Dialysis Options: Making the Right Choice

Nephrologists (Kidney Medical Doctors) and patients with kidney disease work hard together to prevent kidney disease progressing to the point where dialysis is needed. Unfortunately, despite everybody’s best efforts kidney disease may progress to the point where dialysis is a serious possibility.  Once kidney function is below GFR of 20 mL/minute which is usually referred to as below 20% of normal kidney function, It is difficult to predict when dialysis will be needed.  Some patients will be fortunate and have periods of stability and otherwise generally slow worsening while other patients will be less fortunate and have a rapid loss of their kidney function.  Because the time course is unknown and unpredictable, every patient needs to make preparations as if the time course will be relatively short.

When patients have kidney disease that progresses to this point, their nephrologist begins a discussion regarding dialysis options.  It is very important to learn about all the different ways that it a person can receive dialysis because there are important health-related differences between the types of dialysis. Perhaps even more important, the impact of dialysis on the rest of your life defers between different types of dialysis.  Ultimately, it is important to match the patient with the correct type of dialysis for them and make sure that the patient is ready when the time comes that they need dialysis.

What do I mean when I say there are health-related differences between different types of dialysis?  This can mean that you may generally feel better with one type than another.  This can mean that your ability to go back to work or to more fully participate in whatever activities make you happy may be better with some types of dialysis than others.  This can mean to avoid feeling bad after dialysis may be better with some types of dialysis than others.  This can mean avoiding admissions to the hospital.  While it is possible for your choice of dialysis to result in a longer and healthier life, the differences are much more in how you feel than in how long you are going to live.  We call this quality of life and believe that that is very important.

What do a mean when I say that dialysis can impact the rest of your life when you are not in the dialysis unit?  Part of this is a time issue. You want to do dialysis at the time that will allow you to do all the things that you either need or want to do. You want to minimize missing out on work or hobbies or social interactions because of dialysis. Unfortunately any type of dialysis is going to interfere with other aspects of your life. Some things to think include:  dialysis can be done while you sleep at night freeing up your days, dialysis can be done at home allowing you the flexibility to change the dialysis schedule to meet your needs that may change from day-to-day, some dialysis treatments are more likely to leave you washed out feeling and unable to do the things you would like to do after dialysis is over while other types of dialysis have less or none of that effect.

Options

1)  Home:

                        a)  Peritoneal
Dialysis

                        b)  Home
Hemodialysis

2)  In-Center:

In-center Hemodialysis :
Short dialysis in a dialysis unit which usually means about 4 hours 3 times each week

-During the day
-During the evening

In-center Nocturnal Dialysis:
     Longer dialysis while you sleep overnight in a dialysis unit

3)  There are two other options

  1. Preemptive Kidney Transplant: A Preemptive Kidney Transplant is a Kidney Transplant done before dialysis is started.  While this is considered the best and most desirable option, it is difficult to achieve.  CKD patients cannot begin their transplant evaluation until their kidneys reach 20% functioning by a rule that can not be broken.  The transplant evaluation usually takes time as there can be lots of tests that need to be done and other issues.  Then after a CKD patient is accepted onto the transplant list, they can have potential donors get checked out.  This also takes substantial time in most cases and often does not lead to a transplant before dialysis is needed.  Therefore, we go through the process of choosing and getting ready for dialysis at the same time that a preemptive transplant is being evaluated.
  2. Medical treatment only/ Hospice: Everyone with advanced kidney disease has the right to prolong their life by dialysis and every patient also has the right to say they do not ever want dialysis.  This is mostly chosen by people who are elderly or those suffering from other severe illnesses.  Kidney doctors continue to provide medical treatment to keep patients who choose no dialysis comfortable.  At the end of life for these patients, we may decide of hospice care to further make sure they are comfortable

In-center Hemodialysis:  When Nephrologists and dialysis nurses are asked in surveys what type of dialysis they would want for themselves, almost 9 out of every 10 say they would want home dialysis either Peritoneal Dialysis or Home Hemodialysis.  However, almost 9 out of every 10 patients on dialysis in America have chosen In-center hemodialysis as their type of dialysis.  

What are the advantages of home dialysis that nephrologist and dialysis nurses understand and would want for themselves? 

-It turns out that in-center hemodialysis is the type of dialysis that is hardest on the body.  4 hours may seem like a long time, it is a major strain for you to have all the toxins and fluids removed that fast.  That is especially true when dialysis is only done 3 times per week so there is a substantial amount of fluids and toxins to remove.  The fast fluid and toxin removal actually can lead to brain and heart injury in many patients. It is not a complication of one single dialysis.  Instead, it is the stresses of rapid toxins and fluids removal on your heart and brain when you are getting dialysis more than 100 times per year that causes the damage.  

-Many in-center dialysis patients suffer from a long recovery time after dialysis.  This is the time it takes after dialysis until you feel as good as you did prior to the start of dialysis. Recovery time can be as long as 8 hours or more for some patients.   This long recovery period really impacts a significant portion of the rest of the day in many patients. 

-Lack of privacy is an issue in in-center dialysis.  However, it is balanced by having meeting other patients going through similar problems that help some patients cope.

-In-center dialysis patients spend a large amount of time in the unit and away from where they would rather be. 

-In-center dialysis patients have a 3 day stretch each weekend where they go without dialysis from Friday-Monday or Saturday to Tuesday.  In-center patients are hospitalized and die more frequently during that long 3 day stretch between dialysis treatments.  In order to not get sick over those 3 days,  Dialysis patients need to be especially strict with their diet, salt, and fluid restrictions.

Fortunately, there are lots of other dialysis options that would likely leave you feeling better and being healthier.  However, there are some patients who have no good option to in-center hemodialysis. I do not mean to say that in-center hemodialysis is a bad treatment because it can lead to lots of years of extra life.  It is just that I want every patient to think of other options that might leave them better off.  The dialysis units that Clinical Renal doctors use have all possible dialysis choices available and Clinical Renal doctors are available to tell you more about your choices. 

Other options:

Nocturnal in-center dialysis:  This is dialysis still done 3 days a week in a dialysis unit but it is done overnight.  You sleep in the dialysis unit while you get 7-8 hours of dialysis.  This slower dialysis usually leaves patients feeling better. It can almost eliminate recovery time.   It also leaves your days free.  To me, it is great that it both makes you healthier and gives you more daytime to enjoy yourself.  This slower dialysis helps protect your heart and brain from the damage caused by fast dialysis. This slower dialysis is also great for patients who already have heart and fluid problems.

Peritoneal dialysis:  A growing number of patients are choosing this excellent treatment.  Most patients prefer to do this while they sleep leaving their days free and others prefer to do it in the daytime.  Most patients do this totally themselves but others get some help from their family or partner.  Some of our older or very sick patients have the treatment done by their family completely but that is less common.  I am amazed at the success many patients have with Peritoneal Dialysis despite major medical conditions in addition to needing dialysis.  It is very gentle and avoids the bad feeling many patients get after in-center hemodialysis.  It is also a particularly healthy choice for patients with heart problems and fluid problems.  For patients on the kidney transplant waitlist, it seems that patients do better after transplant when they had peritoneal dialysis rather than in-center hemodialysis.

While patients can start in in-center hemodialysis and later change to peritoneal dialysis, it is much healthier to start in peritoneal dialysis at the start. In-center hemodialysis is rough on your kidneys and can make them loose the function they still have when you started dialysis.  Peritoneal dialysis is gentle on you kidneys and your kidneys can continue to function for much longer with peritoneal dialysis.  This small amount of continued kidney function is important to a person doing peritoneal dialysis.  It allows peritoneal dialysis to be done more easily.

Home Hemodialysis:  This has become much easier to do in recent years.  However, peritoneal dialysis is still more commonly used then home hemodialysis because it is simpler and quicker to learn.  

While we still prefer to have a person at home with you, about 1 out of every 3 patients doing Home Hemodialysis in America, have no partner and do it all by themselves.  Home Hemodialysis can be done for about 3-4 hours and about 5 times a week.  The more frequent dialysis means that dialysis can be done slowly and more safely because not as much cleaning of the blood and removal the fluid needs to be done during each treatment.  Part of the strong advantage of home hemodialysis over in-center hemodialysis is that you no longer will have a 3 day period between dialysis treatments over the weekend.  This danger period is eliminated in home hemodialysis done 4-5 times a week.

Many patients do Home Hemodialysis in the evening while they watch TV.  Home Hemodialysis can also be done overnight while you sleep in your bed or reclining chair.  This really frees up your days to enjoy your better health. 

When do you need to make a decision?  Usually, stage 4 CKD patients are asked to make a decision when their GFR is less than 20.  Once you make a decision, your Clinical Renal doctor will work with you to decide when the right time is to get your peritoneal dialysis or hemodialysis access.  Access is the place on your body that is used for dialysis.  For peritoneal dialysis, the access is a thin tube that goes into your belly (abdomen).   For hemodialysis, this is a small surgery to connect an artery and a vein in your arm.  For both types of access, they need to be put in well before you need dialysis.  Dialysis can still be done in an emergency if you do not have access yet but starting dialysis without good access is very risky and often leads to complications.

If you are now needing to make a decision about which type of dialysis you would prefer, your kidney doctor understands that it is a difficult decision that can seem overwhelming.  We are available to discuss your choices and answer any questions you may have.  Clinical Renal also has an education class in our offices to give you more information.  We can also arrange for you to visit dialysis units.  Your decision is not permanent.  You can make a change if you later change your mind.   Please do not delay making your decision and end up having to urgently start dialysis at a time that you do not have dialysis access ready.  That can become a serious problem. 

Choosing the right type of dialysis is an important choice and your Clinical Renal doctor will help you make the best choice for you particular situation.

Posted in Patient Education.