Kidney failure: Choosing the best treatment Introduction

Kidney failure: Choosing the best treatment
Introduction

The kidneys filter the waste from the blood and regulate other functions of the body. When your kidneys fail, you need a treatment that does the work your kidneys normally do.

If you have kidney failure you should make some decisions about your treatment. You may choose not to receive any treatment. If you choose to receive treatment, your options include hemodialysis, which uses a machine to filter the blood out of your body; Peritoneal dialysis, which uses the lining of your abdomen to filter the blood into your body; And kidney transplantation, where a new kidney is placed in your body. Each treatment has advantages and disadvantages. Your treatment decision will have a major impact on your daily life, for example, your ability to retain your job if you work. You are the one who can decide what is the most important. Reading this booklet is a good way to know your options so you can make an informed decision. Y, If you find that the choice you choose does not fit your life well, you can change your treatment. With the help of health professionals, their families and friends, you can live a full and active life.

When Kidneys Fail

Healthy kidneys filter the blood by removing excess fluid, minerals and debris. The kidneys also produce hormones that keep bones strong and blood healthy. When the kidneys fail, harmful waste accumulates in the body, blood pressure can rise, and the body can retain excess fluid and not produce enough red blood cells. When this happens, you need treatment to replace the task of your kidneys.

Treatment option: hemodialysis

Purpose

Hemodialysis cleanses and filters the blood using a machine to temporarily remove hazardous waste from the body, and excess salt and water. Hemodialysis helps control blood pressure and helps the body maintain the proper balance of important chemicals, such as potassium, sodium, calcium and bicarbonate.

Dialysis can replace part of the functions of the kidneys. Medicines, special diets, and restriction of fluid intake are also needed. What you can eat and drink, and how much medication you will need depends on the treatment you choose.

A diagram of the extra corporeal circuit of hemodialysis. Labels are labeled blood drawn for filtration, blood pressure monitor, blood pumping, heparin pumping to prevent clotting, dialyzes, pressure monitor of the input flow to the dialyses, Air, the venous pressure monitor, the air trap and the air detector, and the filtered blood returning to the body.
Hemodialysis.
How Hemodialysis Works

Hemodialysis uses a special filter called a dialyzes that functions as an artificial kidney to filter blood. The dialyses is a cylinder connected to the hemodialysis machine. During treatment, your blood gets through tubes to the dialyzes, which filters the waste and removes excess salt and water. Then, clean blood flows through another set of tubes and re-enters your body. The hemodialysis machine monitors blood flow and removes waste from the dialyzes.

Hemodialysis is usually done three times a week. Each treatment lasts 3 to 5 hours or more. During treatment, you can read, write, sleep, talk or watch television.

How to prepare

You will need to create access to your bloodstream several months before your first hemodialysis treatment. You may have to stay overnight in the hospital, but many patients are given access without hospitalization. This access provides an effective way for blood to be transported from your body to the dialyses and back to the body without causing discomfort. The two main types of access are a fistula and a graft.

An illustration of a forearm with an arteriovenous fistula. The arrows show the direction of blood flow. Two needles are inserted into the fistula. The labels explain that a needle carries blood to the dialyzer machine. The other returns the blood from the dialyzer machine.
Arteriovenous fistula.
A surgeon makes a fistula using the patient's blood vessels; An artery is connected directly to a vein, usually in the forearm. The increase in blood flow causes the vein to grow in size and strength so that it can be used for repeated needle insertions. This type of access is preferred. It may take several weeks to be ready for use.
Illustration of an arm with a graft in loop. The labels are pointing toward the artery and vein. A bent tube, labeled as a loop graft, connects with the artery to the vein. The arrows indicate the direction of blood flow from the artery to the vein.
Graft.
A graft connects an artery to a vein using a synthetic tube. It does not need to develop like the fistula, so it can be used sooner after placement. However, a graft is more likely to have infection and coagulation problems.
Before dialysis, needles are placed in the access to draw blood.

If your kidney disease has progressed quickly, you may not have the time to get permanent vascular access before starting hemodialysis treatments. You may need to use a catheter (a small, flexible tube that is inserted into a vein in your neck, chest, or leg near the groin) as temporary access. Some people use a catheter as long-term access as well. Catheters that will be worn for more than about three weeks should be placed under the skin for convenience and less complications.

For more information on vascular access, see the fact sheet titled Vascular Access for Hemodialysis of the National Institute of Diabetes and Digestive and Kidney Diseases, NIDDK for its acronym, which in Spanish is called the National Institute of Diabetes and Digestive and Kidney Diseases . (This publication is only available in English.)

Illustration of an intravenous catheter for temporary access of hemodialysis. The catheter is inserted through the skin and near the clavicle.
Catheter for temporary access.
Who performs hemodialysis

Hemodialysis is usually performed in a dialysis center by trained technicians in patient care who are supervised by nurses. Medicare pays three hemodialysis treatments per week. If you choose to do the treatment in a center, it will be done during a fixed time, three times a week, Monday, Wednesday and Friday or Tuesday, Thursday and Saturday. If you do not get the schedule of your preference, you can request that they put you on a waiting list for the schedule you prefer. In special cases, you may exchange your schedule with another person. You will need to plan your dialysis program well if you work or have children to care for. Some centers offer overnight dialysis treatments within the center. This treatment is performed over a longer period of time during the night, While sleeping in the center. This type of dialysis reduces limitations on food and fluid consumption, and also gives you more time during the days to work, take care of your children and perform hobbies and other activities.

You can choose to learn to have your own hemodialysis treatments in your home. When you are the only patient, it is possible to have more frequent or long-lasting dialysis treatments that almost replace the normal work performed by healthy kidneys. Home diurnal hemodialysis (DHHD) is done 5 to 7 days a week for 2 or 3 hours per session and you organize the schedule. If your health insurance plan were to pay more than three treatments, you could do the brief treatments in the mornings or afternoons. Home-made hemodialysis at home (NHHD) is done 3 to 6 nights a week while you sleep. Whether you choose DHHD or NHHD, this will allow you a normal diet and fluid intake, With fewer medications for blood pressure and other health problems. Most programs ask that patients who are on hemodialysis at home have a trained assistant during treatments. Learning to have hemodialysis is like learning to drive a car: it takes a few weeks and, at first, it is alarming but then it becomes a routine. The dialysis center provides the machine and training, as well as 24-hour telephone help if you have any questions or problems. New machines for dialysis at home are smaller and easier to use than the machines used in the centers. Learning to have hemodialysis is like learning to drive a car: it takes a few weeks and, at first, it is alarming but then it becomes a routine. The dialysis center provides the machine and training, as well as 24-hour telephone help if you have any questions or problems. New machines for dialysis at home are smaller and easier to use than the machines used in the centers. Learning to have hemodialysis is like learning to drive a car: it takes a few weeks and, at the beginning, it is alarming but then it becomes a routine. The dialysis center provides the machine and training, as well as 24-hour telephone help if you have any questions or problems. New machines for dialysis at home are smaller and easier to use than the machines used in the centers.

You have options for dialysis centers and many cities have more than one center to choose from. You can visit a center to find out if there are any treatments you want or the schedule you need. Some centers allow you to use laptops or cell phones or receive visitors, others do not. Medicare has a list of all centers in the United States on its website at www.medicare.gov/dialysisfacilitycompare/search.html (In English), which shows the quality ratings of each center. Your health plan can have a list of centers you can go to. If you choose a treatment option in a center, it should be close to your home in order to reduce your travel time. If the treatment is done at home, once you are trained, you should only go to the center once a month. So the center can be as far away as you want to travel once a month.

Possible complications

Vascular access problems are the most common reason for hospitalization among people receiving hemodialysis treatment. Some of the common problems are infection, coagulation blockage and poor circulation. These problems may prevent your treatments from working. You may have to undergo repeated surgeries to achieve properly functioning access.

Other problems can be caused by rapid changes in water and chemical balance of your body during treatment. Muscle cramps and hypotension (a sudden drop in blood pressure) are two common side effects. Hypotension can make you feel weak, dizzy or sick to your stomach.

It probably needs a few months to adapt to hemodialysis. Side effects can often be treated quickly and easily, so you should inform your doctor and dialysis staff of any side effects you experience. You can avoid many side effects if you eat a proper diet, limit the consumption of fluids and take your medications as directed.

Diet for Hemodialysis

Hemodialysis and a proper diet contribute to reducing wastes that accumulate in the blood. In all dialysis centers there is a dietitian available to help you plan your meals as instructed by your doctor. When you choose food remember

Consuming balanced amounts of high protein foods like meat, chicken and fish.
Control the amount of potassium you eat. Potassium is a mineral found in: salt substitutes; Some fruits like bananas and oranges; the vegetables; the chocolate; And nuts. Consuming too much potassium can be dangerous for the heart.
Limit the amount of liquids you drink. When the kidneys are not working, water quickly accumulates in the body. Excess fluid causes your tissues to swell and can lead to high blood pressure, heart problems, cramps, and low blood pressure during dialysis.
Avoid salt. Salty foods make you thirsty and cause the body to retain water.
Limit the consumption of foods such as milk, cheese, nuts, dried beans and dark soda / sodas. These foods contain large amounts of mineral phosphorus. Having too much phosphorus in the blood removes calcium from the bones, which weakens them, makes them brittle and can cause arthritis. To prevent bone problems, your doctor may give you special medications, which you should take with meals every day as directed.
For more information on choosing the right foods, see the NIDDK booklet Eat well to feel good during hemodialysis treatment .

Advantages and disadvantages

All people respond differently to similar situations. What can be a negative factor for some could be positive for others. Consult the following list of the general advantages and disadvantages of hemodialysis performed at a facility and at home.

Working with your team of medical professionals

Questions you may want to ask:

Is hemodialysis the best treatment option for me? Why?
If I receive the treatment in a center, can I choose the center?
What should I look for in a dialysis center?
Will my nephrologist see me at the dialysis center?
What does hemodialysis feel like?
What is self-care dialysis?
Is hemodialysis available in my home? How long does it take to learn? Who will train my assistant and me?
What type of vascular access is best for me?
As a hemodialysis patient, will I be able to continue working? Can I get treatment at night?
How much exercise should I do?
Who will be part of my team of medical professionals? How can these people help me?
Who can I talk to about finances, sexuality, or family concerns?
How and where can I talk to other people who have had to face this decision?
Hemodialysis in a center

Advantage

Facilities are widely available.
There are trained professionals who are with you all the time.
You can get to know other patients.
You do not need an assistant or keep equipment in your home.
Disadvantages

The treatments are programmed by the center and are relatively fixed.
You must travel to the center for treatment.
This treatment requires the strictest diet and the greatest liquid restriction of all.
You must take and pay for more medications.
You may experience mood changes more often.
It may take a few hours to feel better after the treatment.
Hemodialysis in the home

Advantage

You can do it at the times you choose, but you should do it as often as your doctor tells you.
You do not have to travel downtown.
You gain a sense of independence and control over your treatment.
Newer machines require less space.
You will experience changes in mood less often.
Home hemodialysis affects less of your work schedule than treatment at a facility.
Your diet and fluid intake will be more similar to normal for you.
You can take new machines with you: on car trips, in trailers or on airplanes.
You can spend more time with your loved ones.
Disadvantages

Must have an assistant.
Helping with treatments could cause stress to your family.
You and your assistant need training.
You need space to store the machine and supplies in the house.
You may need to apply for leave to work for your training.
You should learn how to insert the needles for dialysis.
Daytime and nighttime forms of hemodialysis in the home are not yet available everywhere.
For more information on hemodialysis, see the NIDDK booklet Methods of Treatment for Renal Failure: Hemodialysis . You can also consult the table summarizing three treatment options.

Treatment option: peritoneal dialysis

Purpose

Peritoneal dialysis is another procedure that removes wastes, chemicals and excess water from your body. This type of dialysis uses the lining of the abdomen, or belly, to filter the blood. This lining is called the peritoneal membrane and acts as an artificial kidney.

How Peritoneal Dialysis Works

A mixture of minerals and sugar dissolved in water, called a dialysis solution, is transported through a catheter into your abdomen. The sugar called dextrose removes debris, chemicals and excess water from the tiny blood vessels in your peritoneal membrane and brings them to the dialysis solution. After several hours, the solution used is drained from your abdomen through a tube, carrying with it the debris from your blood. Then your abdomen is refilled with a freshly prepared dialysis solution, and the cycle repeats. The process of draining and refilling is called swapping.

A diagram of a patient receiving peritoneal dialysis.  The labels mark the dialysis solution, the catheter, the peritoneum, and the abdominal cavity.  The dialysis solution drips through the catheter into a plastic bag in the abdominal cavity.
Peritoneal dialysis.
How to prepare

Before your first treatment, a surgeon places a catheter in your abdomen or chest. The catheter tends to work best if you have the right time (usually 10 days to 2 or 3 weeks) for the insertion site to heal. Planning your dialysis access can improve treatment success. This catheter stays there permanently to help transport the dialysis solution to and from your abdomen.

Types of peritoneal dialysis

There are three types of peritoneal dialysis available

Continuous Ambulatory Peritoneal Dialysis (CAPD)
The CAPD does not require a machine and can be done in any clean and well-lit room. With CAPD, your blood is always being cleaned. The dialysis solution passes from a plastic bag through the catheter to your abdomen where it stays for several hours with the catheter sealed. The period the dialysis solution is in your abdomen is called a "dwell time." Then you drain the dialysis solution into an empty bag to discard it. Then refill the abdomen with a fresh dialysis solution so that the cleaning process begins again. With CAPD, the dialysis solution remains in the abdomen for a residence time of 4 to 6 hours or more. The process of draining the dialysis solution used and replacing it with a fresh solution takes 30-40 minutes. Most people change the dialysis solution at least four times a day and sleep with the solution in the abdomen at night. With CAPD, it is not necessary to wake up to do dialysis tasks during the night.
Assisted peritoneal dialysis for continuous cycler (CCPD for its acronym in English)
CCPD uses a machine called a cycler to fill and empty your abdomen three to five times during the night while you sleep. In the morning, you begin an exchange with a time of permanence that lasts all day. An additional mid-afternoon swap could be made without the cycler to increase the amount of debris removed and to reduce the amount of liquids left in your body.
Combination of CAPD and CCPD
If you weigh more than 175 pounds or if your peritoneum slowly filters out debris, you may need a combination of CAPD and CCPD to get the correct dose of dialysis. For example, some people use a cycler at night but they also do an exchange during the day. Others make four exchanges during the day and use a mini-mixer to make one or more exchanges during the night. You will work with your team of medical professionals to determine the best program for you.
Who performs peritoneal dialysis

Both types of peritoneal dialysis are usually performed by the patient without help from anyone. CAPD is a form of self-treatment that does not need a machine. However, with CCPD, you need a machine to drain and refill the abdomen.

Possible complications

The most common problem of peritoneal dialysis is peritonitis, a serious abdominal infection. This infection can occur if the opening where the catheter enters your body becomes infected or if contamination occurs when the catheter is attached or disconnected from the pouches. Infections are less common in presternal catheters, which are placed in the chest. Peritonitis requires antibiotic treatment ordered by your doctor.

To avoid peritonitis, you should be careful to follow the procedures exactly and learn to recognize the first signs of peritonitis, including fever, an unusual or cloudy color of the fluid used, and redness or pain around the catheter. Report these signs to your doctor or nurse immediately so that peritonitis can be treated quickly and avoid other problems.

Diet for peritoneal dialysis

A diet for peritoneal dialysis is slightly different from a diet for hemodialysis at a center.

You will still need to limit salt and fluid intake, but you may eat more of each as compared to hemodialysis in one center.
Must consume more protein.
You may have different restrictions for potassium. You may even have to eat foods high in potassium.
You may need to reduce the amount of calories you consume because there are calories in the dialysis fluid that could make you gain weight.
Your doctor and a dietitian who specializes in helping people with kidney failure can help you plan your meals.

Advantages and disadvantages

Each type of peritoneal dialysis has advantages and disadvantages.

Working with your team of medical professionals

Questions you may want to ask:

Is peritoneal dialysis the best treatment option for me? Why? If the answer is "yes", which type is the best?
How long will it take for me to learn to do peritoneal dialysis?
What does peritoneal dialysis feel like?
How will peritoneal dialysis affect my blood pressure?
How will I know if I have peritonitis? How is it treated?
As a peritoneal dialysis patient, will I be able to continue working?
How much exercise should I do?
Where do I keep supplies?
How often do I see my doctor?
Who will be part of my team of medical professionals? How can these people help me?
Who do I call if I have problems?
Who can I talk to about finances, sexuality, or family concerns?
How and where can I talk to other people who have had to face this decision?
Peritoneal dialysis

CAPD

Advantage

You can do it alone.
You can do it at times you choose as long as you carry out the required exchanges every day.
You can do it in many places.
No machine needed.
It will not suffer the changes in the mood that suffer many patients who receive hemodialysis.
You will not have to travel to a center three times a week.
Disadvantages

It can interrupt your daily activities.
It is a continuous treatment, and all exchanges must be carried out seven days a week.
CCPD

Advantage

You can do it at night mainly while you sleep.
You do not have to carry out exchanges during the day.
Disadvantages

He needs a machine.
Its movement at night is limited by its connection to the cycler.
For more information on peritoneal dialysis, see the NIDDK booklet Treatment Methods for Kidney Failure: Peritoneal Dialysis. (This publication is only available in English). You can also consult the table summarizing three treatment options.

Dialysis is not a cure

Hemodialysis and peritoneal dialysis are treatments that help replace the work done by your kidneys. These treatments help you feel better and live longer, but they do not cure kidney failure. Although patients with kidney failure now live longer than ever, over the years kidney disease can cause problems such as heart and bone disease, arthritis, nerve damage, infertility, and malnutrition. These problems do not go away with dialysis, but doctors now have new and better ways to prevent or treat them. You should talk with your doctor about these complications and their treatments.

Treatment option: renal transplant

Purpose

Kidney transplantation involves surgically placing a healthy kidney from another person in your body. The donated kidney does a sufficient portion of the work that his two kidneys used to do to keep him healthy and asymptomatic.

How Renal Transplant Works

A surgeon places the new kidney into your lower abdomen and connects the artery and vein of the new kidney to your artery and vein. Their blood flows through the donated kidney, which produces urine, just as their own kidneys did when they were healthy. Your new kidney may start working right away or it may take up to a few weeks to produce urine. Unless your own kidneys are causing you an infection or high blood pressure, they stay in place.

A diagram showing the location of a kidney donated in the lower abdomen.  The diseased kidneys remain in the upper abdomen.  The labels refer to the diseased kidneys, the artery, the vein, the transplanted kidney, the transplanted ureter, and the bladder.
Kidney transplant.
How to prepare

The transplant process has many steps. First, talk to your doctor because the transplant is not for everyone. You may have a condition that would make the transplant dangerous or make success unlikely.

You may receive a kidney from a deceased donor (a person who has recently died) or from a living donor. A living donor may or may not be a relative, usually a spouse or friend. If you do not have a living donor, you are placed on a waiting list to receive a kidney from a deceased donor. Waiting for a kidney from a deceased donor can last for several years.

The transplant team considers three factors to match kidneys with potential recipients. These factors help predict whether your body's immune system will accept or reject the new kidney.

Blood type. Your blood type (A, B, AB or O) must be compatible with the donor. Blood type is the most important compatibility factor.
Human leukocyte antigens (HLA). Their cells carry six important HLAs, three inherited from each of their parents. Members of the same family are more likely to be perfectly compatible. You may be given a kidney if HLAs are not perfectly compatible as long as your blood type is compatible with the blood type of the organ donor and other tests do not show compatibility problems.
Cross-compatibility antigens. The last test that is done before implanting an organ is cross-compatibility. A small sample of your blood is mixed with a sample of the donor's blood from the organ in a tube to see if a reaction occurs. If no reaction occurs, the result is called negative cross-compatibility and the transplant operation can proceed.
The time taken for a kidney transplant

The time you have to wait for a kidney donation varies. Since there are not enough deceased donors per person who needs a transplant, you should be put on a waiting list. However, if a volunteer donor gives you a kidney, the transplant can be scheduled as soon as both are ready. Avoiding long waiting is an important advantage of donating a living donor.

The surgery takes 3 to 4 hours. Hospitalization is usually a week. After you leave the hospital, you will have regular follow-up appointments.

In a donation from a living donor, the donor will likely have to stay in the hospital for about the same amount of time. However, a new technique for removing a kidney for donation uses a small incision and possibly will allow the donor to leave the hospital within 2 or 3 days.

Between 85 and 90 percent of transplants from deceased donors are operating one year after surgery. Transplants from living relatives often give better results than transplants from unrelated or deceased donors because generally the compatibility is narrower.

Possible complications

Transplantation is what comes closest to healing. But however good the compatibility, your body may reject your new kidney. A common cause of rejection is not taking medications as they were prescribed.

Your doctor will give you medicines called immunosuppressants to help prevent the immune system from attacking the kidney, a process called rejection. You should take immunosuppressants every day for as long as the kidney is working. However, sometimes even these medications can prevent your body from rejecting the new kidney. If this happens, you should return to some form of dialysis and possibly wait for another transplant.

Immunosuppressants weaken your immune system, which can lead to infections. Some medications may also change your appearance. The face may become fuller; You may gain weight or get acne or facial hair. However, not all patients have these problems, and diet and makeup can help.

Immunosuppressants work because they decrease the ability of immune cells to function.

In some patients, the reduction of immunity for prolonged periods may increase the risk of cancer. Some immunosuppressants can cause cataracts, diabetes, excess stomach acid, high blood pressure, and bone disease. When used for a certain time, these medications may cause liver or kidney damage in a few patients.

Diet for Kidney Transplantation

The diet for patients who will receive a transplant is less limited than for dialysis patients, although you may still need to reduce the consumption of some foods. Your diet is likely to change as your medications, blood values, weight, and blood pressure change.

You may have to count calories. Your medicine may increase your appetite and make you gain weight.
You may have to eat less salt. Your medications may cause your body to retain sodium, which causes high blood pressure.
Advantages and disadvantages