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What are
the kidneys?
Kidneys are paired bean-shaped, fist-sized blood-cleansing
organs of the body. They are attached to the urinary bladder by tubes called ureters
which convey urine formed in the kidney. Each kidney contains hundreds of thousands
of tiny filters called glomeruli, which are interconnected by tubules, to form a
network of nephrons, the working units of the kidneys. Around 200 quarts of blood
is pumped by the heart to the kidneys via the renal arteries. Unclean blood passes
through 140 miles of tubes and filters in both kidneys, resulting in urine formation.
Filtered or cleaned blood then goes back into the circulation via the renal veins.
Urine stored in the bladder is then passed out through the urethra located in the
genital organs.
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What do kidneys do?
Healthy kidneys function like 24-hour cleansing machines of the blood,
removing from it wastes such as urea and creatinine, and extra water from the body.
They also produce several hormones such as renin that help control and maintain
normal blood pressure, and erythropoietin which stimulate bones to make red blood
cells that carry oxygen to your whole body. They also keep body chemicals like salt,
potassium, calcium, phosphorus, acids and bases in balance and keep bones strong.
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What is
chronic kidney disease?
What is kidney failure?
Kidney failure is a condition where the kidneys stop working
normally. There are two kinds of kidney failure: acute renal failure (ARF) and chronic
kidney disease (CKD). In both conditions, the kidneys fail to efficiently remove
wastes and extra fluid from the body. Imbalances in the amounts of salt, potassium,
calcium, phosphorus, and acids may also occur in both.
What is acute renal
failure?
Acute renal failure means the kidneys have failed suddenly,
often due to a toxin, a harmful drug, severe blood loss, trauma, infection, or blockage
to urine flow. It is temporary in most cases and normal or near-normal kidney function
often returns. However, it may progress to CKD if left untreated. In severe cases,
dialysis may be necessary for a short time while the kidneys heal.
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What is chronic kidney disease (CKD)?
Chronic kidney disease is characterized by either permanent
kidney damage that developed progressively and slowly over time, or decreased level
of kidney function with or without kidney damage for three months or more, with
the potential to either cause progressive loss of kidney function or complications
resulting from decreased kidney function.
What are the stages
of CKD?
CKD is classified into 5 stages based on the level of glomerular
filtration rate (GFR). Stage 1 is the mildest stage while stage 5, or end-stage
renal disease (ESRD) is the most severe stage of kidney damage.
What is Pre-ESRD?
Pre-ESRD corresponds to CKD stages I to IV. It is the time
between diagnosis of a kidney disease until the time renal replacement therapy is
begun, either as dialysis or kidney transplantation. It may be brief lasting only
a few weeks, or it may be months or even years.
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What causes
of CKD?
What are the risk factors for CKD?
Older age, family history of CKD, history of acute renal
failure, reduction in kidney mass and low birth weight place an individual susceptible
to developing CKD. Diabetes, high blood pressure, autoimmune diseases, systemic
infections, urinary tract infections, urinary stones, lower urinary tract obstruction,
drug toxicity, and cancer can directly initiate kidney damage. Higher level of spillage
of protein in the urine (albuminuria), higher blood pressure, poorly controlled
diabetes and smoking can cause acceleration of kidney damage and faster decline
in kidney function.
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What are the main causes of kidney disease?
Diabetes is the number one cause of kidney disease, responsible
for about 40% of all kidney failure. High blood pressure is the second cause, responsible
for about 25%. Glomerulonephritis, a group of diseases that cause inflammation and
damage to the kidney's filtering units, is the third leading cause.
Other less common causes
include:
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Inherited diseases, such as polycystic kidney disease
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Malformations during fetal development
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Lupus and other diseases that affect the body's immune system.
-
Obstructions caused by kidney stones, tumors or an enlarged
prostate gland in men.
-
Repeated urinary infections.
I have diabetes. Will my kidneys fail?
Diabetes is a strong risk factor for kidney disease, but
this does not necessarily mean your kidneys will fail. Tight control of your blood
sugar and certain medications can delay or prevent progression of kidney failure.
Spillage of protein or albumin in the urine is the first sign of diabetic kidney
disease. Even if you develop diabetic kidney disease, you can work with your doctor
to keep your kidneys working as long as possible.
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Can I catch kidney disease from someone who has it?
No. Kidney disease is not contagious, but it may be inherited.
Most kidney diseases are caused by diabetes and high blood pressure, conditions
that can run in families. If you are a family member of someone who has diabetes,
high blood pressure, or kidney disease, it is a good idea to ask your doctor to
check your blood pressure and kidney function at regular intervals.
I have a family member with polycystic kidney disease
(PKD). Should I be tested?
Since 60-70% of people with PKD have a family member with
PKD, asking your doctor about being tested seems like a good idea. The first test
used for PKD is an ultrasound to look at the kidneys and see if there are cysts.
Does frequent holding of urination cause CKD?
No, unless one suffers from vesico-ureteral reflux disease
(VURD) which may damage the kidneys in the long term.
Will eating too much
salty foods lead to CKD?
Eating too much salty foods does not necessarily lead to
CKD. However, it can eventually lead to high blood pressure among those who are
at risk, such as those with a family history of hypertension. It can also worsen
pre-existing hypertension, a leading cause of CKD. Among those with moderate kidney
failure or end-stage renal disease, it can lead to water retention resulting to
edema or swelling of the feet, and water in the lungs.
Does drinking too much cola or soft drinks lead to CKD?
No, but it may increase
blood levels of phosphorus and potassium among those with moderate CKD.
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What are
the signs and symptoms of CKD?
Knowing the symptoms of kidney disease can help people detect
it early enough to get treatment. Signs and symptoms of CKD include:
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Changes in urination - making more or less urine than usual,
feeling pressure when urinating, changes in the color of urine, foamy or bubbly
urine, or having to get up often at night to urinate.
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Swelling of the feet, ankles, hands, or face - fluid the
kidneys can't remove may stay in the tissues.
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Fatigue or weakness - a build-up of wastes or a shortage
of red blood cells (anemia) can cause these problems when the kidneys begin to fail.
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Shortness of breath - kidney failure is sometimes confused
with asthma or heart failure, because fluid can build up in the lungs.
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Ammonia breath or an ammonia or metal taste in the mouth
- waste build-up in the body can cause bad breath, changes in taste, or an aversion
to protein foods like meat.
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Back or flank pain - the kidneys are located on either side
of the spine in the back.
-
Itching - waste build-up in the body can cause severe itching,
especially of the legs.
-
Loss of appetite, resulting in weight loss
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Nausea, especially at the sight of food or in the morning,
and vomiting
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Muscle cramping at night
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Trouble concentrating
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Trouble sleeping at night
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More episodes of low blood sugar, if diabetic
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High blood pressure, or worsening hypertension
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How do
I know if I have chronic kidney disease?
What laboratory tests do I need?
Kidney disease can be detected through laboratory tests
or by signs and symptoms. Markers of kidney damage include abnormalities in the
composition of the blood or urine or abnormalities in imaging tests. High blood
levels of creatinine and urea nitrogen (BUN) or high levels of protein in your urine
suggest kidney disease. Glomerular filtration rate, or estimated creatinine clearance
and endogenous creatinine clearance are tests which will tell you how well your
kidneys are working.
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In Stage 1 and Stage 2 CKD, there are often few or no symptoms.
Early CKD is usually diagnosed when the following signs are present, alone or in
combination:
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High blood pressure
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Higher than normal levels of creatinine or urea in the blood
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Blood or protein in the urine
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Evidence of kidney damage or multiple cysts or enlarged
or small kidneys in an ultrasound, CT scan, MRI, or contrast X-ray
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Abnormal looking filters (nephrons) on kidney biopsy
In Stage 3 CKD, anemia (a shortage of red blood cells) and/or
early bone disease may appear and should be treated to help you feel your best and
reduce problems down the road. When CKD has progressed to Stage 4, abnormal levels
of blood or urine electrolytes such as sodium, potassium, calcium, and phosphorus,
as well as acids may be detected.
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What will
happen if I am diagnosed with CKD?
What should I do?
If I have signs and symptoms of kidney disease, what should I do?
You should ask for a referral to or consult a nephrologist,
a specialist in kidney diseases. If CKD or risk factors for CKD are detected early,
medications and lifestyle changes may help slow its progress and keep you feeling
your best for as long as possible. With early diagnosis, it may be possible to slow
or even stop progression of CKD, depending on the cause. As such, early referral
to a nephrologist is very important in initiating an appropriate action plan. A
nephrologist can help you and your primary care doctor to:
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Slow the rate of decline of your kidney function
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Decide if a kidney biopsy might be useful
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Diagnose the type of kidney disease and whether it might
be reversible with treatment
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Manage complications of kidney disease, such as anemia,
high blood pressure, metabolic acidosis, and changes in mineral balance
It may be prudent for a non-nephrologist to screen patients
at increased risk for CKD and to institute risk reduction strategies when possible.
Alternatively, he may refer them to a nephrologist for pre-ESRD care. You may visit
http://www.keeponline.org on how to go
about early evaluation.
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I just found out I have chronic kidney disease.
Does this mean I am going to die soon?
No. In the early stages of CKD, you may experience little
or no symptoms at all and you can still go about your usual daily chores and lifestyle.
In the latter stages, particularly end-stage renal disease, dialysis or a kidney
transplant can keep you alive when your kidneys fail. The more you learn and take
part in your treatment, the better you can feel. Some people live for decades with
kidney failure.
What are
the treatment options for CKD?
What is pre-ESRD care?
Pre-ESRD care is care aimed at helping delay or prevent
progressive kidney failure and ameliorating its complications. It may take the form
of lifestyle and dietary modifications, as well as drug treatment in most cases.
It encompasses control of blood pressure and diabetes, identification of reversible
causes of kidney damage, prevention and treatment of anemia, bone disease, and cardiovascular
complications of CKD. It also includes adequate preparation for eventual renal replacement
therapy, be it dialysis or kidney transplantation.
Blood glucose control
If you have diabetes,
strict control of your blood glucose levels can help slow the progression of kidney
disease.
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Keep your hemoglobin A1c, which measures blood glucose control
over the last two to three months, to less than 6.5%.
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To reach this level of strict glycemic control, you will
need to monitor your blood glucose closely to avoid hypoglycemia.
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Blood pressure control
- Keep your blood pressure at 120/70 or lower
if you have diabetes and/or protein in your urine.
- Keep your blood pressure at 130/80 or lower
if you have kidney problems but not diabetes.
Lifestyle
changes such as losing weight, exercising, eating less salt and drinking less alcohol
Repairing the damage
If you have an obstruction that blocks your urine
flow, surgery may help. If you have an infection, antibiotics may clear it up.
Stop medications that may damage your kidneys. Most painkillers
can cause damage to your kidneys. Your doctor may be able to suggest a different
medication that is less or not harmful to your kidneys. Sometimes diagnostic studies
are ordered with contrast dye. It may be necessary for you to have the study, but
first find out if there are alternative methods.
Some diseases, such as IgA nephropathy, glomerulonephritis,
and lupus can cause kidney damage when your immune system overreacts and inflammation
occurs. It is sometimes possible to slow the disease process by controlling the
immune system with steroids and/or other medications.
Smoking is a risk factor for faster progression of kidney disease, so stopping smoking
can also help slow progression. Avoiding too much protein, potassium- and phosphorus-rich
foods in the diet may also help.
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What will happen if
I refuse pre-ESRD care?
Refusing pre-ESRD care may result in accelleration of kidney
damage and earlier development of or worsening of complications of CKD, such as
anemia, loss of appetite and fatigue. In short, progression to ESRD or early death
may become inevitable. Cardiovascular complications such as heart enlargement and
heart failure may also set in earlier. Hence, refusal may result in more frequent
hospitalizations, bigger expenses, emotional trauma, and poor quality of life. Moreover,
you may not be prepared well for eventual need for renal replacement therapy, resulting
in hasty and risky initiation of dialysis.
Lifestyle choices
for those with chronic kidney disease
What is my role with my Chronic Kidney Disease?
There is a lot that can be done early in CKD to keep you
feeling well and to maintain your kidney function for as long as possible. You also
may be able to help prevent some long-term complications of kidney disease, such
as bone disease or heart problems, by acting early. Your role is to learn all you
can and work with your care team to get the best possible care.
Diet and exercise are
two areas where you have a lot of control. Talk with your care team and your dietitian
to determine individualized dietary guidelines based on lab tests and your stage
and type of CKD. Stay active and get plenty of exercise.
I was
diagnosed with kidney disease.
Should I stop exercising and rest more?
While
we all need rest, we need exercise too. It’s been shown that exercise is good for
people with kidney disease. So, you should try to stay active. If you’ve been sedentary
in the past, talk to your doctor about starting a mild exercise program. The key
is to start slowly and build up gradually.
How can smoking affect
my CKD?
Smoking is an important risk factor that can make kidney
disease worse, especially among diabetics. In addition, smoking increases high blood
pressure and cardiovascular risks, two health problems that often occur along with
kidney disease. You’ll be taking better care of yourself if you can reduce the amount
you smoke—or better yet—quit altogether.
What can I do about muscle cramps?
Cramps—especially leg cramps—are common for those with kidney
disease. Cramps are thought to be caused by imbalances in fluid and electrolytes,
but may also be caused by nerve damage or blood flow problems. If you experience
cramps, here are suggestions that may help:
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Stretch the muscle
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Massage
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A hot shower or bath
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Wear comfortable shoes
A number
of nephrologists prescribe quinine for their patients who are bothered
by frequent cramps. Quinine does have potential risks, so be sure it really helps
you before taking it for a lengthy period of time.
What
can I do about itching?
While
problems with itching are common for those with kidney disease, it can be difficult
to determine the cause. Below are some
reasons you may be itching and what may be done to help.
- Blood levels of phosphorus or parathyroid
hormone (PTH) that rise as kidney function drops can lead to itchy skin.
If you have high phosphorus or PTH levels, your doctor can prescribe a phosphate
binder drug for you to take with meals and snacks to get your blood levels into
the target range.
- Itching can be caused by dry skin. Try a good
moisturizing cream or lotion.
- Allergies can cause itching.
- Many people find that getting out in the sun
a bit helps with itching, though the reasons for this are unclear.
Ask your nephrologist
and/or dermatologist for tips on how you can deal with stubborn itching.
What to eat
Should I be on a low
protein diet?
Protein, found in meats, fish, poultry, dairy products,
nuts, and some grains, helps your body form muscle and tissue. But when your kidneys
are not working well, the byproducts of protein breakdown can build up in your blood.
This can make your kidneys work harder.
Some studies of low protein diets show that they can slow
the progression of kidney failure. But other studies show that such diets do not
help. Due to these mixed results, and the need to maintain good nutrition, doctors
differ about the need to limit protein for people with chronic kidney disease (CKD).
The answer is often moderation.
In all cases, it's crucial to avoid malnutrition. A blood
test for albumin, a form of protein, is a good way to tell if you are getting enough
good food. Your albumin level should be 4.0 g/dL or higher. If you notice weight
loss, loss of appetite, or other signs of poor nutrition, talk to your doctor.
So, how much
protein do you need? K/DOQI national guidelines for kidney disease suggest a daily
protein intake of 0.75 grams per kilogram of body weight for mild to moderate CKD
(Stages 1, 2, or 3). If you weigh
80 kilograms, you would need 80 x 0.75, or 60 grams of protein per day.
In
more severe kidney disease (Stages 4 and 5), the guidelines suggest considering
0.6 grams of protein per kilogram body weight each day.
If your diet includes very little protein, your doctor may prescribe
supplements of nutrients you would normally get from protein, like ketoacids and/or
amino acids.
A renal dietitian
has special expertise helping people with kidney disease put together healthy meal
plans. Ask your doctor about a referral to a renal dietitian.
Check with your doctor or dietitian before making any changes to
the protein level in your diet.
Should I be on a low phosphorus diet?
Ask your doctor
- the answer will often be yes. Phosphorus
is a mineral found mostly in dairy products and meats.
Your body uses it to form strong bones and teeth.
But starting in moderate CKD, your kidneys begin to lose the
ability to remove extra phosphorus from your body. Because
too much phosphorus can harm your bones, it makes sense to eat less phosphorus. Some experts think 800 to 1,200 mg.
of phosphorus per day is a good target. Foods
high in protein tend to be high in phosphorus, too
Should I be on a low
potassium diet?
Having the right level of potassium in your body helps all
your muscles work smoothly, including your heart. When kidneys fail, they start
to lose this ability.
Your potassium level should be checked regularly with a
blood test. If your levels are too high, your doctor will ask you to start a LOW
potassium diet. Many foods have potassium, but some like avocados, dried fruits
like raisins, apricots and prunes, potatoes, oranges, bananas and salt substitutes
are very high in potassium. So if you are suffering from chronic kidney disease,
it would BEST TO AVOID FRUITS AND OTHER PRODUCTS RICH IN POTASSIUM AS SHOWN IN THE
PICTURE BELOW.
What can I do about loss of appetite?
Poor appetite is a common symptom of advanced kidney disease.
Even if you are not hungry, it is important to eat and keep good nutrition. As kidney
function drops, you may notice that protein foods, such as eggs, meat, chicken and
fish lose their appeal. You need calories and quality protein to feel your best.
To get good nutrition try to:
-
Eat more bland, starchy foods or whatever appeals to you
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Eat small portions of protein foods.
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Try a liquid nutritional drink like Nepro® once a day
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Graze all day—have several small meals instead of three
large ones
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Boost the protein content of your meals by adding egg whites,
egg white powder or protein powder
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Get help from a renal dietitian, if lack of appetite continues.
Finally, if you are in Stage 5 CKD and your appetite or
nutritional well-being does not improve, this may be a sign that you should start
dialysis. Many people find their appetite improve after some time on dialysis.
What are the treatment options for end-stage renal disease
(ESRD)?
There are three types of treatment for kdiney failure: hemodialysis, peritoneal
dialysis and transplantation. Dialysis is a medical term that means cleaning the
blood by artificial means. During dialysis, wastes and extra fluid that build up
due to kidney failure are removed from the blood using a dialyzer (artificial kidney)
or your own abdomen (peritoneal membrane). Kidney transplantation involves receiving
a kidney transplant from another person (donor) through surgery. The new kidney
(graft) is placed in your abdomen and will do the work your damaged kidneys did.
What happens if I refuse treatment for ESRD?
There are some people who choose either no treatment or
decide to stop treatment. You must understand that if you don’t choose a treatment
option, you will die. You and your healthcare team can talk about your wishes if
you choose to stop treatment at any time. They will help you understand what it
means and what to expect once treatment is stopped.
How is dialysis done?
Dialysis is done by using a special fluid called dialysate.
Dialysate, a mixture of pure water and chemicals, is carefully controlled to pull
wastes out of your blood without removing substances your body needs.
A semipermeable membrane keeps the blood apart from the
dialysate. This membrane lets the wastes and fluid in your blood flow through into
the dialysate. Your blood cells and larger molecules, like protein that you need,
cannot fit through the holes.
What is hemodialysis?
Hemodialysis, the most common treatment option for treating
ESRD, is a way of cleaning your blood using a dialysis machine and a special filter
called dialyzer. The dialyzer works as an artificial kidney, straining toxins and
removing extra fluid that build up because of ESRD. However, the dialyzer does not
completely replace your original kidney’s function. Remember, healthy kidneys work
24 hours a day, 7 days a week, while hemodialysis takes a few hours a day, 2-3 days
a week.
What happens during
hemodialysis?
During a dialysis treatment, two needles connected to hollow
plastic tubes are inserted into your fistula or graft. Your blood is pumped out
by the machine through one line to the dialyzer to be cleaned. Once cleaned, it
is returned to your body through another plastic tube. Your nephrologist will prescribe
the length of your treatment, usually four hours a day done three times a week,
either Mon/Wed/Fri or Tues/Thurs/Sat, but may vary depending on your body size,
laboratory results and medical condition. You will have the same morning or afternoon
time for each treatment.
What is a hemodialysis access and how does it work?
Before hemodialysis can begin, you need to have a way to
safely remove from and return blood to your body. Your native veins are not strong
or big enough to run your blood through the dialyzer. To prepare for dialysis, you
will need surgery to create an access and this is best done by a vascular (vessel)
surgeon.
What are the types of hemodialysis accesses?
There are three types of accesses: a fistula, a graft, or
a catheter.
A fistula, or arteriovenous fistula is created surgically by connecting the artery
directly to a vein. It is usually placed in your arm, but may also be placed in
your leg. With proper use and care, this type of access produces the best results
for dialysis.
A graft, or arteriovenous
graft is created by connecting the artery and vein with an artificial tube.
A catheter is inserted into a vein in the neck, under the
collar bone, or in the groin area to allow temporary hemodialysis to be done until
a fistula is created, healed and ready for use. This type of access can only be
used on a temporary basis.
What is peritoneal
dialysis?
Peritoneal dialysis is another form of cleaning the body
of wastes and extra fluid that build up due to kidney failure. The lining of your
own abdomen (peritoneal membrane) is used as an artificial filter or dialyzer.
What happens during
peritoneal dialysis (PD)?
During a peritoneal dialysis treatment, two plastic bags,
one containing clean dialysis solution and the other empty, are connected via 2
separate plastic tubes to your peritoneal catheter, a hollow tube surgically implanted
into your abdominal cavity. By gravity, the clean solution is drained into your
abdomen and allowed to stay or “dwell” for a couple of hours during which exchange
of waste products and extra fluid (“cleaning”) occurs from small blood vessels (capillaries)
to the solution. The spent solution or “dialysate” is then drained out into the
empty bag to complete one exchange. Your nephrologist will prescribe the number
and duration of exchanges, usually 4-5 four-hours exchanges a day, but may vary
depending on your body size, laboratory results, medical condition and your preference.
A common PD schedule might be to do one exchange when you wake up, one at lunchtime,
one at dinner, and one at bedtime. If you can use a cycler, you may need only one
exchange during the day, or you may be able to do your treatments at night only.
Which is better, peritoneal dialysis (PD) or hemodialysis
(HD)?
PD and HD each have pluses and minuses. Which one will work
better for you will depend on your needs and lifestyle. Your doctor will be able
to tell you if you are medically better suited for one treatment or the other, but
most often, the choice will be yours.
PD may be a good choice if you want to keep a job, because
you will have more control over your treatment schedule. PD also makes it easier
to travel and allows a more liberal meal plan and fluid limits. There are also no
needle sticks with PD. You many also want to consider that PD can cause weight gain
and body image issues, due to the catheter that must stay in your abdomen. Treatments
must be done with good hygiene and good technique to avoid painful infection, plus
you need room to store the supplies.
HD may be a good choice if you want to have off-days without
treatment, want to socialize with other patients, or don't want to have a catheter
in your abdomen. Swimming is more possible with HD than with PD. Other aspects of
HD include a more restricted diet, a more rigid treatment schedule that may conflict
with work or school, more physical ups and downs and two needle sticks at each treatment.
If I have kidney disease,
will I need dialysis?
In the early stages of chronic kidney disease, you do not
need dialysis. These stages can last for many years. But if your kidneys fail, you
will need dialysis or a kidney transplant to keep you alive.
If I have kidney disease, how long will it be before
I need to start dialysis?
Depending what stage your kidney disease is and how quickly
it progresses, you may never need dialysis, or you may need dialysis right away.
Dialysis is usually recommended when your kidney function is about 10-15% of normal,
or about 25% if you have diabetic kidney disease, or if you have severe symptoms
caused by your kidney disease, like shortness of breath, fatigue, muscle cramps,
or nausea and vomiting. If you are not having symptoms, you may be able to wait
a bit longer. Since chronic kidney disease often happens slowly, sometimes people
do not even know how bad they feel until they start dialysis and begin to feel much
better! It is important to start getting ready for dialysis or a transplant well
in advance.
I am in Stage 4 kidney disease and can't have a transplant. Can
I do dialysis for the rest of my life?
Yes, dialysis is something you can do
for the rest of your life. Some people have been on dialysis for 30 years or more
without getting a transplant. How long you can live on dialysis, and how well you
do, will depend on a number of things, including:
-
How healthy you are, other than kidney disease
-
How positive your attitude is (optimists live longer, depression
can be treated)
-
Whether you receive good quality medical care and dialysis
-
How much you learn about dialysis and take an active role
in your care.
Will I have to quit work when
I start dialysis?
No. You dont have to quit work when you start dialysis.
Can I travel on dialysis?
Yes. With proper planning, you can travel while on dialysis.
Start small—with day trips and quick weekend getaways. Then you can build up confidence
and work up to longer vacations. Your center can forward a copy of your dialysis
prescription and other records to the center you will visit.
If you do peritoneal dialysis, you can take your supplies
with you, or have them shipped to your destination. Check with your PD nurse. Your
PD nurse can help you learn safe ways to do your exchanges while camping or taking
a driving trip.
Once I am on dialysis, will my kidneys get better?
The chances that your kidneys will get better depend on
what caused your kidney failure. Kidney failure is divided into two general categories,
acute and chronic. Acute (or sudden) kidney failure is often temporary. In chronic
kidney failure, the kidneys normally do not heal.
In acute kidney failure, kidney function may recover with
or without dialysis. But when the damage to your kidneys has been continuous and
progressive over a number of years, as it is in chronic kidney disease, then the
kidneys usually do not get better since the damage is considered irreversible. Hence,
long-term dialysis is needed. While your kidneys will not get better once you are
on dialysis, you may feel significantly better and live life to the fullest.
Could my health get worse if I start dialysis?
Dialysis will not make your health worse. Many people
need a few weeks to adjust to dialysis. It takes time to get used to the routine,
the medications and the treatments. Once dialysis is working well to remove extra
wastes and fluids, you should begin to feel much better.
Does dialysis hurt?
Dialysis itself does not hurt. In hemodialysis the needles
may hurt going in, but they should stop hurting after that. You can ask for numbing
medicine before you get the needle sticks if they bother you. Many people get used
to the needles in time. Painful muscle cramps can happen during hemodialysis, especially
if you gain a lot of fluid weight between treatments. Your care team can help stop
the cramps when they happen and work with you to keep them from happening again.
You can help by following your fluid limits and learning about dialysis.
In peritoneal dialysis (PD), abdominal pain can be a sign
of an infection called peritonitis. Some people who do PD with a cycler machine
sometimes have pain at the end of a drain cycle. When you are trained in PD, you’ll
learn ways to help prevent these problems.
How do I know if I am getting
enough dialysis?
The best sign that you are getting good dialysis is that
you feel well, look healthy and can do the things you want to do. With adequate
dialysis, you should have a good appetite. When it’s time for your next treatment,
you should feel like you don’t need it! This is the goal of dialysis.
What is my “job” on dialysis?
It may seem as if dialysis is so complex that only a medical
professional could understand it. To do well on dialysis, your job is to become
your own expert. You should learn to take care of yourself and maintain your own
safety. While an at-home treatment will allow you to control your schedule, making
it easier to keep a job and health insurance, you'll still have to do your job if
you choose in-center hemodialysis. You should:
-
Follow your diet and fluid limits
-
Take your medications
-
Get regular exercise
-
Take care of your access
-
Do as much for yourself as you can, such as weighing in
before hemodialysis, or learning to do your own needle sticks
-
Get every minute of treatment you are prescribed
Where do I go for dialysis?
PD patients are trained to perform their dialysis at home
or in their places of work. Most hemodialysis patients must go to a dialysis center,
while others undergo treatment at home (home hemodialysis).
What should I ask about a dialysis center before choosing
one?
Each dialysis center is a little different. Policies and
practices vary. Some will schedule treatments around your job, while others will
not. Some allow patients to eat during dialysis, while others do not. Some centers
have patient education and exercise programs, and some don’t. We suggest you consult
your nephrologist and visit centers near you before making a choice.
Lifestyle changes
on dialysis
Why do I need to limit how much fluid I drink on dialysis?
Healthy kidneys control fluid balance in your body. When
your kidneys lose the ability to control your fluid balance, dialysis can help remove
excess fluid buildup.
Taking too much fluid off too quickly in a hemodialysis
session can cause cramps and low blood pressure. This is one reason why it’s best
to limit your fluid weight gain between treatments. In peritoneal dialysis, your
fluid limits will depend on how effectively fluid is removed by your exchanges.
Fluid overload can cause high blood pressure and shortness
of breath. Over time, too much fluid can damage your heart by making it work harder.
What can I do if I’m on dialysis and I’m thirsty?
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Reduce salt in the diet. Salt makes you thirsty. Learn
to read food labels to look for sodium content.
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Bring a list of medications to a pharmacist and ask if any
have thirst or dry mouth as side effects. If so, the doctor may be able to prescribe
a different medication.
-
Find some very sour lemon hard candies to suck on.
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Ask other patients how they deal with thirst.
What are phosphate binders and why do I need them?
Healthy kidneys remove excess phosphorus, a mineral that
is present in many foods. Dialysis is not very efficient at removing phosphorus
and too much in your system is harmful. High phosphorus stimulates overproduction
of parathyroid hormone (PTH), which contributes to bone disease and can also cause
itching. ortunately, phosphate binders can help. Binders are medications taken within
a few minutes of all meals and snacks. In your gut, they bind to phosphorus in your
food to reduce the amount of phosphorus absorbed into your bloodstream. Reducing
phosphorus in your diet and taking phosphate binders helps calcium stay in your
bones, where it belongs.
Phosphate binders usually contain calcium. Calcium carbonate and calcium acetate
are common phosphate binders. Newer phosphate binders without calcium are also available.
Sevelamer is the most commonly used non-calcium phosphate binder.
What vitamins should I take or avoid?
Water-soluble vitamins
Hemodialysis and peritoneal dialysis reduce water-soluble
B and C vitamins. Renal diets also tend to be low in B vitamins and vitamin C. The
easiest way to replace these vitamins without getting too much is by taking a special
renal multivitamin once a day. Be sure to take it after hemodialysis on treatment
days.
If you take over-the-counter vitamins, read the label. Over-the-counter
vitamins often have 1,000% to 2,000% of the RDA of some B vitamins—and these high
doses could be toxic to someone whose kidneys don't work. Look for B vitamin levels
of about 100% of the U.S. recommended daily allowance (RDA). The exceptions are
two B Vitamins that help red blood cell formation: folic acid and vitamin B-6. These
are recommended for dialysis patients at levels several times the RDA. imit vitamin
C to about 60 mg per day. High levels of vitamin C can cause oxalate crystals to
form in people with reduced kidney function.
Fat-soluble vitamins
Avoid vitamin A supplements. Since this vitamin is fat-soluble,
not water-soluble, it can build up to higher than normal levels in people on dialysis.
Vitamin E is also fat-soluble and is not removed by dialysis. However, some nephrologists
recommend 400 to 800 IU per day of natural-source vitamin E, because some studies
have found that it can help dialysis patients.
What medication can help control my high PTH?
Keeping PTH in the target range (not too high and not too
low) helps prevent bone problems that are common in kidney disease. If your blood
level of parathyroid hormone (PTH) is too high, your doctor may prescribe a form
of active vitamin D to help bring your PTH level down.
How can I adapt to the changes in my body on peritoneal
dialysis (PD)?
PD is a lifesaving therapy you can do yourself at home.
It offers many advantages such as control over your schedule and relaxed dietary
and fluid limits. However, there are physical changes you should be aware of, including:
-
A tube sticking out of your belly
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An increase in your waist size
-
The tendency to gain weight from sugar in the PD fluid
The catheter tubing can be held in place with a special
“PD belt” or by other means, so it doesn't look obtrusive or get in your way. You
may feel self-conscience during intimacy at first; however, in time you may learn
to accept it and then ignore it.
The best way to accept the drawbacks of PD is to remember
the benefits of this lifesaving therapy.
How can I care for my dialysis access?
Here are some other ways that you can care for your
fistula and graft:
-
Keep your access arm clean, and watch for signs of
infection such as tenderness, swelling, redness, fever or flu-like symptoms.
-
Avoid tight clothing or lying on top of your access
arm while you sleep—these can slow the blood flow through your fistula or graft
and raise the risk of clotting.
-
Need to have your blood pressure measured or blood
drawn? Insist that the staff use your non-access arm when blood is needed to be
drawn for tests.
-
Feel the “thrill” or vibration of blood through your access
several times a day. If the flow stops or even feels different, this could mean
a blood clot. Call your dialysis care team right away! With quick action, many clots
can be dissolved or removed.
-
Each day, use a stethoscope to listen to the “bruit” or
whoosh-whoosh of blood through your access. If the bruit gets higher in pitch, like
a tea kettle, it could mean narrowing of the blood vessels. If the bruit stops,
you may have a blood clot. Call your dialysis care team right away if you notice
a change.
-
Always wash your access arm well before each dialysis treatment,
as your care team teaches you.
-
Be sure the care team member who will put needles into your
access has clean hands and fresh gloves.
-
Some dialysis centers—and some patients—-have a “three strikes
and you’re out” rule for their access. If a care team member cannot place the needles
in three tries, someone else takes a turn. If you have an access that is difficult
to stick and you find someone who is very good at sticking it, you may want to ask
the charge nurse for that care team member if she or he is available.
-
At each dialysis, the needle sites should be at least half
inch away from the sites used the last time. Know where your next needle stick should
be, or better yet, learn to put in your own needles! Good “sticks” can help keep
your access working well.
-
Your dialysis team will teach you how to hold your needle
sites to stop the bleeding after a treatment. Be sure to wear a glove when you do
this.
How can I care for my catheter?
Because catheters are both inside and outside your
body, they are very prone to infection.
To care for your
catheter:
-
It is very important to always keep your catheter
clean and dry. This may mean you can’t swim or take showers or baths, but need to
wash up with a washcloth instead. Ask your doctor to be sure you understand how
to protect your catheter.
-
Be careful not to pull or tug on the catheter, especially
while getting dressed and undressed. Your care team should teach you how to put
a dressing over the catheter to protect it while it is not being used for dialysis.
-
Watch for signs of infection: redness, swelling, pain,
pus or fever. Call your dialysis center right away if you notice any of these.
-
During dialysis, be sure the staff person who will
connect your catheter to the dialysis tubing washes his or her hands first and wears
gloves and a mask. You should wear a mask, too! The ends of the catheter should
never be left open to the air.
 
-
Catheters can be "positional.” This means they may work
better when you are sitting in one position than if you sit another way. Pay attention
to what works best so you can tell your staff and get the best possible treatment.
-
Some people carry staph bacteria in their noses and throats
without getting sick. If you are a staph carrier, ask your doctor about an antibiotic
ointment you can put in your nose before dialysis. This can keep you from breathing
staph germs onto your catheter and getting an infection.
-
Never use scissors near or around your catheter for any
reason. With good care, a catheter can be a helpful “bridge” while your fistula
or graft is healing or can allow you to have dialysis when other forms of access
are not available.
PD catheter
As part of your PD training, you'll learn how to care for
your catheter and prevent infections. Follow your care team's advice, and ask your
PD nurse if you have questions.
Here are some ways
to care for your PD catheter:
-
Before you do a PD exchange or exit site care, put on a
mask and scrub your hands well with liquid soap. Clean under your fingernails, between
your fingers, the backs of your hands, and your palms. Use a timer to be sure you
wash long enough, and make lots of lather to wash germs away.
-
Dry off with clean paper towels. Use a paper towel to turn
off the faucet so your hands stay clean. Don't touch anything other than your catheter
once your hands are washed. This will help you avoid infection.
-
Look at your catheter and tube each day: Are there cracks
or holes? Look at your exit site: Is it red, swollen, painful, or draining? If you
see any of these problems or if your exit site feels tender or hardened, call your
dialysis center.
-
Wash the skin around your exit site once a day, the way
your PD nurse teaches you, start close to your catheter and move away in an outward
motion. Rinse the soap off in the same way. Pat skin dry.
-
Fasten your catheter to your skin so it does not move around,
using tape or a special “PD belt” to keep the catheter and tubing from pulling.
-
It's safest to avoid swimming and tub baths. If you do get
your doctor's permission to swim, the ocean or a private, well-chlorinated pool
are better choices than hot tubs, public pools, lakes or rivers. Follow your doctor's
recommendation for an exit site dressing to use during swimming. Always clean and
dry your exit site promptly after getting it wet.
What is kidney transplantation (KT)?
Kidney transplantation is the surgical implantation
of a healthy kidney (allograft) from a donor, either living (living donor KT) or
brain-dead (cadaver KT), into the abdomen of a person with late stages of CKD (recipient).
Like dialysis, it is aimed at treating complications of CKD, albeit in a continuous
manner just like the recipient’s previously healthy kidneys. As such, it has the
greatest potential for restoring a healthy, productive life.
When should I start the process to get a kidney transplant?
If your kidneys are failing, a kidney transplant is
one of two available treatment options for you. You may begin the process of getting
a transplant way before you need some form of renal replacement therapy, most of
the time dialysis. If you want a kidney transplant, you must contact a transplant
center and ask for a transplant evaluation. Only a transplant team can tell you
that you are definitely eligible (or not eligible) for a transplant. If you are
eligible, you may opt to get a transplant right away (preemptive KT) or receive
maintenance dialysis as a bridge until a suitable donor is found. Recent studies
suggest that outcomes are somewhat better with preemptive transplant than getting
a transplant once on dialysis. Unfortunately, the former requires a willing living
kidney donor-probably a relative, spouse or friend. If you do not have a living
donor, you can ask to be placed on a national waiting list to receive a cadaver
kidney from someone who has recently died-usually in an accident.
Can I get on the kidney transplant waiting list before
I start dialysis?
Yes, you may want to be evaluated for a transplant before
you start dialysis. After your evaluation is done and you get on the waiting list,
credit for waiting time starts when your kidney function drops to less than about
20%.
Can anyone give me a kidney, whenever I want?
A parent, sibling, distant relative, spouse and even a friend,
neighbor and stranger can be donors. If you have a willing living kidney donor,
you will both need to be evaluated for general health and to see if your blood type
and immune system are matched closely enough with the donor. How close the match
needs to be depends on the rules and protocol of each transplant center. Based on
studies, best outcomes are achieved if the recipient and donor have the same blood
type (ABO blood group compatible) and are closely matched (HLA match). Normally,
a patient’s parent, sibling or close relative is more closely matched than a neighbor
or a stranger at large.
I have a strong family history of diabetes. Can family
members donate?
Diabetes is a disease that runs in families. Hence, a family
member is predisposed to develop diabetes sooner or later, if at all. Since diabetes
is the leading cause of CKD, family members are discouraged from donating for such
reasons. However, if the risks are acceptable to both potential donor and recipient
and no other donor is available, a family member may still donate.
I have heart disease. Can I still get a transplant?
Yes, but it depends on the severity of heart disease. KT
is relatively a minor surgical procedure and most patients with mild heart disease
and ESRD do well during surgery if close attention to pre-operative preparation
is done. Potential recipients with moderate to severe heart disease must undergo
thorough evaluation before surgery to avoid cardiac complications.
Heart disease is a common complication of CKD and is the most common cause of death
among dialysis patients. Such problems often reverse to some extent after successful
KT. However, some other problems such narrowing of blood vessels of the heart may
accelerate after KT as a side effect of some anti-rejection medications. Therefore,
heart disease per se is not a reason to withhold KT.
I have polycystic kidney disease (PKD). Can family members
donate?
PKD is a disease that also run in families. Hence, family
members are at risk of developing PKD and its complications, including CKD. For
this reason, it is prudent to look for a donor other than a family member.
I am hepatitis B positive. Can I still get a transplant?
Yes, you can still get a transplant even if your are hepatitis
B positive provided you do not have active infection and your viral load is negligible.
A liver biopsy may be needed as part of the pre-KT evaluation. In most cases, anti-rejection
medications that may cause flare up of the disease and possible liver failure are
avoided. The potential risks and benefits of a successful KT and possible liver
failure must be strongly considered in all cases.
Am I too young or too old to get a transplant?
There are no age limitations as far as getting a transplant
is concerned. Even the very young and the very old may benefit from successful KT.
Co-morbid conditions, and the potential risks and benefits of KT will primarily
dictate eligibility for KT rather than age itself.
What is allograft rejection?
The immune system is the body’s defense system. It guards
against and destroys foreign entities introduced into the body. Allograft rejection
(AR) happens when the immune system recognizes the allograft as something foreign
and destroys it, much in the same way as it would when bacteria or a virus enters
the body. It is preventable and reversible with the use of potent anti-rejection
medications. The most common cause of AR is non-compliance to anti-rejection medications.
How is allograft rejection diagnosed?
AR is diagnosed based on clinical and laboratory parameters.
Decreasing urine volume, fever, rising blood pressure, pain on the allograft site,
and increasing serum creatinine and/or potassium may suggest AR. However, these
may also result as side effects of anti-rejection medications, so the distinction
must be definitely made (usually by kidney biopsy), because treatment is different.
How is allograft rejection prevented?
AR is prevented by administration of anti-rejection medications,
which are usually given in various combinations depending on the transplant center’s
immunosuppression protocol. They are designed to suppress or down-regulate the recipient’s
immune system so that it does not recognize and destroy the allograft.
Can I stop my anti-rejections medications after KT?
Stopping anti-rejection medications after KT inevitably
leads to allograft rejection and eventual loss of function. It will result in activation
of the immune system, recognition and destruction of the allograft.
What are the common complications after KT?
The most common complications after KT are infections, allograft
rejection, and drug toxicity. These are particularly common in the first few months
after KT, when the dose of anti-rejection medications are highest and the body’s
immune system is maximally suppressed. Eventually, these become less common as the
dose of medications are decreased and the immune system becomes tolerant of the
allograft.
Do I have to wear a face mask forever after KT?
Since you are prone to infections after KT, many air-borne
infections may be easily prevented by simply wearing an effective face mask, especially
in crowded places. No harm is done when you protect your self against possible infections,
so wearing a face mask after KT is but prudent. After a couple of months, you may
choose not to wear a face mask because the risks of infection are less, but are
still real.
Do I still need dialysis after kidney transplantation?
After living donor kidney transplantation, dialysis is normally
not needed anymore because the new kidney immediately works to remove unwanted fluid
and retained waste products. In a few cases, however, the new kidney may not work
right away efficiently because of AR; hence, dialysis may still be required, until
the new kidney is able to work adequately.
After cadaveric kidney transplantation, dialysis is usually
required since the new kidney has been stressed and possibly not functioning after
being “dead” for many hours, making recovery of normal function slow.
If my transplant fails, can I go back to dialysis?
Yes. You can go back to dialysis after a failed transplant,
either because the new kidney did not function adequately to ameliorate complications
of ESRD or did not work at all.
If my transplant fails, can I get another transplant?
Yes. You can still get another transplant, but the short
and long term risks of allograft rejection are higher because of the prior transplant
(sensitization).
Acknowledgements
The Philippine Society of Nephrology wishes to thank all
the patients, family members, professionals, and companies who generously offered
their devotion, time and resources in making this section of this website possible.
We also thank the Philippine Renal Disease Registry, the National Kidney and Transplant
Institute, National Kidney Foundation (NKF), International Society of Nephrology
(ISN), American Society of Nephrology (HDCN), Hypertension, Dialysis, and Clinical
Nephrology (HDCN), Kidney Early Evaluation Program (KEEP), American Association
of Kidney Patients (AAKP), and KidneyDirections, whose prior concepts, works and
publications were adapted in this endeavor.
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