Table 2.

Potential biological factors contributing to poor outcomes upon early dialysis initiation

Potentially harmful factor	Dialysis modality	Pathophysiological consequences
Mechanical stress of dialysis therapy	Hemodialysis more than peritoneal dialysis	Vascular and endothelial damage
Membrane bioincompatibility	Hemodialysis	Inflammation, complement activation
Oxidative stress	Hemodialysis and peritoneal dialysis	Inflammation, oxidative stress
Infection including bacteremia related to vascular access	Hemodialysis	Acceleration of atherosclerosis, inflammation
Infections and peritonitis related to peritoneal access	Peritoneal dialysis	Acceleration of atherosclerosis, inflammation
Non-access related infections including pneumonia	Hemodialysis and peritoneal dialysis	Acceleration of atherosclerosis, inflammation
Repetitive low blood pressure episodes upon excessive ultrafiltration	Hemodialysis and peritoneal dialysis	Repeated bouts of acute tubular necrosis, loss of residual renal function, ischemic events
Ischemic limbs related to vascular access	Hemodialysis	Steal syndrome, necrotic fingers
Damage to peritoneum related to peritoneal dialysis	Peritoneal dialysis	Fibrosing peritonitis
Increased exposure to toxic medications such as ESA	Hemodialysis and peritoneal dialysis	Thromboembolic events, increased platelet activation
Low serum creatinine levels from low muscle mass (sarcopenia)	Hemodialysis and peritoneal dialysis	Increased PEW rates and risk of death
Use of anticoagulation therapy (heparin)	Hemodialysis	Risk of bleeding
Heightened anxiety upon each dialysis treatment	Hemodialysis and peritoneal dialysis	Reduced quality of life, depression, increased risk of death
Social burden and psychological stigma of dialysis dependency	Hemodialysis and peritoneal dialysis	Malfunctioning social status, impaired work and social prospects, loss of independency, depression
Frequent commuting to dialysis clinic	Hemodialysis more than peritoneal dialysis	Increased risk of motor-vehicle and other accidents
Immunological reactions from the remnant renal allograft (upon early dialysis reinitiation)	Hemodialysis and peritoneal dialysis	Bouts of acute rejection and inflammation, allograft rupture and bleeding
Reduced albumin levels	Peritoneal dialysis more than hemodialysis	Decreased pool of antioxidative albumin, PEW
Loss of vital nutrients and molecules such as carnitine and vitamin C	Hemodialysis more than peritoneal dialysis	PEW, anemia
Frequent blood loss and iron depletion	Hemodialysis more than peritoneal dialysis	Iron deficiency, resistant anemia requiring increased ESA doses

Abbreviations: ESA, erythropoietin-stimulating agent; PEW, protein–energy wasting.