Kidney failure: dialysis, transplant and choosing a treatment

Learning that your kidneys are failing is hard, but there are several treatment paths. This article explains what kidney failure is and how the main treatments differ, using information from the US National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), the NHS and MedlinePlus.

1. Introduction

Kidney disease can worsen over time and lead to kidney failure. The NIDDK says that if less than 15 percent of the kidney is working normally, this is considered kidney failure ^[1]. The CDC calls this stage end-stage kidney disease and says it requires dialysis or a kidney transplant to survive ^[5]. Not everyone with kidney disease reaches this stage ^[5]. Reaching it can feel overwhelming, but you can work through the choices with others. The CDC recommends including a kidney doctor, called a nephrologist, on your care team ^[5], the NIDDK advises working with a dietitian on your eating plan ^[1], and a renal social worker can help you think through the decision ^[2]. This article is general information, and your own doctor decides which treatment is suitable for you.

2. Causes and what happens

Waste products and extra water build up in the body when the kidneys can no longer remove them ^[1]. Chronic kidney disease is the usual route, and diabetes and high blood pressure are its two most common causes ^[4]. MedlinePlus says dialysis is typically needed when about 10 to 15 percent of kidney function remains, and that doctors discuss it in advance ^[4]. The NIDDK adds that many people start dialysis when their filtering rate is low, with the timing varying from person to person ^[2].

3. Treatment options

The NIDDK describes four options ^{[1, 2]}.

Hemodialysis

A machine pumps blood through a filter outside the body and returns it. It is usually done at a dialysis centre about three times a week, with sessions lasting around four hours, or at home. Minor surgery is needed to create access to the blood vessels ^{[1, 2]}. The NIDDK says hemodialysis helps control blood pressure and balance minerals such as potassium, sodium and calcium in the blood ^[2]. In a dialysis centre, trained staff are with you, but the schedule is less flexible and diet and fluid limits are the strictest. Home hemodialysis can fit around work and travel, but you and a helper need several weeks of training, you need space at home for the machine and supplies, and you must learn to place needles in your vascular access ^[2].

Peritoneal dialysis

This is done at home and uses the peritoneum, the lining of the belly, as the filter. A catheter, a soft tube, is placed in the belly by surgery a few weeks before starting. In one form, exchanges of fluid are done by hand several times a day. In another, a machine does the exchanges overnight ^[2].

Kidney transplant

A healthy kidney from a living or deceased donor is placed in the body. The NIDDK says medicines to prevent rejection are needed for as long as the kidney works, and the wait for a donor kidney can take years, during which dialysis may be needed. Transplant usually has the fewest diet limits ^{[1, 2]}.

Conservative management

This means care without dialysis or transplant. The goals are to keep quality of life as good as possible, control symptoms and plan for the end of life. The NIDDK says only dialysis or transplant filters wastes from the blood, and that people can restart dialysis if they change their mind ^{[1, 2]}.

4. Complications and diet

The NHS lists these complications ^[3]:

• Hemodialysis: a skin infection around, and bleeding from, the blood vessel used for treatment, and too much fluid in the body, which can lead to heart failure.
• Peritoneal dialysis: skin infection where the catheter enters the belly, hernia, and peritonitis, an infection of the belly lining that needs treatment straight away because it can lead to sepsis.

The NIDDK says diet needs differ. People on hemodialysis usually have the strictest fluid and food limits, people on peritoneal dialysis have looser fluid limits, and a dietitian can plan eating for balance of nutrients, salt and minerals ^{[1, 2]}. The NIDDK also says none of these treatments will help the kidneys get better, and that dialysis replaces only part of kidney function ^[2].

5. Choosing a treatment

The NIDDK says the choice is personal, can be changed later and is best made early with your care team, family and people who have lived with each treatment. Things to think about include ^[2]:

• Daily routine, work and travel
• Space at home for equipment and supplies
• Whether a trained partner is available for home treatment
• Ability to learn the procedures
• Access to a dialysis centre or home training
• Other health conditions
• Diet and fluid limits
• Costs and insurance
• Personal priorities and values

The NIDDK also suggests thinking about advance directives, which state your treatment wishes if you cannot speak for yourself ^[2].

6. Prevention and slowing progress

The CDC says that for people with chronic kidney disease, treatment can slow progression. Steps include blood pressure and blood sugar control, being active, not smoking, following a kidney-healthy eating plan, taking medicines as prescribed and including a kidney specialist in your care team ^[5].

7. When to see a doctor

If you have kidney disease, ask your care team early about the stages and what each treatment involves ^{[2, 4]}. The NHS advises urgent medical advice if you are having dialysis and the skin around your access site or belly catheter is painful, swollen or a different colour, you have tummy pain or a lump in your tummy, you get a very high temperature or feel hot, cold or shivery, your heart beats faster than usual, you cannot pass urine or pass much less than usual, or the fluid draining from peritoneal dialysis looks cloudier than usual or has white flecks in it ^[3]. Bleeding from the blood vessel used for hemodialysis that does not stop is an emergency, so get emergency help straight away and follow any advice your care team has given you ^[3]. Stick to your treatment schedule and talk with your care team before changing treatment ^[2].

In an emergency, call your local emergency number (112 in India, 911 in the United States).

8. Conclusion

Kidney failure can be managed with hemodialysis, peritoneal dialysis, a kidney transplant or conservative care, and each has different demands and possible complications. Early planning with the care team and loved ones helps people choose what fits their health and life.