Download Treatment Options For Advanced Kidney Disease

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Letter: NUH NHS Trust, c/o PALS, Freepost NEA 14614,
Nottingham NG7 1BR
Treatment options for
patients with advanced
kidney disease
Renal Department
www.nuh.nhs.uk
This document can be provided in different languages and
formats. For more information please contact the
Renal Department on
Tel: 0115 9691169 ext. 57202
Rebecca Sims, Renal Department © August 2015. All rights reserved. Nottingham
University Hospitals NHS Trust. Review August 2017. Ref: 0915/v3/0815/AS.
Public information
Making a choice
More information available from
Renal Replacement Therapy (RRT) is the term used for the
treatments that are started when your kidneys fail.
If your kidneys stop working, you have the following options
available:
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Have a kidney transplant.
Have Peritoneal Dialysis.
Have Haemodialysis.
Have Conservative Care.
Contact details
Notes and questions
This leaflet explains each different method in more detail. It is
designed to give you an initial overview of the methods.
Your doctor and the specialist nurses will discuss the different
types of RRT available to you and help you to make a decision
about which type would be best for you. Not all forms of RRT
are suitable for all patients because of medical considerations. If
this applies to you, the reasons will be explained to you by your
medical team.
Sometimes because of medical considerations and personal
preference, you may decide that renal replacement therapy is
not right for you. You will then be looked after by specialist
doctors and nurses through the Conservative Care programme.
You and your family will have the opportunity to talk through all
aspects of this decision.
You may wish to use the space at the back of this leaflet to note
down any questions that you or your family/carers may have so
that you can discuss these with your doctor or nurse.
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Most of these can be treated very effectively and our
experienced conservative care nurses and kidney doctors would
regularly review this treatment. The patients care would be
shared between their GP, community team and kidney team at
the hospital.
For patients choosing conservative care, the kidney team can
support them and their family and ensure that, whenever
possible, patients are able to be involved in choosing how and
where they are cared for in the last days of life.
Kidney transplant
A kidney transplant is not a cure, but is a good form of treatment. If
you are medically suitable, it is felt to be the best type of renal
replacement therapy. This is because a well-functioning transplant
means no dialysis and fewer lifestyle changes.
A pre-emptive transplant, carried out before dialysis is required,
is considered the best form of treatment. However, this timing is
not always possible. Many patients will need a period of dialysis
whilst waiting for a transplant organ to become available.
Organs can be donated from a living or deceased donors.
1. Live related transplant
This is when a member of the recipient’s family donates a
kidney.
2. Live non-related transplant
The kidney is donated by an individual who is not blood related
to the recipient, but who is likely to be a partner /spouse or a
close friend.
3. Cadaveric transplant
The kidney is donated by an anonymous individual who has
recently died. This individual would have given permission for
his or her organs to be donated to someone in need.
The transplanted kidney takes
its blood supply from the large
pelvic blood vessels. The urine
drains into the bladder.
Usually the patient’s own
kidneys do not need to be
removed.
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Advantages of kidney transplant
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A new healthy kidney takes over the work of the failed
kidneys.
You will have very few, if any, diet and fluid restrictions.
After frequent early check ups, there will usually be fewer
hospital clinic visits.
For Live Related, and Live-Non Related transplants, the
surgery can be planned in advance.
For Live Related, and Live-Non Related transplants, the
transplanted kidney is less likely to be rejected by the
recipient’s body.
Disadvantages of kidney transplant
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Time spent waiting for a kidney transplant can be long and
stressful.
The transplanted kidney may be rejected, and you then have
to commence (or return to) dialysis treatment.
You will have to take immunosuppressant medications every
day to reduce the risk of your body rejecting the kidney.
These can cause side effects such as increase in the risk of
infections. Some of the side effects may be serious.
For Live Related, and Live Non-Related transplants, a family
member, spouse or friend will undergo a surgical procedure.
For Cadaveric transplants, the surgery cannot be planned in
advance. You could be called at any point when a kidney is
available and will need to be contactable at all times.
Although transplants have very many advantages, it is
important to recognise that transplants may fail, even after
many years, and you would then need to return to a dialysis
treatment of your choice. For some individuals, it is possible
to consider a further transplant in the future.
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Unfortunately, busy units often have limited flexibility on
dialysis days, times and length of sessions.
There are usually fairly strict dietary and fluid restrictions.
Travelling is more difficult and holidays must be taken in
places where dialysis facilities are available.
Conservative Care – choosing not to have dialysis
Unfortunately, some patients with advanced kidney disease may
also have other serious health problems, particularly in older age.
For patients with problems such as severe heart disease,
advanced dementia or advanced incurable cancers, it is possible
that they are not strong enough to physically tolerate dialysis.
Dialysis may not improve the quality of their life and dialysis
complications may even shorten their life. In this situation, it may
be a better option to choose not to have dialysis and to be looked
after by the conservative care team.
Some patients are certain that they do not wish to have dialysis.
For others, choosing not to have dialysis is quite understandably a
very difficult decision and they need time to think things through
and talk with carers or their family.
The choice would be discussed in detail with the doctors and
nurses at the hospital. Our specialist conservative care team is
trained to support patients and their carers or family at this time.
Patients with advanced kidney disease who choose not to have
dialysis will eventually die of kidney failure. As kidney disease
progresses, there may be some symptoms such as increased
tiredness, nausea, skin itching or swelling.
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Main Hospital or Satellite Unit Haemodialysis
Peritoneal Dialysis (PD)
Patients attending the main unit will usually be those who are
starting dialysis for the first time, are waiting to start the home
haemodialysis training programme or are waiting for a local
satellite unit placement.
Peritoneal Dialysis is a simple and straightforward method of
dialysis that can be performed at home.
Those attending the main unit regularly tend to be those who are
more frail or dependant, unwell or unstable on dialysis, or who
live close by.
Patients attending satellite units for haemodialysis usually have
no other major medical problems and are often able to travel
independently to these more local facilities.
Benefits of Hospital Haemodialysis
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You are encouraged to participate as far as possible in setting
up your dialysis, but if needed nurses are available to dialyse
you.
It keeps the dialysis regimen separate from family life.
There are no equipment or storage requirements at home.
You will have access to doctors, nurses and multi-disciplinary
team if required.
Disadvantages of Hospital Haemodialysis
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Depending upon where you live, there may be lengthy
journeys to and from a dialysis unit.
As there are sometimes unforeseen events in hospital units,
there may be delays in starting dialysis sessions.
There may be a long wait at the unit for transport service to
take you home. Hospital transport is often shared and is not
always available immediately after you have finished your
treatment.
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This dialysis method makes use of the patient’s own peritoneal
membrane (the lining of the abdominal cavity) to gently remove
waste products and excess fluid. A small operation is required to
place a permanent catheter (soft tube) into the abdomen. A
special dialysis fluid can then be drained into the abdominal
cavity. The fluid is left in place for a set time. When it is drained
out, the fluid will contain toxins and excess fluid that would
normally be removed in the urine.
Peritoneal dialysis is performed manually by the patient, usually
four times a day. It takes approximately 20 minutes to do each
bag exchange. Changing the fluid manually like this is called
Continuous Ambulatory Peritoneal Dialysis (CAPD).
There are other methods of performing peritoneal dialysis that
can be used if medically indicated. Some patients require help
from relatives or carers to do the fluid exchanges. Special
equipment is available to help patients who have poor vision or
stiff hands.
Most people will be able to find a form of peritoneal dialysis to
suit them, but it may not be suitable for all patients. It may not
work for those who have had significant abdominal surgery and
those who are extremely frail would find it difficult.
Peritoneal dialysis is supported by a specialist community
nursing team. They will meet you before you start your treatment
and will visit you regularly to monitor your progress. You will also
have access to support from the Renal Unit 24 hours a day, 7
days a week.
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Peritoneal dialysis fluid is drained in and
out of the peritoneal
cavity. This is a painless and gentle method of removing waste
products and excess
fluid.
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There is greater flexibility to tailor your dialysis regimen to
your lifestyle. This should make it easier to lead a more
normal life and fit dialysis around your family and work.
Less restrictive diet and fluid intake on short daily dialysis.
No travelling to the hospital and waiting for transport to pick
up and drop off.
You can recover from dialysis in the comfort and privacy of
your home.
You will be supported by a specialist community team who
will visit you regularly. Telephone advice is available at all
times.
Disadvantages of doing haemodialysis at home
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Advantages of peritoneal dialysis
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A gentle and continuous method of dialysis, working more
like your own kidneys.
Peritoneal dialysis preserves any remaining kidney function
better than haemodialysis.
Peritoneal dialysis puts less strain on the heart and blood
vessels than haemodialysis. It can therefore be helpful for
some patients with heart problems.
It is a good first choice of dialysis method as, unlike
haemodialysis, there is no risk of blood vessel damage which
could restrict future dialysis options.
There are usually fewer dietary and fluid restrictions than
with haemodialysis.
Peritoneal dialysis is carried out in the comfort of your own
home with privacy and flexibility. This is particularly important
for patients who work or have family commitments.
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A designated room is required for the machine.
Storage facilities and minor plumbing alterations are
required. The renal unit will plan and carry out these works,
and will usually be able to cover all or much of the cost of the
conversion.
Patients need to undergo a training programme with initial
sessions in the hospital unit “training wing” (this is usually for
about three months, but this can be scheduled around home
and work commitments).
Ideally, a helper or carer should be present at home during
sessions.
It can impact on home and family life.
Unlike treatment on CAPD and APD, equipment is not
portable so other methods are needed to dialyse away from
home for work or leisure travel.
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Dialysis sessions are three times each week, but when travel
and waiting times are included total time per week for
haemodialysis may actually be more than for peritoneal
dialysis.
Although haemodialysis is usually well tolerated, some
patients feel unwell during these sessions. Additionally many
patients find that they feel less well as dialysis approaches.
After a dialysis session, some patients can feel very tired.
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Peritoneal dialysis can also be carried out in other locations
for example at work, whilst staying with friends or family or
whilst travelling.
There are very few restrictions on holidays. If you plan
ahead, the dialysis fluid can be sent to almost any
destination in the UK or abroad.
There is no travelling to hospital for dialysis.
Disadvantages of peritoneal dialysis
Whilst you are on haemodialysis, you can read, write, sleep, talk
or watch TV. You are not able to disconnect in the middle of a
session. Some patients maintain or improve their physical
fitness by doing exercises while on dialysis.
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Home Haemodialysis
Some people are medically suitable to have Home
Haemodialysis. Other factors are important, such as having
suitable accommodation and being able to use the equipment
safely.
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The soft plastic peritoneal dialysis tube needs to be
surgically fitted into the abdomen in a small operation.
It does require some space to store equipment at home.
To ensure good technique, a short period of training is
required. This is usually done over three to five full or half
day visits to the Home Therapies Unit.
There is a risk of peritonitis (infection inside the abdomen) if
strict cleanliness is neglected during the dialysis fluid
exchange. There is also a small risk of long term scarring to
your peritoneum, particularly if peritonitis occurs.
Usually patients having home haemodialysis are those who
would otherwise have chosen peritoneal dialysis to fit in with
employment and family life but are not able to do so because of
medical reasons. For those that are able to do home
haemodialysis, it offers similar flexibility in terms of the
frequency and timing of treatment sessions.
Benefits of doing haemodialysis at home
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Evidence has shown that medical outcomes for most
patients receiving home haemodialysis are far better than the
outcomes for patients undergoing haemodialysis treatment in
a main centre or satellite unit. There may be reduced fatigue
and fewer symptoms of kidney failure. It may also reduce the
number of doses of some of your medications.
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Haemodialysis (HD)
Haemodialysis involves filtering your blood through a machine.
The waste products and excess fluids are removed using an
artificial kidney called a dialyser.
Blood is taken from your body, usually through needles in an
enlarged blood vessel in the arm. The blood is pumped around
by the machine, through the dialyser and back into your body. At
any one time, only a small proportion of your blood is going
through the machine.
There are three different settings where haemodialysis can take
place:
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Some patients are able to have haemodialysis at home.
At the main regional Renal Unit which is based at the
Nottingham University Hospitals’ City campus.
In any satellite unit, which are located at the Queen’s
Medical Centre in Nottingham, Ilkeston Community Hospital,
and the Kingsmill Hospital in Mansfield. (Some are operated
wholly by NHS staff and some in conjunction with a private
healthcare company.)
In all cases, the medical care is provided by doctors working
within the Nottingham University Hospitals NHS Trust’s Renal
Unit.
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Haemodialysis is performed a minimum of three times each
week for four to five hours per session. If needed, it can be
performed more frequently and for longer periods.
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It is necessary to access the blood circulation to perform
haemodialysis. This means a surgical procedure to create an
access point called a fistula. During the operation an artery
and vein are joined together, usually in the forearm. After a
few weeks the vein becomes larger and carries more blood.
At each dialysis session a needle is placed in the fistula
which diverts the blood to the dialysis machine. The cleaned
blood is returned to the patient through a second needle in
the fistula.
If a fistula cannot be created, a permacath (semi permanent
plastic tube) is implanted into one of the blood vessels. This
may restrict activities such as bathing and swimming and
there is a higher risk of infection. There is a small risk of
permanent damage to blood vessels which can make future
dialysis more difficult.
If you still pass urine, starting haemodialysis can mean that
you lose your final small amount of kidney function which
means a stricter fluid restriction compared to peritoneal
dialysis.
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