The truth about dialysis

Renal failure or End Stage Renal Disease (ESRD), which is often related to diabetes or hypertension, is a serious medical problem. An understanding of the scope of this condition is essential for optimising treatment of ESRD and establishing meaningful strategies for prevention.

The incidence of terminal renal failure is rising at an alarming rate inspite of impressive advances in the management of ESRD. An estimated one lakh people develop ESRD every year. This is in addition to a pre-existing pool of about 20 lakh sufferers. More than 75 per cent of those suffering from ESRD do not get treated at all. Further, the burden of renal disease is growing rapidly in India. Particularly distressing is the number of older patients who need renal replacement therapy. In fact, more than 50 per cent of patients undergoing renal dialysis or transplantation for ESRD are 65 years old or more.

It is vital for kidneys to function properly to sustain life. Kidneys act like blood purifiers as they filter out toxic products and excess fluid from the body. They also maintain the chemical balance of important electrolytes such as sodium and potassium. End stage kidney disease occurs when the kidneys are no longer able to function at a level that is necessary for healthy day-to-day life. It usually occurs as chronic renal failure worsens to the point where kidney function is less than 10 per cent of normal function. At this point, the kidney function is so low that without dialysis or kidney transplant, complications are multiple and severe, and death will occur from accumulation of fluids and waste products in the body.

Chronic renal failure usually occurs over a number of years as the internal structures of the kidney are slowly damaged. In the early stages, there may be no symptoms. In fact, progression may be so gradual that symptoms do not occur until kidney function is less than one-tenth of the normal function. This is usually in response to a chronic disease such as diabetes or high blood pressure. In some cases, kidney disease is hereditary.

People with the following conditions are at greater-than-normal risk of developing kidney failure and end-stage renal disease: Diabetes (type 1 or type 2), high blood pressure, glomerular diseases, haemolytic uremic syndrome, sickle cell anaemia, severe injury/burns and liver disease. Inherited kidney diseases such as polycystic kidney disease, congenital obstructive uropathy, cystinosis and prune belly syndrome also put people at risk of ESRD.

Symptoms of renal failure
The main symptoms are constant fatigue, swelling around the feet/ankles/eyes, loss of appetite and nausea. Blood tests will show a very high concentration of a toxic substance called creatinine, which the body is not able to excrete. Urine tests will normally show abnormally high protein content as the kidneys are not able to re-absorb the protein.

Preventive care is possible and early kidney damage is manageable. However, ESRD cannot be treated with conventional medical treatments such as drugs. Treatment depends on the degree of kidney function that remains and may include medication (to prevent bone density loss, and/or to treat anaemia), diet restriction, dialysis and kidney transplant.

Kinds of dialysis
Dialysis is a well-accepted therapy option, since there is a shortage of kidney donors. There are two types of dialysis options available — Haemodialysis (HD) and Peritoneal Dialysis (PD). Haemodialysis is machine dialysis therapy done at hospitals, wherein the patient’s blood is cleansed outside of the body. It is performed under medical supervision and requires the patient to visit a hospital about 3 times a week.
Peritoneal dialysis involves using the peritoneal membrane (the lining of the abdomen) within the body for dialysis and is done at home. A catheter or tube is inserted into the abdominal cavity with a minor surgical procedure. PD is further classified into Continuous Ambulatory Peritoneal Dialysis (CAPD) and Automated Peritoneal Dialysis (APD).

CAPD, which is often called ‘machine-free dialysis’, is done 7 days a week and involves 3-5 exchanges a day for about 30 minutes. It is done every 4-8 hours. The process has several advantages, including the  ease of administering the treatment at home, simple and bloodless procedure, no involvement of machine etc.
In APD, a machine does the exchanges or ‘cycles’ of dialysis while the patient is asleep. The patient is connected to the cycler at bedtime, 7 days a week, for 9-11 hours each night.

Since peritoneal dialysis is easy to perform, it’s the more popular treatment. It is fast emerging as the treatment of choice for patients seeking independence and quality of life, and for patients who do not have convenient access to haemodialysis facilities.

People with ESRD are now living longer than ever. Mortality among dialysis patients has been declining. Dialysis treatments (both haemodialysis and peritoneal dialysis) help a person feel better and live longer. Obviously, the primary goal should be prevention of ESRD. Aggressive treatment of hypertension and hyperglycemia is likely to reduce the incidence of ESRD. Screening for diabetes and hypertension may be a fruitful approach to reduction in ESRD rates. With the availability of adequate information, knowledge and resources, it is possible to deal with ESRD.