Kidneys Failure
You may choose to forgo treatment. If you choose to receive treatment, your choices include hemodialysis, peritoneal dialysis, and kidney transplantation. Each treatment has advantages and disadvantages
When Your Kidneys Fail
Healthy kidneys clean your blood by removing excess fluid, minerals, and wastes. They also make hormones that keep your bones strong and your blood healthy. When your kidneys fail, harmful wastes build up in your body, your blood pressure may rise, and your body may retain excess fluid and not make enough red blood cells. When this happens, you need treatment to replace the work of your failed kidneys.
Hemodialysis: Hemodialysis cleans and filters your blood using a machine to temporarily rid your body of harmful wastes, extra salt, and extra water. Hemodialysis helps control blood pressure and helps your body keep the proper balance of important chemicals such as potassium, sodium, calcium, and bicarbonate.
Dialysis can replace part of the function of your kidneys. Diet, medications, and fluid limits are often needed as well. Your diet, fluids, and the number of medications you need will depend on which treatment you choose.
Hemodialysis uses a special filter called a dialyzer that functions as an artificial kidney to clean your blood. The dialyzer is a canister connected to the hemodialysis machine
Hemodialysis.
Arteriovenous fistula.Several months before your first hemodialysis treatment, an access to your bloodstream will need to be created. You may need to stay overnight in the hospital, but many patients have their access created on an outpatient basis. This access provides an efficient way for blood to be carried from your body to the dialyzer and back without causing discomfort. The two main types of access are a fistula and a graft.
- A surgeon makes a fistula by using your own blood vessels; an artery is connected directly to a vein, usually in your forearm. The increased blood flow makes the vein grow larger and stronger so it can be used for repeated needle insertions. This kind of access is the preferred type. It may take several weeks to be ready for use.
- A graft connects an artery to a vein by using a synthetic tube. It doesn’t need to develop as a fistula does, so it can be used sooner after placement. But a graft is more likely to have problems with infection and clotting.
Possible Complications: Vascular access problems are the most common reason for hospitalization among people on hemodialysis. Common problems include infection, blockage from clotting, and poor blood flow. These problems can keep your treatments from working. You may need to undergo repeated surgeries in order to get a properly functioning access.
Other problems can be caused by rapid changes in your body’s water and chemical balance 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.
You’ll probably need a few months to adjust to hemodialysis. Side effects can often be treated quickly and easily, so you should always report them to your doctor and dialysis staff. You can avoid many side effects if you follow a proper diet, limit your liquid intake, and take your medicines as directed.
Diet for Hemodialysis: Hemodialysis and a proper diet help reduce the wastes that build up in your blood. A dietitian is available at all dialysis centers to help you plan meals according to your doctor’s orders. When choosing foods, remember to
- eat balanced amounts of high-protein foods such as meat, chicken, and fish.
- control the amount of potassium you eat. Potassium is a mineral found in salt substitutes; some fruits, such as bananas and oranges; vegetables; chocolate; and nuts. Too much potassium can be dangerous to your heart.
- limit how much you drink. When your kidneys aren’t working, water builds up quickly in your body. Too much liquid makes your tissues swell and can lead to high blood pressure, heart trouble, and cramps and low blood pressure during dialysis.
- avoid salt. Salty foods make you thirsty and make your body hold water.
- limit foods such as milk, cheese, nuts, dried beans, and dark colas. These foods contain large amounts of the mineral phosphorus. Too much phosphorus in your blood causes calcium to be pulled from your bones, which makes them weak and brittle and can cause arthritis. To prevent bone problems, your doctor may give you special medicines, which you must take with meals every day as directed.
- + You don’t have to have a partner or keep equipment in your home.
- - Treatments are scheduled by the center and are relatively fixed.
- - You must travel to the center for treatment.
- - This treatment has the strictest diet and fluid limits of all.
- - You will need to take—and pay for—more medications.
- - You may have more frequent ups and downs in how you feel from day to day.
- - It may take a few hours to feel better after a treatment.
Peritoneal dialysis is another procedure that removes wastes, chemicals, and extra water from your body. This type of dialysis uses the lining of your abdomen, or belly, to filter your blood. This lining is called the peritoneal membrane and acts as the artificial kidney.
How Peritoneal Dialysis Works
A mixture of minerals and sugar dissolved in water, called dialysis solution, travels through a catheter into your belly. The sugar—called dextrose—draws wastes, chemicals, and extra water from the tiny blood vessels in your peritoneal membrane into the dialysis solution. After several hours, the used solution is drained from your abdomen through the tube, taking the wastes from your blood with it. Then your abdomen is refilled with fresh dialysis solution, and the cycle is repeated. The process of draining and refilling is called an exchange.
Types of Peritoneal Dialysis
Three types of peritoneal dialysis are available.
- Continuous Ambulatory Peritoneal Dialysis (CAPD)
CAPD requires no machine and can be done in any clean, well-lit place. With CAPD, your blood is always being cleaned. The dialysis solution passes from a plastic bag through the catheter and into your abdomen, where it stays for several hours with the catheter sealed. The time period that dialysis solution is in your abdomen is called the dwell time. Next, you drain the dialysis solution into an empty bag for disposal. You then refill your abdomen with fresh dialysis solution so the cleaning process can begin again. With CAPD, the dialysis solution stays in your abdomen for a dwell time of 4 to 6 hours, or more. The process of draining the used dialysis solution and replacing it with fresh solution takes about 30 to 40 minutes. Most people change the dialysis solution at least four times a day and sleep with solution in their abdomens at night. With CAPD, it’s not necessary to wake up and perform dialysis tasks during the night. - Continuous Cycler-assisted Peritoneal Dialysis (CCPD)
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 one exchange with a dwell time that lasts the entire day. You may do an additional exchange in the middle of the afternoon without the cycler to increase the amount of waste removed and to reduce the amount of fluid left behind in your body. - Combination of CAPD and CCPD
If you weigh more than 175 pounds or if your peritoneum filters wastes slowly, you may need a combination of CAPD and CCPD to get the right dialysis dose. For example, some people use a cycler at night but also perform one exchange during the day. Others do four exchanges during the day and use a minicycler to perform one or more exchanges during the night. You’ll work with your health care team to determine the best schedule for you.
To avoid peritonitis, you must be careful to follow procedures exactly and learn to recognize the early signs of peritonitis, which include fever, unusual color or cloudiness of the used fluid, and redness or pain around the catheter. Report these signs to your doctor or nurse immediately so that peritonitis can be treated quickly to avoid additional problems.
Diet for Peritoneal Dialysis: A peritoneal dialysis diet is slightly different from an in-center hemodialysis diet.
- You’ll still need to limit salt and liquids, but you may be able to have more of each, compared with in-center hemodialysis.
- You must eat more protein.
- You may have different restrictions on potassium. You may even need to eat high-potassium foods.
- You may need to cut back on the number of calories you eat because there are calories in the dialysis fluid that may cause you to gain weight.
Dialysis Is Not a Cure
Hemodialysis and peritoneal dialysis are treatments that help replace the work your kidneys did. These treatments help you feel better and live longer, but they don’t cure kidney failure. Although patients with kidney failure are now living longer than ever, over the years kidney disease can cause problems such as heart disease, bone disease, arthritis, nerve damage, infertility, and malnutrition. These problems won’t go away with dialysis, but doctors now have new and better ways to prevent or treat them. You should discuss these complications and their treatments with your doctor.
Kidney Transplantation: Kidney transplantation surgically places a healthy kidney from another person into your body. The donated kidney does enough of the work that your two failed kidneys used to do to keep you healthy and symptom free.
Complications: Transplantation is the closest thing to a cure. But no matter how good the match, your body may reject your new kidney. A common cause of rejection is not taking medication as prescribed.
Your doctor will give you medicines called immunosuppressants to help prevent your body’s immune system from attacking the kidney, a process called rejection. You’ll need to take immunosuppressants every day for as long as the transplanted kidney is functioning. Sometimes, however, even these medicines can’t stop your body from rejecting the new kidney. If this happens, you’ll go back to some form of dialysis and possibly wait for another transplant.
Immunosuppressants weaken your immune system, which can lead to infections. Some medicines may also change your appearance. Your face may get fuller; you may gain weight or develop acne or facial hair. Not all patients have these problems, though, and diet and makeup can help.
Immunosuppressants work by diminishing the ability of immune cells to function. In some patients, over long periods of time, this diminished immunity can increase the risk of developing cancer. Some immunosuppressants can cause cataracts, diabetes, extra stomach acid, high blood pressure, and bone disease. When used over time, these drugs may also cause liver or kidney damage in a few patients.
Withdrawing from Treatment: For many people, dialysis and transplantation not only extend life but also improve quality of life. For others who have serious ailments in addition to kidney failure, dialysis may seem a burden that only prolongs suffering. You have the right to refuse or withdraw from dialysis. You may want to speak with your spouse, family, religious counselor, or social worker as you make this decision.
If you withdraw from dialysis treatments or refuse to begin them, you may live for a few days or for several weeks, depending on your health and your remaining kidney function. Your doctor can give you medicines to make you more comfortable during this time. You may start or resume your treatments if you change your mind about refusing dialysis.
Even if you’re satisfied with your quality of life on dialysis, you should think about circumstances that might make you want to stop dialysis treatments. At some point in a medical crisis, you might lose the ability to express your wishes to your doctor. An advance directive is a statement or document in which you give instructions either to withhold treatment or to provide it, depending on your wishes and the specific circumstances.
An advance directive may be a living will, a document that details the conditions under which you would want to refuse treatment. You may state that you want your health care team to use all available means to sustain your life. Or you may direct that you be withdrawn from dialysis if you become permanently unresponsive or fall into a coma from which you won’t awake. In addition to dialysis, other life-sustaining treatments you may choose or refuse include
- cardiopulmonary resuscitation (CPR)
- tube feedings
- mechanical or artificial respiration
- antibiotics
- surgery
- blood transfusions