
without capacity whose appointed legal agents request
for it to be discontinued (56).
Another approach to consider is an incremental ap-
proach to dialysis initiation defined as a gradual increase
in the dialysis prescription over time for those patients
with residual renal function. It has been proposed that this
approach could potentially offer several benefits, including
lessening the effect of the dialysis treatment itself, preser-
vation of residual renal function, access preservation for
those on HD and preservation of the peritoneal membrane
for those on PD, reduced costs, and the potential for sym-
ptom relief with decreased treatment burden. Although
there are no randomized, controlled trials comparing in-
cremental with conventional dialysis, in a recent analysis
of a cohort of patients on incident HD (57), there was no
difference in overall mortality for the incremental HD
group (twice weekly HD or less) compared with the con-
ventional HD group (thrice weekly). However, those on
incremental HD with a higher comorbidity burden had an
associated higher mortality, suggesting that the approach
of incremental HD would be most viable in those with
fewer comorbidities. Similarly, this incremental approach
has also been explored in patients on PD, as illustrated in a
small report of patients on PD on an initial regimen of two
icodextrin exchanges per day in an off-label use (58). This
approach requires close monitoring, because adjustments
are required to maintain adequacy as residual renal func-
tion declines with time.
Conclusion and Future Directions
In summary, the role of dialysis in managing the symp-
tom burden of patients with advanced CKD is unclear.
A variety of symptoms often develops as CKD progresses.
Initiation of Dialysis for Symptom Management, Cabrera et al. 691
Sorting out the relative contribution of the uremic environ-
ment from aging, the effect of various comorbidities, and the
effect of myriad medications is challenging. HRQOL assess-
ments suggest that, although some symptoms improve with
the start of dialysis, others will not improve. Furthermore, the
early initiation of dialysis does not improve patient outcomes
or quality of life compared with late initiation.
The decision to initiate dialysis and the timing of that
decision may or may not have an effect on the symptoms
and quality of life of patients with advanced CKD. In this
complex environment, dialysis initiation should be a shared
decision–making process among the CKD/dialysis team, the
patient, and the family. The information that is provided to
patients and their families should include the benefits and
harms of the various treatment options specific to that in-
dividual and the possible positive and negative effects on
patient symptoms and quality of life. It is important that
patients and families have realistic expectations of potential
treatment options. Helping patients and families to be part
of a problem-solving approach to individualized manage-
ment will maximize treatment benefits.
Future research is needed to develop a better under-
standing of the effect of advanced CKD on patients’ symp-
toms and their perception of their quality of life. In
addition, attention needs to be focused on better appreci-
ating the effect of dialysis itself (and the different dial-
ysis regimens) on patients’ quality of life. This can help
guide the decision of when to initiate dialysis and the
role of nondialytic supportive care in individual patient
management.
Lastly, the routine incorporation of assessments of pa-
tient symptoms and the severity of these symptoms into
routine care of the patient with CKD is critically important
(59). Regulatory agencies have focused on the measure-
ment of more easily quantifiable laboratory examinations
rather than the more subjective assessments of patient per-
ceptions of their symptoms and quality of life. This is per-
haps beginning to change now, because some patient
symptoms, such as depressive symptoms, are being incor-
porated into standardized patient care. However, assess-
ing the entire constellation of uremic symptoms on an
ongoing basis will indeed be challenging.
Disclosures
None.
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Published online ahead of print. Publication date available at www.
cjasn.org.
See related commentary, “Commentary on Symptom Management
of the Patient with CKD: The Role of Dialysis” on pages 694–695.