An Introduction to the Kidneys and Chronic Kidney Disease
IX. TREATING KIDNEY FAILURE
If chronic kidney disease progresses until 85 to 90 percent or more of total kidney function is lost, patients will need long-term dialysis treatments or a kidney transplant to replace the function of their own kidneys. Ideally, you, your family and your doctor started talking about treatment choices early in the course of chronic kidney disease. In this section, we will provide you with a summary of the treatment choices for kidney failure. Three choices are available:
- Dialysis (hemodialysis or peritoneal dialysis)
- Kidney transplantation
- No treatment
You should gather all the information you can so you feel comfortable that you are making an informed decision.
A. Dialysis: Hemodialysis
To understand the meaning of hemodialysis, let's break down the word "hemodialysis." Hemo refers to blood and dialysis refers to the process of removing wastes from the blood, which your kidneys used to do before you had kidney failure. This form of dialysis uses a dialysis machine, that has a special filter, called an artificial kidney, or a dialyzer, to remove excess fluid and waste products from your blood.
On average, the entire process takes about three or four hours, and it must be done three times a week. The amount of dialysis you need is based in part on how long it takes to remove enough wastes from your blood to prevent the effects of kidney failure, which are discussed in Section Section VII.
Your dialysis care team will test your blood once a month to make sure you are receiving the right amount of hemodialysis, called your "delivered dose". Studies have shown that patients feel better and have a better quality of life when they receive the right amount of dialysis treatment. For more information, see "Treating Kidney Failure With Hemodialysis," which is part of this series. You can also order a copy of the National Kidney Foundation publication "Getting the Most From Your Treatment: What You Need to Know About Hemodialysis."
Hemodialysis can take place either in a dialysis center with other patients, or in your home. In a dialysis center, specific treatment days and times will be scheduled for you. A trained dialysis professional (either a nurse or patient care technician) is on hand to begin and end the hemodialysis treatment and to monitor your progress throughout.
In home hemodialysis, you and a family member or other "care partner" are trained to do the procedure in your own home. No matter where your hemodialysis takes place, however, you can feel free to write, read, rest, listen to music or visit with a friend while your blood is being cleaned. Many kidney patients make this a relaxing break in their busy days.
Some of the pros and cons of each type of hemodialysis are summarized in the following chart:
| * Pros (+) | Center Dialysis | Home Dialysis |
| Trained staff are there to do your dialysis treatments. | You can choose the time of day you dialyze. | |
| You get to know other patients. | You don't have to travel to a center for your treatment. |
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| Many centers encourage active participation in your dialysis treatments. | You may have more of a sense of independence and being in control of your treatment | |
| Cons (-) * | Your treatment times are scheduled by the center. | You need space for dialysis machine and supplies. |
| You must travel to a dialysis center. | There may be extra stress on the family member who helps you. |
Before you can have hemodialysis, you must have an access (or entrance) to your bloodstream created. This is a surgical procedure that can be done in three ways:
- A surgeon can connect a vein to an artery usually in your arm. This is called a fistula.
- The surgeon can use a piece of synthetic material to connect an artery and vein in your arm or leg. This is called a graft.
- In some cases, a soft tube, or catheter, may be connected to a vein in your upper chest or neck.
Fistulas are usually considered the first choice for your access because they tend to last longer and have fewer complications. If your blood vessels are not large enough or strong enough for a fistula, your doctor may decide to give you a graft instead. Catheters are generally used as a temporary access, but they may sometimes be permanent.
If you have a fistula or graft, your nurse or technician will begin your treatment by placing two large needles into your access - one in the artery side and one in the vein side. Each needle is connected to a soft tube. The tubing connecting to the artery side carries your blood to the dialyzer (artificial kidney). There, a specially prepared sterile fluid solution, called dialysate, aids the filtration of excess wastes and fluid from your blood (as a healthy kidney would do).
As your blood is cleansed, it is returned to you through the tubing connected to the needle in the vein side of your access. Even though your blood travels outside your body, it is always contained in tubing. When the treatment is completed, the needles are removed, the access site is cleaned and you are ready to take on the rest of the day.
If you have a catheter, this can be connected directly to the dialysis tubing, and no needles are used.
Hemodialysis is a relatively painless and safe procedure. While it does not cure kidney failure, it can improve the quality of your life and help you to live longer. Patients' lives have been extended more than 20 years by hemodialysis treatments.
Hemodialysis may be done at a center or at home.
B. Dialysis: Peritoneal dialysis
Peritoneal dialysis uses your own peritoneum to filter wastes and excess fluid from your blood instead of the artificial kidney doing the filtering. This type of dialysis requires surgical placement of a small soft tube, called a peritoneal catheter, in your lower abdomen. Then, a specially prepared sterile solution, called dialysate, passes from a sterile bag, through the catheter and into your peritoneal cavity (your belly). Your peritoneum acts as a filter between your blood vessels and the dialysate solution.
As the dialysate bathes the peritoneal membrane, waste products and excess salt and water flow out of the blood, through the membrane and into the dialysate. After a certain amount of time, the used dialysate and waste products are drained from the abdomen into an empty discard bag. You then fill your belly with fresh dialysate and begin the cleansing process again. The process of draining out the used solution and adding fresh solution is called an exchange.
It is important that you get the right amount of peritoneal dialysis to keep you healthy. Your doctor will give you a prescription that tells you:
- how long you need to keep the solution in your belly before draining it out (your dwell time)
- what type and amount of dialysate you need to use
- the number of exchanges you need to do each day.
A number of different types of peritoneal dialysis can be done, but the major ones are:
- Continuous Ambulatory Peritoneal Dialysis, or CAPD, in which a soft catheter is permanently placed in your lower abdomen. You do four to six exchanges each day. During CAPD, you can go about your daily business. You can fold the empty bag under your clothes around your waist or in a pocket. Some types of PD setups allow you to detach the empty bag and place a cap over the end of your catheter.
- Continuous Cycling Peritoneal Dialysis, or CCPD, uses a machine called a cycler to automatically fill and drain dialysate from your abdomen while you are sleeping. You may also need to keep dialysate solution in your abdomen during the day to continue the cleansing process. Sometimes, you may also be advised to do one or two additional exchanges during the day.
- Nighttime Intermittent Peritoneal Dialysis, or NIPD is the same basic procedure as CCPD except that your belly is dry during the day. This procedure may not be as effective in removing wastes because the cleansing process is not continued during the day.
Before starting peritoneal dialysis, you will be trained in how to do the procedure. You should always follow the steps you have learned carefully. Mistakes can lead to a serious infection called peritonitis, which can damage the peritoneal membrane and may prevent you from continuing with PD.
Peritoneal dialysis is a daily treatment. Getting enough dialysis is as important in PD as it is in hemodialysis. The amount of dialysis you receive, your delivered dose, should be measured on a regular basis by your dialysis care team. If your kidneys still produce urine, tests will be done routinely to check how much kidney function you have left. These tests tell your dialysis care team how well you are doing and whether any changes are needed to ensure that you are getting the most from your treatment. (For more information about this, see "Treating Kidney Failure With Peritoneal Dialysis," which is part of this series. You can order the National Kidney Foundation publication "Getting the Most From Your Treatment: What You Need to Know About Peritoneal Dialysis."
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| PD patients learn to do the steps at home. | ||
Whether you are a hemodialysis or peritoneal dialysis patient, the following steps can help ensure that you do well on your treatment:
- Do all your scheduled dialysis treatments or exchanges.
- Complete the full treatment time prescribed for you.
- Follow your daily dietary and fluid allowances.
- Take all your medications exactly as prescribed for you.
Each form of dialysis has its own set of advantages and disadvantages. What's best for you will depend on a variety of factors, including your overall health, personal preferences and daily routine. Also, patients can typically switch from one type of dialysis to another as their needs or their lifestyles change. Also, keep in mind that though dialysis will make you feel better and may prolong your life, it won't solve all the problems associated with your kidney condition. You will still have to take medications and follow a special diet that will be different from the one you followed in the earlier stages of your disease. The more you learn about your treatment plan, however, and the more active you are in making treatment choices, the more likely it is that you'll find the level of comfort you need to make dialysis a natural part of your life.
C. Kidney Transplantation
Another major treatment option for many patients with chronic kidney failure is kidney transplantation. This procedure involves removing a normal functioning kidney from one individual and placing it into someone whose kidneys have failed. If the transplant is successful, the new kidney takes over, and you no longer need dialysis. The kidney may come from one of the following:
- a living-related donor, who is a blood relative, such as a parent, brother or sister, or adult child
- a living-unrelated donor, which includes a spouse or close friend or sometimes, a stranger (non-directed donor)
- a cadaver donor, or someone who has died recently and had signed a donor card, indicating a wish to donate organs and tissues to help someone in need.
If you and your doctor decide that transplantation might be an option for you, the doctor will refer you to a transplant center for an extensive medical evaluation, which will determine whether you are a good candidate for a transplant. If you have a living donor, that person will also need to have a medical evaluation. After this is completed, all the results are presented to a transplant committee at the center. If everything is in order, the transplant coordinator will work with you and your donor to set up a date for the transplant.
If you do not have a potential living donor, your name will be placed on a waiting list to receive a cadaver donor kidney after completing the evaluation. You will be listed with your local or regional Organ Procurement Organization (OPO) and with the United Network for Organ Sharing (UNOS), which is a private organization under contract with the federal government to operate the national system for organ sharing.
A kidney transplant is placed in your lower abdomen.
No one can predict when a suitable cadaver kidney will become available for you so your transplant surgery may be performed with little prior notice, at any time, day or night. You have to be prepared to go when you get the call from the transplant center.
Your new kidney is surgically placed in the lower right or left side of your abdomen. The renal artery and vein of the donor kidney are connected to your own artery and vein. The ureter of the donor kidney is connected to your bladder. The new kidney often begins to make urine right after the surgery, but may take up to a few weeks to work well enough for you to discontinue dialysis treatment.
Transplantation, like dialysis, does carry risks. Among these is the possibility that your body may try to reject the transplanted kidney. To help prevent this, you will need to take special medications to prevent rejection. These are called immunosuppressants or anti-rejection medications. You will need to take these medications as long as you have the transplant. As with any medications, side effects may occur. Some of the medications make you more prone to infection, weight gain, and excess hair growth. If, for any reason, the transplanted kidney is rejected by your body, you can still resume dialysis and possibly be considered for a second transplant.
Kidney transplants are generally very successful, and the chance that the transplanted kidney will function well have improved with newer medications to prevent rejection. Transplant patients are seen and evaluated regularly following discharge from the hospital. Taking medications as prescribed and following dietary guidelines is as important as in the other treatment options.
Currently, the greatest barrier to transplantation is a lack of donated organs.
D. Choosing Not to Start Treatment
For many people with kidney failure, treatments like dialysis or a kidney transplant greatly improve quality of life. For some patients, however, treatment may not improve quality of life significantly - often because of their serious health problems. It is important to know that in such a situation, you have the right to decide not to start treatment.
Obviously, the decision not to start treatment is a very serious one. Once your kidneys have failed completely, you cannot survive without dialysis or a kidney transplant. Before considering this option, you should discuss it carefully with your doctor and your loved ones.
Your doctor will speak to you about what treatment involves and what deciding not to start treatment would mean for you. While the doctor may offer an opinion as to whether treatment would benefit you significantly, the final decision about starting or not starting treatment remains with you. For more information, speak to your doctor and read "If You Choose Not to Start Dialysis Treatment," available from the National Kidney Foundation.
