Treatment Options

When you first hear this diagnosis, it’s scary. But there are a few things you should know.

First, there are three treatment options available. Your renal care team will pick one to match your lifestyle and physical needs Treatment options vary with the nature and stage of the disease. Several medications, including corticosteroids, are available to treat or control early-stage kidney disease. In the case of late-state disease or kidney failure, the options include dialysis or kidney transplantation.

Non-treatment is also an option. However, the non treatment choice will lead to death.

Second, you are the most important member of your renal care team. Other members include your doctor, your nurse, your family, your friends, self-help groups, dialysis clinic personnel, nutritionists or dieticians, and qualified social workers.

Third, you are not alone. Estimates show that more than a million people worldwide have kidney failure.

The process of removing waste matter and maintaining electrolyte balance through diffusion is called dialysis. Usually performed by the kidneys, this is performed by artificial means in kidney patients. The two main types of dialysis are:

• Peritoneal Dialysis
• Haemodialysis

• CAPD
• APD
• Advantages and Disadvantages

Peritoneal dialysis occurs inside the body. It uses your peritoneal membrane (the lining of you abdomen) as the filter. For this treatment, a tube called a catheter is surgically placed through the wall of your abdomen.

Special dialysis solution will flow into the peritoneum through the catheter. Waste products and excess fluids pass from the blood. They move through the peritoneal membrane, into the dialysis solution. Then, they are drained from the peritoneal cavity. Peritoneal dialysis can be performed by hand or by using a machine. Tubing and bags are worn only during the solution exchange.

Continuous Ambulatory Peritoneal Dialysis (CAPD)allows gravity to draw dialysis solution into and out of the peritoneal cavity, using a system of tubing and bags.

With CAPD, you connect tubing and a bag of sterile dialysis solution to the peritoneal catheter. By raising the bag to shoulder level or higher, the solution flows into the peritoneum. When empty, simply remove and throw away the tubing and solution bag.

During daily activities, the peritoneal membrane acts as a filter for you blood. Waste products and excess water transfer to the dialysis solution. After a few hours, you attach new tubing and an empty bag to the catheter. Then, lower the bag to drain the waste-filled fluid from the peritoneum.

1. Connect the tubing set to the catheter.
2. Drain out the used solution.
3. Fill with the new solution.
4. Disconnect the tubing set from the catheter.
5. Throw away the used solution, disposable tubing and bags.

The number of exchanges per day, and length of time per exchange, varies by person. Usually, CAPD is performed four times a day. Each solution exchanges lasts about half an hour. Assist devices help people with problems seeing or with problems using their hands to do CAPD.

The second type of peritoneal dialysis, Automated peritoneal dialysis (APD) involves a machine. You attach the tubing and solution bags to the machine. Before going to sleep, you connect the tubing to the peritoneal catheter. During the night the machine performs the dialysis.

For extra therapy, dialysis solution remains in the peritoneal cavity during the day. The peritoneal cavity of most adults can hold about two to three litres of fluid.

Haemodialysis

Blood is pumped outside the body to an artificial kidney machine. The machine cleanses the blood and returns it to the body. Only a small amount of blood is out of the body at any time.

A “fistula” (the surgical linking of an artery to a vein) provides access to blood vessels. So does a “graft” (tubing surgically placed under the skin, linking an artery to a vein).

Two needles are placed into the fistula or graft. The needles are then attached by plastic tubing to a special filter. This filter is an artificial kidney called a dialyser. One needle withdraws blood for cleansing. The other needle returns filtered blood to the body.

A pump pushes blood through the dialyser. Blood passes on one side of the filter. Solution made by the dialysis machine passes on the other side. The solution draws excess fluid and waste out of the blood. A filter is used with pores large enough to allow waste to leave. Larger molecules like blood cells cannot pass through the filter.

The average person receives three treatments per week. Each treatment lasts three to four hours. There are two options for haemodialysis: (1) home haemodialysis, and (2) in-centre or clinic haemodialysis.

It is estimated that every year over 100, 000 people are diagnosed to have kidney failure in India. Due to various reasons, including the non-availability of organs, only about 2,500 kidney transplants are done.

During a transplant, a healthy donated kidney is placed deep under your skin near your hip bone. In some cases, the non working kidneys may be removed to control infection or high blood pressure.

Transplantation is the most “natural” solution to kidney failure. However, the National Kidney Foundation believes that only about 50% of dialysis patients meet the physical requirements for a transplant, or choose this treatment option.

Before 1995, India used to be the great kidney bazaar. Poor people would be enticed to sell a kidney for what seemed to them a huge amount (a few thousand rupees). When the Transplantation of Human Organs Act was passed, it is a little difficult to get a kidney donor.

• A blood relation: This is ideal. You can get the kidney from someone who is alive. The operation should be performed at a time suited to both donor and recipient. This way, the kidney is not kept in storage for long. There is greater match of tissues and lower chance of rejection. It is cost effective because, as there is less chance of rejection, you may spend less on medication. Besides, there is less legal procedure involved.
• An unrelated donor: A good tissue match may be difficult to find. You may have to wait from two weeks to two years. If you find a donor, then the donor is interrogated as a safeguard against organ trade.
• A cadaver: The Indian Organ Transplant Act approves the harvest of organs from the brain dead. There are 60,000 accident cases reported in India each year. While many of these victims are brought to the hospital in a brain dead state, organs are not efficiently harvested from their bodies for the following reasons:
  1. Many of these victims are not even attended to in hospitals, as they are expected to be shifted to referral or government hospitals. While this happens the victims die.
  2. Brain Death certification is to be given by an approved neurologist. There are not many of these. They must be available when the accident victim is brought in. They must have the facilities to conduct the tests to declare brain death. After this is done, an organ bank has to be coordinated with. In many places the trauma/neuro unit is not situated close to an organ bank. The effort is quite often not made and sometimes it is too late.
  3. The relatives of the brain dead person do not permit the removal of the organs.
  4. The brain dead person has to be put on a ventilator until a suitable recipient or organ storage is found. This is expensive and it is not clear as to who will pay for this. So hospitals do not bother about this, and let the victims go without harvesting body parts.

You will be admitted to hospital a couple of days before the date of transplant and a series of test will be conducted. These will include blood tests, chest x ray, ECG and ultrasound. Heart functions, the liver, the abdomen, the bladder and the kidneys will be studied.

Kidney transplants are performed under general anaesthesia. You will not feel pain during the surgery. The right lower corner of your abdomen is cleaned. The surgeon will make a long and deep cut through layers of muscle to get to the transplant site. The donated kidney is placed between the upper thigh and the abdomen, in the pelvis. Your kidneys, which have failed, will not be removed unless they are swollen or infected.

The new kidney has to be connected to the artery that carries blood from your heart into your legs and the vein that carries blood back to your heart from your legs. Your artery and vein are clamped and sewn to the artery and vein on the donated kidney. Then the clamps are released, allowing blood to flow in and out of your new kidney.

The tube that carries urine out of the kidney is stitched into the side of your bladder. Then your muscle layers are sewn together with dissolvable stitches and your skin is stitched up.

The operation is a major one and takes about four hours.

You may feel some pain and stiffness in your abdomen when the influence of the anaesthesia wears out. Close monitoring of your body functions continues for a week or so. You will be on powerful immuno-suppressants and these drugs might produce side effects.

If all goes well, you will be discharged after ten days or so and you will be asked to come in for regular follow ups.

The kidney transplant is a major operation and you should be briefed on all possible complications.

The immuno-suppressant cyclosporin has increased the survival rate substantially. The five-year survival rate of a live related tissue-matched transplant is pretty high, about 90 per cent. With cyclosporin, the five-year graft survival rate of a cadaveric transplant patient is 75-80 per cent.

These are rough indicators based on local hospital records.

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