Is Kidney Replacement Therapy Required for Everyone with Kidney Disease?

by Dr. Tarun Kumar Saha | Jan 02, 2023 | Nephrology

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2. What is Kidney Replacement Therapy (KRT)?

Kidney failure is the fifth and final stage of chronic kidney disease (CKD). It is also known as end-stage renal disease (ESRD) or end-stage kidney disease (ESKD). Kidney failure is irreversible and can be fatal if left untreated. However, kidney replacement therapy can help provide a better prognosis.

Here is a guide to everything related to kidney replacement therapy. Continue reading to learn more.

What is Kidney Disease?

The term “kidney disease” refers to a condition in which your kidneys are damaged, no longer function properly, and are unable to filter waste from your blood.

Signs and symptoms of early-stage kidney disease:

Mostly asymptomatic
High blood pressure
Foamy urination
Swelling of the feet
Excessive urination at night

Signs and symptoms of late-stage kidney disease:

Breathing difficulty
Nausea and vomiting
Weakness and fatigue
Itchiness
Bone pain
Muscle cramps
Altered sensorium

Kidney disease is caused by different health problems that can damage the kidneys. The damage can occur all at once or over many years. Eventually, acute or chronic kidney disease progresses to kidney failure over time.

Common causes of kidney disease include:

Diabetes
Hypertension
Autoimmune Diseases
Polycystic Kidney Disease
Kidney stones

Did you know that kidney failure is irreversible and can be fatal if left untreated?

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What is Kidney Replacement Therapy (KRT)?

Kidney Replacement Therapy (KRT), also known as Renal Replacement Therapy (RRT), is a structured treatment regimen for patients with severe kidney failure. It consists of medical procedures that help to replace the work of healthy kidneys. There are two types of KRT, namely, dialysis and kidney transplantation.

When is KRT needed?

Not all kidney disease patients require replacement therapy. You may have kidney disease for a long time before requiring KRT. However, if your kidney disease progresses to the point where your kidneys lose the majority of their function (ESRD) with a glomerular filtration rate (GFR) of less than 15 (or, in some patients, less than 10), your healthcare provider may recommend KRT.

Replacement treatments are initiated when the kidneys are irreversibly damaged and the patient would be at a life-threatening risk without them

Types of Renal Replacement Therapy

Dialysis

It is a treatment that replaces the kidneys’ normal blood-filtering function with an external apparatus known as a dialysis machine.

Dialysis is classified into two types: peritoneal dialysis (PD) and hemodialysis (HD). PD is performed at home, whereas HD can be performed at home or in a dialysis centre.

Hemodialysis

Hemodialysis is a procedure where waste materials and extra fluid are removed from the patient’s blood by pumping it through a dialysis machine. The device functions by exposing the patient’s blood to a dialysate solution, which draws impurities out of the patient’s blood and into it. The number of weekly treatments varies from person to person and can be done at home, allowing patients to continue working.

A surgically made pathway known as vascular access (VA) is used to connect a patient to a dialysis machine so they can receive treatment. VA enables blood to be drawn from the patient’s body, circulated through a dialysis machine, and then returned to the body.

The majority of dialysis catheter placement procedures can be carried out under local anaesthesia as an outpatient procedure. The following are the various types of vascular access:

Arteriovenous (AV) Fistula Catheter: It is the best type of access that is surgically created between an artery and a vein in the lower arm and needs to be placed two to three months before it can be used for dialysis.

Central Venous Catheter (CVC): Another type of access, a central venous line, can be inserted and used right away (typically in the upper chest or neck). However, it is a temporary means of access that is more prone to complications than the other types and should only be used if no other route is available.

The AV fistula is designed for long-term dialysis, whereas catheters are designed for temporary or short-term use.

Hemodialysis treatments typically last three to five hours and are performed three times a week. They are carried out in a hospital or dialysis centre, and the duration of treatment depends on your body size, the amount of waste in your body, and your current health.

Peritoneal Dialysis

Peritoneal dialysis involves inserting a peritoneal dialysis (PD) catheter into your abdomen to help filter your blood through the peritoneum, a membrane in your abdomen. During treatment, a special fluid called dialysate flows into the peritoneum. The dialysate absorbs waste, draws it out of the bloodstream, and then drains from your abdomen.

This procedure takes a few hours to complete and must be repeated three to four times per day. However, fluid exchange can occur while you are sleeping or awake.

During each cycle, the dialysate in the abdomen is drained out and discarded. The peritoneal cavity is then filled again with fresh dialysate.

The process of filling and then draining your abdomen is called an exchange. Different methods of peritoneal dialysis have different schedules of exchange. The two main schedules are:

Continuous ambulatory peritoneal dialysis (CAPD)
Continuous cycling peritoneal dialysis (CCPD)

Continuous ambulatory peritoneal dialysis (CAPD) involves filling your abdomen with dialysate, allowing it to remain there for a predetermined amount of time, and then draining the fluid. Due to gravity, the fluid flows through the catheter and into and out of your abdomen.

With CAPD, you may require three to five exchanges during the day and one with a longer dwell time while sleeping. You can do the exchanges at home or at work, and you can go about your normal activities while the dialysate is in your abdomen.

Continuous cycling peritoneal dialysis (CCPD), also known as automated peritoneal dialysis (APD), involves the use of a machine (an automated cycler) that performs multiple exchanges while you sleep at night. Your abdomen is automatically filled with dialysate by the cycler, where it stays for a while before draining into a sterile bag that you empty the next morning.

You must stay connected to the CCPD device for roughly 10 to 12 hours each night. Though you are not connected to the machine during the day, you begin one exchange in the morning with a dwell time that lasts the entire day.

Hemodialysis and peritoneal dialysis both have negative side effects. Fatigue (tiredness) is a common side effect in people who have long-term dialysis.

Side effects of hemodialysis include low blood pressure, sepsis, muscle cramps, itchy skin, sleep difficulties, and bone and joint pain, while those of peritoneal dialysis include peritonitis (inflammation of the peritoneum due to a bacterial infection), hernias, and weight gain.

Kidney Transplantation

Kidney transplantation is a major surgery during which one healthy kidney from a living donor or a recently deceased person (a deceased donor) will be implanted. The transplanted kidney replaces the functions of your existing kidneys.

Kidney transplantation is considered the treatment of choice for many patients with severe chronic kidney disease because quality of life and survival are often improved compared to patients who use dialysis.

Compared with dialysis, kidney transplantation is associated with a lower risk of death, fewer dietary restrictions, and a lower long-term treatment cost. Some people may also benefit from receiving a kidney transplant before needing to go on dialysis, a procedure known as a preemptive kidney transplant.

However, a kidney transplant may pose a greater risk than dialysis for some individuals with kidney failure. If you have any of the following conditions, you may be ineligible for a kidney transplant.

Advanced age
Severe heart disease
Alcohol or drug abuse
Active or recently treated malignancy (cancer)
Additional conditions that contraindicate the use of anti-rejection drugs

Significant risks are associated with kidney transplant surgery, including the potential for blood clots, bleeding, infections, and rejection of the transplanted kidney, among others.

You will also be required to take anti-rejection drugs to help stop your body from rejecting the donor kidney. These drugs may have a number of negative side effects, including weight gain, diabetes, high blood pressure, high cholesterol, excessive hair growth, and other conditions.

Dialysis or Kidney Transplant?

While both treatments have advantages and disadvantages, deciding between a kidney transplant and lifelong dialysis is a complex decision that necessitates careful thought and consideration of the serious risks and benefits.

However, the long term survival advantage is greater with kidney transplantation than with staying on dialysis.