by Valerie Tan, MD
Chronic Kidney Disease, or CKD, is a condition where the kidney function, defined by the estimated glomerular filtration rate (eGFR), falls less than 60 mL/min/1.73 m² for three months or more.
The most common causes of kidney failure are diabetes mellitus and hypertension.
CKD is classified into five stages (CKD 1-5) based on the eGFR. Classification also includes the level of albuminuria and is classified into 3 stages (A1-A3).
CKD is a progressive disease state ultimately leading to the need for renal replacement therapy. CKD 5 is reached when the eGFR is less than 15 mL/min/1.73 m².
Patients at this stage are defined as having End Stage Kidney Disease (ESKD) or simply kidney failure, because at this stage, the kidney function is too low to maintain fluid and metabolic homeostasis.
ESKD is fatal without treatment. ESKD can be managed with renal replacement therapy, which includes dialysis such as hemodialysis or peritoneal dialysis and kidney transplantation.
In 2021, there were over 4,000 Hawaiians on dialysis, and as of 2025, this number has increased to about 7,000 Hawaii residents.
Dialysis is typically needed when almost 90% or more of kidney function is lost.
There is no definite level of eGFR that dictates when dialysis is needed, but dialysis should begin before life-threatening complications from kidney failure can occur. Generally, most patients will start dialysis when the eGFR is approximately 6-10 ml/min/m2.
Dialysis is a medical procedure that involves the removal of solutes and excess fluid across a semipermeable membrane that serves as a filter.
There are two main types of dialysis modalities, hemodialysis (hemo = blood), and peritoneal dialysis (peritoneal pertaining to the peritoneum, which is the lining of the abdomen).
Dialysis can be done at the dialysis center or at home (home therapy). Home therapy options include peritoneal dialysis and a home version of hemodialysis.
Hemodialysis is utilized by ~85% of patients who are on dialysis. During this process, a machine pumps blood out of the body, filters it via a dialyzer, and then returns the filtered blood to the patient.
A vascular access in the form of a dialysis fistula or graft, or in some cases, a central venous catheter, is needed in order to have access to the patient’s blood.
The majority of hemodialysis patients choose in-center hemodialysis, which is done three times a week for roughly 4 hours per session.
Home hemodialysis is a modified version involving more frequent but shorter treatments that allow for more schedule flexibility.
Peritoneal dialysis is a home therapy modality utilized by roughly 13-14% of dialysis patients in the US.
During peritoneal dialysis, dialysis solution (dialysate) is instilled into the abdomen via a peritoneal dialysis catheter, dwells or stays in the abdomen for some time, and is then drained.
The filtering process happens during the dwell time, and the lining of the abdomen (peritoneum) acts as the filter that allows excess fluids and waste products to pass from the bloodstream into the dialysate.
This three-step process comprises the dialysis exchange and is repeated a number of times over a prescribed number of hours. Peritoneal dialysis can be done manually (CAPD) or with the use of a peritoneal dialysis machine (APD or CCPD).
Although the majority of patients with ESKD utilize in-center hemodialysis, home therapies like peritoneal dialysis and home hemodialysis provide some advantages, such as a more flexible treatment schedule, better fluid and metabolic control, flexibility to travel, and higher modality satisfaction.
The preferred treatment for ESKD is kidney transplantation. It is the process where the patient undergoes surgery and receives a donated kidney from either a live donor or a deceased donor. Only one kidney is transplanted into the patient (recipient) as a single functioning kidney is enough to maintain fluid and metabolic homeostasis, and thus there is no further need for dialysis.
The kidney transplant evaluation process, however, is long and arduous, and wait times for an organ can be long, so most ESKD patients undergo some type of dialysis while undergoing evaluation or waiting for a kidney transplant.
Kidney transplant recipients, however, often experience a better quality of life and have a projected longer survival compared to those who remain on dialysis.
Choosing what type of renal replacement therapy to do is influenced by a lot of factors such as the patient’s overall condition and age, severity and stability of other comorbid medical conditions, availability or access to the different dialysis modalities and transplant centers, lifestyle, and personal, religious, or cultural beliefs.
The decision of when to start and what type of modality to choose is a shared decision between the patient and the nephrologist.
DR. VALERIE TAN is a board-certified Nephrologist and works at Hawaii Nephrologists, LLC in Waipahu, Hawaii.
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