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hi my name is dr. Mike Evans and this is
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a quick overview for people with kidneys
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that are failing who need some insight
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into the treatment options including the
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different types of dialysis as well as
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how to know when it's time to start
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dialysis so let's start with a kidney
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101 you know we talk a lot about balance
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and health and your kidneys are the
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superstar of balance whether it's fluids
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or body chemistry's or blood pressure
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our kidneys orchestrate with other major
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organs to keep this delicate equilibrium
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going 24/7 all this while filtering out
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waste products created by our body's
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metabolism so when your kidneys start to
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shut down your body has a hard time
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keeping a balance you might retain fluid
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or waste products your potassium or
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sodium might become abnormal your blood
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pressure might rise this can all make
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you feel rotten and raise your risk for
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serious illness so you need a new way to
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filter and balance your fluids and
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electrolytes and this is where decisions
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about kidney transplant and dialysis
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come in it takes quite a while to plan
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to transplant or dialysis though your
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doctor will usually start planning for
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this when your GFR which stands for
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glomerular filtration rate I test of
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your kidney is around 20 this is about
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the same as 20% kidney function this
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doesn't mean you need to start dialysis
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though most people start dialysis when
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their GFR gets below 12 or so actually
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doctors are moving away from starting
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dialysis based on just a number since
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this led the people starting dialysis
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earlier and when we look back these
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people actually didn't seem to do any
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better
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so now new Canadian guidelines consider
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your numbers but recommend starting
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dialysis when you begin developing
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symptoms of kidney failure such as
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severe fatigue nausea decreased appetite
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and shortness of breath
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however this symptom assessment can be
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tricky especially if you have other
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illnesses going on so you need to work
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with your kidney team and your
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nephrologist that the doctors to look
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after kidneys to figure out the symptoms
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that will improve with dialysis we want
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people to start thinking about their
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treatment options at least a year before
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they are going to need to start dialysis
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as it takes at least 3 to 6 months to
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make dialysis happen so let's consider
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your dialysis options one option is
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actually do nothing you know you may
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feel that because of where you are in
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life that your best choices is actually
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to let your kidney failure run its
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course
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we call this conservative care and the
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goal is to preserve
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they function for as long as possible
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through diet medications but knowing
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that this will not stop the slow decline
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in the kidney function and will
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ultimately lead to death conservative
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care is often chosen by people with
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other medical conditions who aren't
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candidates for transplant and feel the
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burden of discomfort caused by dialysis
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outweigh the potential benefits the next
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option is to get a new donated kidney
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either from a living donor a relative or
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a friend usually or someone who has died
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suddenly known as a deceased donor not
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everyone is a candidate for kidney
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transplant so it's really important to
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find out if this is a treatment option
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for you as far as the two types of
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kidneys deceased donor kidneys are not
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available immediately in fact in Canada
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about 20% of people on dialysis are
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waiting for deceased donor kidney
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transplant and it usually takes on
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average about five to eight years if you
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can get a transplant this is the best
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treatment option for most people since
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you will live longer and better than on
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dialysis so that's why it's important to
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think about the other type of kidney
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donor getting a kidney from a living
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donor usually a family member or friend
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kidneys from a living donor tend to last
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longer than those from a deceased donor
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and the transplant can happen earlier
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even before you start to alysus that's
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why it's important for you to talk to
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family and friends about the possibility
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of them donating a kidney to you this
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reminds me of my neighbor and friend
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John neighbor Esme who found out that
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the guy who rented out his basement
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needed a new kidney and so we went to
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and got himself tested and it turned out
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he was a match so he donated his own
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kidney incredible we need more people
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like John and it's probably a lesson
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altruism for all landlords I suspect
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okay
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I digress but but this leads us to our
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third option dialysis dialysis when we
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replace a function of the kidney using
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special equipment to clean the blood
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there are two basic kinds of dialysis
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hemodialysis which happens outside the
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body and peritoneal dialysis which
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happens inside the body hemodialysis is
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when your blood is passed through an
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artificial kidney which is called of
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course a dialyzer you'll need to make
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some changes to your diet and drink less
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fluid hemodialysis is usually done for
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four hours three times each week and
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requires access to your blood either
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through an intravenous line inserted in
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your neck or a fistula
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a fistula is created surgically
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by connecting an artery and a vein in
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your arm now this can take three months
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to be ready for you so it requires some
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planning just ask your doctor which is
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the right option for you
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occasionally hemodialysis is done at
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home even sometimes at night while
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you're asleep which frees up your days
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and your diet but most of the time when
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we were talking about HD we're talking
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about you going to a clinic or a
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hospital to have it done peritoneal
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dialysis or PD is when the blood is
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cleaned through a lining in the inside
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of your abdomen call your parent Neum
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with PD we put a tube close to your
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belly button into the peritoneum and
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pour in a special solution called
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dialysate and leave it there for a few
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hours
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the solution slowly sucks that the
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medical word is diffuses the waste
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products out of your blood you then
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drain the fluid back out through the
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tube and then fill up the parent name
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again we call this an exchange and it
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generally takes twenty to thirty minutes
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there are two ways to do peritoneal
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dialysis this has to do with the timing
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of the exchanges so first we have
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continuous ambulatory peritoneal
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dialysis or CA PD typically this means
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for exchanges that you perform yourself
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every day using bags of dialysis fluid
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during the time between exchanges you
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can move about as normal secondly we
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have a PD or automated peritoneal
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dialysis where a machine that you set up
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just before going to bed that's the
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exchanges for you at night for seven to
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ten hours while you are asleep
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during the day you might have some fluid
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in your abdomen but you are free to move
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about normally okay so now you know
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about kidney failure and if you want to
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do dialysis the next task is picking
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which treatment you prefer well let's
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start with some obvious reasons to have
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your dialysis done at the hospital doing
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dialysis at home requires an ability to
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self manage and problem-solve and I
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suspect your aptitudes in this
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department are better than you think and
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I also get that it can be scary for you
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or or your loved ones to learn a new
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skill especially if you're set in your
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ways having said that I think there are
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some conditions that can make it hard to
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self care reliably so for example
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alcohol or drug addiction or cognitive
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impairment or maybe you have another
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medical condition or you just find
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things very hard right now these can all
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be especially challenging for you if you
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don't have reliable helper some people
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have had a lot of abdominal surgeries
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can't do peritoneal
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dialysis either the next category of
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challenges that need some
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problem-solving but can usually be
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overcome so your your loved one may have
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limited vision or hearing or maybe some
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learning problems or physical
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limitations and so on extra training
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mentorship and family support may be
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required so for example hearing disabled
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patients can use vibration alarms frail
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patients can have family members trained
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there is mentorship from patients who
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have overcome the same barriers or in
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some places a visiting nurse can help
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set up your dialysis cycler machine at
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night dialysis experts will often say
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that if you can manage an ATM Bank
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machine or have the manual dexterity to
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button a shirt you can manage home
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dialysis just like there are factors
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that make us think that dialysis in a
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clinic is likely the answer there are
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factors that make us think that dialysis
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at home will be a better choice for
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example you might live far away from a
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dialysis clinic or have a fear of
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needles or you might not be happy
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following the fluid restriction or diet
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required for hemodialysis all issues
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that can make peritoneal dialysis at
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home a better choice having said all
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that I think the biggest reasons people
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pick home peritoneal dialysis are
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personal with the number one reasons
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being flexibility and control people
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often pick home PD because they prefer
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to self-manage in the comfort of their
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own home and they don't want to travel
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to the hospital three times a week you
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may want to travel you may care for
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others and need to be around or perhaps
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your work or school can't accommodate
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frequent absences it is possible to
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travel with HD but you'll need a
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hemodialysis clinic where you're going
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and this might be expensive and limit
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your travel options another factor that
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might drive your choice is whether there
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is evidence that one type of dialysis is
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better in terms of health outcomes well
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there's never been a definitive trial
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comparing peritoneal dialysis and
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in-center hemodialysis so there's a bit
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of controversy but most of us think that
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patients who are candidates for either
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type of dialysis will do just as well in
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either form in terms of survival and
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quality of life I think the reality here
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is that patients do best when they're
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able to get the information ahead of
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time come up with a plan and pick the
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type of dialysis that fits with their
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lifestyle if we exclude really sick
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people who would not be able to do home
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dialysis studies tell us that most
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patients who receive comprehensive
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education about the different types of
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dialysis will choose home Dallas
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usually peritoneal dialysis okay let me
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summarize there are two main treatments
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if you need dialysis one is hemodialysis
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where you typically go into a hospital
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or clinic on a predictable schedule and
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are hooked up to a dialyzer for about
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four hours three times a week and you
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need to make dietary changes some
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patients are trained to do their own
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hemodialysis at home the second
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treatment is peritoneal dialysis at home
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which can be done with 30-minute
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exchanges four times a day or by setting
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up a machine at bedtime which
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automatically does the exchanges while
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you sleep PD is portable and you can
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take it with you if you need to travel
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or if you want to do it outside your
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home both these approaches require
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procedure for access and some training
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so if possible it's important that you
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make this decision at least three to six
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months before you actually need dialysis
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both of them require you to keep an eye
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on your symptoms severe fatigue nausea
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decreased appetite and shortness of
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breath since these will guide you and
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your kidney team to know when it's time
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to start dialysis failing kidneys is is
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definitely a journey and hopefully this
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overview combined with discussions with
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experts expert patients and people you
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trust will make your journey more
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personalized I hope this helps and take
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care
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you
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