Treating kidney failure

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1 Treating kidney failure Hemodialysis, peritoneal dialysis & kidney transplantation

2 Table of Contents n n n n n n n n n Introduction What are the kidneys? Why are the kidneys important? Why do kidneys fail? What are the treatments for kidney failure? Dialysis Kidney transplantation What type of treatment is best? What if I choose not to start treatment?

3 1 n Introduction This brochure provides an overview of the treatments available for kidney failure. There are many causes and types of kidney disease. Kidney disease is usually progressive and may lead to kidney failure. This brochure describes the two types of dialysis (hemodialysis and peritoneal dialysis), transplantation, and the role of diet and medication in treating kidney failure. n What are the kidneys? The kidneys are the master chemists of the body. Normally, there are two of them, one on either side of the spine under the lower ribs. They are reddish brown in colour and shaped like kidney beans. Each kidney is about the size of your clenched fist. Kidneys LOCATION OF KIDNEYS

4 2 n Why are the kidneys important? Healthy kidneys do three essential things. They remove wastes from the blood via the urine and return the cleaned blood back to the body. They regulate the levels of water and different minerals needed for good health. They produce hormones that control other body functions such as blood pressure. Many other organs depend on the kidneys in order to work properly. When the kidneys no longer work well enough, dialysis treatment or a kidney transplant is needed to keep on living. n Why do kidneys fail? Slow and progressive deterioration of kidney function is called chronic kidney disease (CKD). It is usually irreversible and may lead to complete kidney failure. Kidney failure occurs when the tiny filters in the kidney (nephrons) that remove wastes stop working. Damage to the nephrons can be caused by conditions such as diabetes and high blood pressure. In some cases, good Acute kidney failure. Sometimes kidney failure occurs rapidly and this is called acute kidney failure. This may be a result of injury, infection, or other causes. Dialysis treatment may be urgently needed for a period of time, but kidney function often recovers.

5 3 4 control of these conditions may slow or even prevent the development of complete kidney failure. n What are the treatments for kidney failure? There is no cure for kidney failure. In the early stages of kidney disease, proper food choices, medications and good blood pressure control may be all that is needed to slow the damage to the kidneys. However, once the kidneys are functioning at less than 10-15% of their normal rate (this stage is called endstage renal disease or ESRD), either dialysis or transplantation is needed to keep on living. These treatments are known as renal replacement therapies (RRT) because they attempt to replace the normal functioning of the kidneys. n Dialysis Overview Dialysis is a treatment which cleans the blood and removes wastes and excess water from the blood. Normally, this work is done by healthy kidneys. There are two types of dialysis. In hemodialysis, the blood is passed through an artificial kidney machine to clean it. Peritoneal dialysis uses a filtration process similar to hemodialysis, but the blood is cleaned inside your body rather than in a machine.

6 4 The type of dialysis treatment you receive depends on what is most appropriate for your particular needs. It may also depend on what is available in your community. Each type of dialysis has its strengths and limitations. The healthcare team can provide information and support to help you understand all the options and answer any questions. Hemodialysis How it works. During hemodialysis, the blood is passed through an artificial kidney to clean it. The cleaned blood is returned to the bloodstream. Only a small amount of blood is out of the body at one time. Therefore the blood must circulate through the machine many times before it is cleaned. Hemodialysis treatment is usually performed three times a week and takes four to five hours. Dialyzer HEMODIALYSIS MACHINE

7 5 4 Where it takes place. Hemodialysis can be done in a hospital dialysis unit, in a clinic away from the hospital, in a self-care centre (with some help from the staff), or at home. Special training is needed for self-care or home hemodialysis, including nocturnal home hemodialysis which is done at night while sleeping. Being attached to the dialysis machine. The most common way for you to be attached to the dialysis machine is via an internal fistula in the arm. Here, an artery and a vein are surgically joined, and the stronger blood flow from the artery causes the vein to become larger. Needles can then be inserted into the enlarged vein to connect you to the dialysis machine. Other methods are an internal graft (a short piece of tubing is placed under the skin and the needles are inserted into this graft) and a central venous catheter (usually a temporary method in which a soft tube is surgically inserted into a large vein in the neck or near the collarbone). Some changes needed with hemodialysis. You will need to plan your weekly activities around your hemodialysis schedule. You may have to take time off work or school before starting your hemodialysis treatments and when these treatments begin. However, once your health is more stable, you should be able

8 6 return to your normal activities, making some adjustments as needed depending on your energy level. You will need to learn appropriate food choices to meet your nutritional needs and control the build-up of food wastes and water. Your dietitian will work with you to design an individual eating plan that is healthy and enjoyable. Medications and vitamins may also be prescribed. Peritoneal dialysis How it works. With peritoneal dialysis the blood is cleaned inside your body rather than in a machine. The inside of your abdomen is called the peritoneal cavity and it is lined with a thin membrane called the peritoneum. This membrane surrounds the intestines and other internal organs. In peritoneal dialysis, this cavity is filled with dialysis fluid which enters the body through a permanently implanted catheter. Excess water and wastes pass through the peritoneum into the dialysis fluid. This fluid is then drained from the body and discarded. The process (called an exchange ) is repeated four to six times in every 24-hour period (for Continuous Ambulatory Peritoneal Dialysis, also called CAPD). In most cases this treatment can be performed without assistance, at home or at work.

9 7 More about Continuous Ambulatory Peritoneal Dialysis (CAPD): In CAPD, you carry about two to three litres of dialysis fluid in your peritoneal cavity all the time. An exchange is usually done four times a day by draining out the old fluid and refilling your peritoneal cavity with fresh fluid. The exchanges are often done early in the morning, at lunchtime, late in the afternoon and at bedtime. Each exchange takes about 30 to 45 minutes. During this time you can do other things, like eat your meals or get ready for bed. Sometimes an extra exchange is done while you sleep. Another type of peritoneal dialysis (called either Automated Peritoneal Dialysis or Continuous Cycler Peritoneal Dialysis) uses a machine called an automatic cycler to perform the exchanges every night while you sleep. More about Automated or Continuous Cycler Peritoneal Dialysis (APD, CCPD): In APD or CCPD, a machine called an automatic cycler performs exchanges every night while you sleep. In the morning, when you come off the machine, about two or three litres of dialysis fluid are usually left in your peritoneal cavity for the day. In the evening, you drain this fluid out when you connect yourself to the automatic cycler for the night. While this type of peritoneal dialysis allows you to do dialysis at home with no interruptions to your day, it does require that you be attached to the machine every night for eight to ten hours. Some people may also do an additional exchange or two during the day to provide adequate removal of waste products.

10 8 Gaining access to the peritoneal cavity. A tube called a catheter, made of soft, non-irritating plastic, is inserted in your abdomen usually below and to one side of your navel, and stays there as long as you are using this form of dialysis. Catheters are inserted at the bedside using local anesthetic, or in the operating room, depending on what is best for you, and on your individual situation. The dialysis fluid flows into, and is drained out of, the peritoneal cavity through this special tube. Peritoneum Peritoneal cavity Catheter PERITONEAL CAVITY

11 9 Some changes needed with peritoneal dialysis. As with hemodialysis, you will need to plan your weekly activities around your peritoneal dialysis schedule. You may have to take time off work or school before you start peritoneal dialysis and when the treatments begin. However, once your health is more stable, you should be able to return to your normal activities, making some adjustments as needed depending on your energy level. Since peritoneal dialysis works continuously, you have greater freedom in food choices than with hemodialysis. However, you will need to learn about appropriate food choices to meet your nutritional needs and control the build-up of food wastes and water. Your dietitian will work with you to design an individual eating plan that is healthy and enjoyable. Medications and vitamins may also be prescribed. n Kidney transplantation A kidney transplant is another treatment for people with kidney failure. It is a surgical procedure in which a healthy donated kidney is transplanted into your body. The transplanted kidney is able to do the work of two healthy kidneys.

12 10 A successful kidney transplant will allow you to return to a more normal lifestyle and will free you from dialysis treatments. It is widely considered to be the best way of treating kidney failure, but it is not suitable for everyone. To find out if you are a candidate for a kidney transplant, your healthcare team will perform a series of tests as part of a complete medical assessment. New kidney LOCATION OF TRANSPLANTED KIDNEY If you are a suitable candidate for a transplant, you will be put on a transplant waiting list until a kidney is found that is compatible with your body. The length of time you will have to wait is hard to predict because it depends on how hard you are to match, and how many kidneys become available. The donated kidney may come from a living person (living donor) or from a person who has died suddenly (deceased or nonliving donor). The transplant operation

13 11 4 takes two to four hours. After the surgery, you will need to take anti-rejection medication every day and have regular blood tests to watch for any signs of rejection. Rejection occurs when the body recognizes that the transplanted kidney is not its own and mobilizes the immune system to fight against it. Anti-rejection medications (called immunosuppressives) are used to prevent or treat rejection. They work by blocking the activity of the immune system. Some of these medications may cause side effects; your doctor will explain what these are. Rejection is more common in the early months after a transplant, but can occur any time. It may even happen when medications are taken faithfully. Rejection episodes can usually be treated successfully. It is hard to say how long a kidney transplant will last. Many factors influence how long it will work. Some kidneys have lasted longer than 25 years. On average, about half of transplanted kidneys are still working 10 years later. If the transplant stops working, you will be able to go back on dialysis. The transplanted kidney may not be removed. You may qualify for another kidney when you and your doctor think you are ready.

14 12 Deceased Donor Transplants. A healthy kidney from someone who has died suddenly is transplanted into your body. Before a deceased donor s kidneys can be transplanted, many medical tests are done to determine if they are healthy. Also, the family of the donor must consent to the organ donation. You will not know the identity of your donor. The success rate for a transplant from a deceased donor is high: 85 90% of these kidneys are working well after one year and will last on average from 10 to 15 years. Success rates are improving every year with advances in medical research. Unfortunately, the waiting time for a kidney transplant from a deceased donor is usually long. Most people wait three years or longer.

15 13 4 Living Donor Transplants. In a living donor transplant, a kidney is donated by a healthy person whose blood group and tissue type are compatible with yours. A living kidney donation comes most often from a family member such as a parent, child, brother or sister. A donor can also be a spouse, friend or co-worker. Or it can be a stranger. A genetic link between donor and recipient, although beneficial, is not always required. This is largely due to improved antirejection medications. Extensive tests will be done to determine the health and suitability of the potential donor. People who donate a kidney can live a normal life with one kidney, and there are few risks to healthy donors. For this type of transplant, there is a shorter waiting period and the organ donation and transplant surgeries can be scheduled when both the donor and recipient are in the best possible health. This will help to ensure the quality of the donated kidney is at its highest. The success rate for a transplant from a living donor is high: 90 95% of these kidneys are working well after one year and will last on average from 15 to 20 years. Success rates are improving every year with advances in medical research.

16 14 n What type of treatment is best? Choosing a treatment depends on what is most appropriate for your particular needs and circumstances, and what is available in your community. Each treatment has requirements, advantages and considerations. Your healthcare team can provide information and support to help you understand all the options and answer any questions you or your family may have.

17 15 n What if I choose not to start treatment? For some people, the treatment options of multiple medications and dietary changes, along with dialysis or a kidney transplant, may not offer a good enough quality of life. They may feel the burden of treatment outweighs the benefits of continued life. In these situations, people have the right to decide not to start treatment. Or, if treatment has already been started, people have the right to choose to stop it and to be supported with conservative care. Conservative care is a treatment option which provides comfort care, both physical and emotional, if you decide to let the disease run its course. The decision not to start treatment should be made carefully with the help of the healthcare team to make sure that all important supports are available. Before considering this option for yourself, it is important to discuss your feelings fully with your doctor and family. You may also wish to speak with your religious adviser or a mental health professional about your decision.

18 16 n Notes

19 17

20 T h e K i d n ey Fo u n d a t i o n OUR VISION Kidney health, and improved lives for all people affected by kidney disease. OUR MISSION The Kidney Foundation of Canada is the national volunteer organization committed to reducing the burden of kidney disease through: n funding and stimulating innovative research; n providing education and support; n promoting access to high quality healthcare; and n increasing public awareness and commitment to advancing kidney health and organ donation. For further information, or if you wish to help us in our efforts, please contact The Kidney Foundation of Canada office in your area. You can also visit our Web site at This material is available in accessible formats upon request by contacting or calling R E F. N O. : B R - T R E AT K D D S - E N G - 0 8

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