Choosing the Right Renal Replacement Therapy
Dr. Ashish Sharma
Head of Department of Renal Surgery and Transplantation
Post Graduate Institute of Medical Education and Research,
Patients with end-stage kidney disease often face the dilemma of which therapy to choose. Whether to go for kidney transplantation or to go for dialysis. If patients have to stay on dialysis, they have to choose whether to go for haemodialysis or peritoneal dialysis.
Risk a Transplant or Continue with Dialysis?
Kidney transplantation is the best option available for patients whose kidneys have stopped functioning. Kidney transplant gives them the best opportunity to be independent and away from health care facilities. They can focus on their day to day life and can get back to work. It is also the cheapest form of treatment as monthly cost of treatment is between Rs 5000-10000 per month after the initial three months as compared to dialysis where it exceeds Rs 20000 per month for the rest of the life. Moreover, it is the only treatment which replaces all the functions of the kidney and patients can take normal diet and intake of liquids. So for most patients, this is the treatment to be chosen.
The disadvantage of transplant is the need and risk of undergoing major surgery. There are side effects of immunosuppressive medications and there is need to take these medications very regularly as otherwise, these are rejected by the body.
Finding a Donor Is the Real Challenge
However, one needs to have a kidney donor, for transplantation to take place and not all patients will have a living donor willing and fit to donate a kidney. In fact, only a minority of kidney failure patients will have a living donor in the family who can donate a kidney for them. If no living donor is available in the family, patients have the option to be listed for getting an organ donated after death.
Even this option is limited as current donation rates in India are abysmally low and there is a long waiting list of many years before one can get a kidney from the donated organs. So till the time, patient gets the organ from the list, he has to stay on dialysis. Some patients specially with older age or with severe heart or vascular disease may also be not the right candidates for kidney transplantation as they may not be able to undergo the stress of a major surgery. This means that they have to stay on dialysis for the rest of their life.
More About Dialysis While Waiting for a Transplant
There are two types of dialysis – Haemodialysis and Peritoneal dialysis. In haemodialysis, blood is taken out from the body and is put through a filtering membrane in a dialysis machine which removes the waste products and after filtration blood is returned to the patient. Along with removal of waste products, dialysis also removes the excess water from the body. Patient needs to have a minor surgery (AV fistula) made to get the blood out of the body and to return it back.
There are four common sites to make an AV fistula. For some patients, veins may not be suitable to make AV fistula and they may need a synthetic graft to prove access for dialysis. The native fistula itself takes about 6 to 12 weeks to become functional. Till the time, it is functional, patients need to have a catheter in their neck from where the blood can be drawn and returned. The disadvantages with hemodialysis are that the patient needs to go to dialysis Centre at least twice a week and spend four to five hours for each session. There are many restrictions in the diet and the amount of liquid intake is severely restricted. Some patients with cardiac problems may not tolerate removal of blood from the body and may not be able to undergo haemodialysis at all.
The other option of dialysis is peritoneal dialysis where a plastic catheter is put inside the tummy and peritoneal dialysis fluid is put through the catheter four times a day and is retained for few hours before it is drained out. The thin membrane of your tummy acts as a filter and the waste products are removed along with dialysis fluid (called one exchange). The disadvantages of this mode of therapy is that one is constantly involved in doing four exchanges 7 days a week. Some patients especially elderly ones may need a caretaker to help the patient join all the tubings and put fluid inside the tummy. There are machines available which can do these exchanges automatically during the night and are more convenient but do limit your movements in the bed.
Freedom From Dialysis?
Need for regular dialysis sessions put restrictions. The advantages of peritoneal dialysis is that one need not go to the hospital or clinic and can manage the dialysis therapy at home. One can also plan travel with peritoneal dialysis by taking peritoneal fluid supplies with them or arranging at the place to visit where as patients on haemodialysis will need to have an appointment with local dialysis centre.
But patients who have had a transplant are free to visit wherever they want. So best course is to register with a transplant center for getting a kidney transplant. Until then follow diet and exercise instructions and continue with the dialysis.