Kidneys - dialysis and transplant

When the kidneys fail, the main treatment options are dialysis, a kidney transplant, or comprehensive conservative care. The right choice depends on your health, your circumstances and your personal preferences, and it can usually be reviewed and changed over time.

Dialysis#

There are two forms of dialysis: peritoneal dialysis and hemodialysis.

Peritoneal dialysis#

Peritoneal dialysis takes place inside your body, using the peritoneal membrane as a natural filter. This membrane is a fine layer of tissue that lines the peritoneal (abdominal) cavity and covers organs such as the stomach, liver, spleen and intestines. It has a rich blood supply.

The treatment uses a soft tube called a catheter. A surgical operation is needed to place the catheter into the peritoneal cavity. The catheter is about 0.5 cm wide and stays in your body until dialysis is no longer needed. One end sits a few centimetres outside the body so it can be connected to a bag of special fluid (dialysate).

Through the catheter, the fluid flows into and out of the peritoneal cavity. Waste products and extra fluid pass from your blood into the special fluid, which is then drained away. Each time used fluid is replaced with fresh fluid, the cycle is called an “exchange”. The number of exchanges needed varies from person to person.

There are two main types of peritoneal dialysis:

• Continuous ambulatory peritoneal dialysis (CAPD). Four exchanges are usually done each day. Each exchange involves connecting a new bag of fluid, draining out the old fluid and running in the new fluid. It takes about 30 minutes and can be done almost anywhere with a few sensible precautions. Between exchanges you are free to go about your daily activities. Exchanges are typically done on waking, at lunch time, at dinner time and before bed, with some flexibility on busy days. CAPD works by gravity: placing the drain bag at floor level lets the old fluid drain out, and raising the new dialysate bag above shoulder level lets the fresh fluid flow in.
• Automated peritoneal dialysis (APD). A machine called a cycler does the exchanges. Each night the catheter is connected to the cycler’s tubing, and it moves dialysate in and out of the body while you sleep. APD is done every night and usually takes about eight to 10 hours. During the day, dialysate is often left in the body so that dialysis continues.

If you choose peritoneal dialysis, you will be taught how to order and care for your supplies, minimise the risk of infection, perform the exchanges, care for the site where the catheter leaves your body, manage your general health, and deal with any problems that come up.

Hemodialysis#

Hemodialysis creates a circuit in which blood is pumped from your bloodstream to a machine that filters out waste and excess water. The filtered blood is then pumped back into your bloodstream. Only a small amount of blood is outside your body at any one time. The process is not painful and takes about four to five hours.

For hemodialysis, the machine needs reliable access to your bloodstream. A “vascular access” is created during surgery. “Vascular” refers to blood vessels, including both arteries (which carry blood away from the heart) and veins (which carry blood back to the heart). The surgery is usually done as a day case, so an overnight stay is not needed. It can take up to two months for the access to “mature” before it is ready to use.

There are three types of vascular access:

• Fistula – joins one of your arteries to a vein. The vein enlarges and becomes the fistula, usually in your lower or upper arm. A fistula generally needs about six to eight weeks to develop after surgery before needles can be put into it.
• Graft – uses a piece of tubing joined between an artery and a vein. It also cannot have needles put into it until a few weeks after surgery.
• Catheter – usually a temporary tube placed into a large vein until a fistula or graft is ready. Catheters can be used immediately.

People with a vascular access need to look after it and practise careful hygiene to prevent infection. Talk to your doctor and healthcare team about how to care for your graft or fistula, because it is your lifeline for kidney failure treatment.

Hemodialysis can be done at home, or at a dialysis unit in a hospital or a satellite centre for people who need extra medical support. Your healthcare professionals will advise you on your options.

Hemodialysis is needed at least three times a week. At a dialysis unit you will have regular appointments for a four-to-five-hour session. If you dialyse at home, your schedule is tailored to you and may include shorter or longer sessions, with three to six treatments each week; extra treatments can help you feel better. If you choose home hemodialysis, special plumbing is installed and the machine and supplies are provided.

You will learn to manage your own dialysis. A spouse, friend, carer or partner can be trained to help you, though some people dialyse by themselves. Dialysing at home means you can choose when to dialyse — during the day or overnight while you sleep — and it is also possible to dialyse more often, which has health benefits.

Choosing a dialysis option#

The type of dialysis you choose may be influenced by several factors, including your health and medical suitability, your personal lifestyle (work, family responsibilities, travel and leisure) and your personal preference. Your healthcare professional will discuss the pros and cons of each option with you, your family and your healthcare team. It is usually possible to switch between options if one no longer suits you.

Kidney transplant#

A kidney transplant is a treatment for kidney failure, but it is not a cure. It can offer a more active life, freedom from dialysis, and freedom from restrictions on fluid and dietary intake. A transplanted kidney requires a lifetime of management and care.

Kidney transplants can come from living or deceased donors. The person receiving the kidney is the recipient, and the person giving it is the donor. Living donors can be relatives, partners or close friends, and occasionally people unknown to the recipient. Deceased donors are people who gave permission for their organs to be donated after death.

A transplant from a deceased donor is offered to medically suitable people who have been stabilised on dialysis. If the kidney comes from a living donor, the operation can sometimes be done when the kidneys are close to failing but before dialysis starts — this is called a pre-emptive transplant.

Kidney transplants are very successful, and success rates are higher with living donor kidneys than with deceased donor kidneys. If a transplant works well in the first year, there is a good chance it will keep working well for many years.

Who can have a transplant#

Not everyone is suitable for a transplant. Sometimes other medical problems make dialysis or comprehensive conservative care the better option. Factors that affect suitability include:

• agreement with the idea of transplantation and acceptance of the risks involved
• general good physical health, apart from kidney failure
• willingness to go through the tests and the operation
• willingness to take lifelong anti-rejection medication

The operation#

Surgery takes about two to three hours. A cut is made in your lower abdomen, on the right or left side, and the new kidney is placed in your pelvis. The renal artery and vein of the transplant kidney are connected to an artery and vein in your pelvis, and the ureter of the new kidney is connected to your bladder so urine can flow.

Your own failed kidneys are usually left in place to provide whatever function they still have. Occasionally they need to be removed — for example if they are very large or in the case of chronic infection — in a separate operation before the transplant.

After transplant surgery#

It is normal to feel some pain around your wound, and you will be given medication to help with this. Your transplanted kidney may start to make urine immediately, or you may need dialysis for a few days while it recovers. A catheter will be placed in your bladder for around five days to drain urine into a bag.

You will have daily blood tests to check how the kidney is working, measure your medication levels and pick up any problems early. If the kidney is working well, you may find you need to drink plenty of fluid. A physiotherapist may help you with an exercise plan, and it is important to do coughing, breathing and leg exercises while you are on bed rest.

How long you stay in hospital depends on how well your body responds and whether there are complications. Most people stay between six and 10 days. You may feel better soon after surgery, or take longer to adjust.

Anti-rejection care and rejection#

You will need to take anti-rejection medication for as long as you have the transplanted kidney to stop your body rejecting it.

In the early period after a transplant, you may have rejection episodes. These are often picked up only by your regular blood tests, and a rising eGFR or creatinine is usually the first sign of acute rejection. Many rejection episodes can be managed with changes to your medications, while some need extra treatments such as plasma exchange or special infusions. A biopsy of the transplanted kidney is often used to confirm rejection and decide on treatment.

Chronic rejection is a gradual process that leads to scarring and damage in the transplanted kidney. It usually develops over several years and can be very difficult to treat.

To give your transplant the best chance, look after yourself while you are on the waiting list and attend your regular reviews, where you can raise any concerns.

How a transplant may affect you#

Having a transplant should have a positive effect on your life. Even so, it is a major life event that can bring a range of emotions before and after the operation. You may have mood swings or feel stressed or depressed as you adjust to the transplant and as your body responds to the anti-rejection medication.

If a transplant stops working#

If a kidney transplant stops working, dialysis treatment will be needed again. Another transplant may also be possible.

Comprehensive conservative care#

Comprehensive conservative care is the treatment choice for people who have decided that dialysis and transplant are not right for them. For many, this is because they are already very frail and do not want complex treatments. Some people have complex treatment for a while and then choose to stop.

For many who are already frail, lifespan with kidney failure is very similar whether or not they have dialysis. Comprehensive conservative care means a person’s care continues to be supervised and supported by health professionals. They may use medication and a modified diet to improve their quality of life. This kind of supportive care does not artificially prolong life once the kidneys fail completely.

If you are unsure about which option to choose, it is always possible to try dialysis for a short while to see how it goes.

Key points#

• If a kidney transplant stops working, dialysis treatment will be necessary again.
• The two main types of peritoneal dialysis are continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD).
• The catheter is about 0.5 cm wide and remains in your body until dialysis is no longer needed.
• People with a vascular access need to take care of it and practise careful hygiene to prevent infection.
• Extra dialysis treatments can help you to feel better.

Where to get help#