Patient information: Dialysis or kidney transplantation — which is right for me?

INTRODUCTION

Dialysis and kidney transplantation are treatments for severe kidney failure, also called renal failure, stage 5 chronic kidney disease, and end-stage renal disease. There are two types of dialysis: hemodialysis and peritoneal dialysis.

When the kidneys are no longer working effectively, waste products and fluid build up in the blood. Dialysis takes over a portion of the function of the failing kidneys to remove the fluid and waste. Kidney transplantation can completely take over the function of the failing kidneys.

This article discusses these therapies, including the advantages, disadvantages, and care required for kidney transplantation and dialysis. You and your family should discuss all of the options with your healthcare provider to make an informed decision.

WHEN WILL DIALYSIS OR KIDNEY TRANSPLANTATION BE NEEDED?

Early in the course of kidney disease, medications are used to help preserve kidney function and delay the need for dialysis or transplantation. These early treatments are directed at the underlying kidney disease, secondary factors (such as hypertension) that promote kidney disease progression, and the complications of chronic kidney disease.

As the kidneys lose their ability to function, fluid and waste products begin to build up in the blood. Dialysis should begin before kidney disease has advanced to the point where life-threatening complications occur. This usually takes many months or years after kidney disease is first discovered, although sometimes severe kidney failure is discovered for the first time in people who were not previously known to have kidney disease. (See "Patient information: Chronic kidney disease".)

It is best to begin dialysis treatments when you have advanced kidney disease, but while you still feel well. You and your doctor will decide when to begin dialysis after considering a number of factors, including your kidney function (as measured by blood and urine tests), overall health, and personal preferences.

KIDNEY TRANSPLANTATION

Kidney transplantation is considered the treatment of choice for many people with severe chronic kidney disease because quality of life and survival are often better than in people who use dialysis. However, there is a shortage of organs available for donation. Many people who are candidates for kidney transplantation are put on a transplant waiting list and require dialysis until an organ is available.

A kidney can come from a living relative, a living unrelated person, or from a person who has died (deceased or cadaver donor); only one kidney is required to survive. In general, organs from living donors function better and for longer periods of time than those from donors who are deceased.

Some people with renal failure are not candidates for a kidney transplant. Older age and severe heart or vascular disease may mean that it is safer to remain on dialysis rather than undergo kidney transplantation. Other conditions that might prevent a person from being eligible for kidney transplantation include:

• Active or recently treated cancer
• A chronic illness that could lead to death within a few years
• Poorly controlled mental illness (psychosis)
• Severe obesity (a body mass index greater than 40, (calculator 1)
• Inability to remember medications
• Current drug or alcohol abuse

Most centers exclude people who are HIV-positive. In selected cases, however, people with HIV may be eligible for kidney transplantation if their disease is well-controlled.

People with other medical conditions are evaluated on a case-by-case basis to determine if kidney transplantation is an option.

Advantages — Kidney transplantation is the treatment of choice for many people with end-stage renal disease. A successful kidney transplant can improve your quality of life and reduce your risk of dying from kidney disease. In addition, people who undergo kidney transplantation do not require hours of daily dialysis treatment.

Disadvantages — Kidney transplantation is a major surgical procedure that has risks both during and after the surgery. The risks of the surgery include infection, bleeding, and damage to the surrounding organs. Even death can occur, although this is very rare.

After kidney transplantation, you will be required to take medications and have frequent monitoring to minimize the chance of organ rejection; this must continue for your entire lifetime. The medications can have significant and bothersome side effects.

HEMODIALYSIS

In hemodialysis, your blood is pumped through a dialysis machine to remove waste products and excess fluids. You are connected to the dialysis machine using a surgically created path called a vascular access, usually referred to as an access. This allows blood to be removed from the body, circulate through the dialysis machine, and then return to the body.

Hemodialysis can be done at a dialysis center or at home. When done in a center, it is generally done three times a week and takes between three and five hours per session. Home dialysis is generally done three to seven times per week and takes between three and ten hours per session (often while sleeping). More detailed information about hemodialysis is available separately. (See "Patient information: Hemodialysis".)

Advantages — It is not known if hemodialysis has clear advantages over the other type of dialysis (peritoneal dialysis) in terms of survival. The choice between the two types of dialysis is generally based upon other factors, including your preferences, home supports, and underlying medical problems. You should begin with the type of dialysis that you and your doctors think is best, although it is possible to switch to another type as circumstances and preferences change.

Disadvantages — Low blood pressure is the most common complication of hemodialysis and can be accompanied by lightheadedness, shortness of breath, abdominal cramps, nausea, or vomiting. Treatments and preventive measures are available for these potential problems. In addition, the access can become infected or develop blood clots.

Many patients who receive hemodialysis in a center are either unable to work or choose not to work due to the time required for travel and treatment.

PERITONEAL DIALYSIS

Peritoneal dialysis (PD) is typically done at home. To perform PD, the abdominal cavity is filled with dialysis fluid (called dialysate) through a catheter (a flexible tube). The catheter is surgically inserted into the abdomen near the umbilicus (belly button). (See "Patient information: Peritoneal dialysis".)

The fluid is held within the abdomen for a prescribed period of time (called a dwell). The lining of the abdominal cavity (the peritoneal lining) acts as a membrane to allow excess fluids and waste products to diffuse from the bloodstream into the dialysate. The used dialysate in the abdomen is then drained out and discarded. The peritoneal cavity is then filled again with fresh dialysate. This process is called an exchange.

The exchange may be done manually four to five times during the day. The exchange may also be done automatically using a machine (called a cycler) while you sleep.

Advantages — Advantages of peritoneal dialysis compared to hemodialysis include more uninterrupted time for work, family, and social activities. Most people who use PD are able to continue working, at least part-time, especially if exchanges are done during sleep.

Disadvantages — People who use PD must be able to understand how to set the equipment up and use their hands to connect and disconnect small tubes. If you cannot do this, a family or household member may be able to do it.

Disadvantages of peritoneal dialysis include an increased risk of hernia (weakening of the abdominal muscles) from the pressure of the fluid inside the abdominal cavity. In addition, you can gain weight and you have an increased risk of infection at the catheter site or inside the abdomen (peritonitis).

WHICH THERAPY IS BEST FOR ME?

Kidney transplantation is the optimal treatment for most patients. Patients who are not candidates for kidney transplantation or who must wait for a kidney can usually be treated with either hemodialysis or peritoneal dialysis.

Choosing between peritoneal dialysis and hemodialysis is a complex decision that is best made by you and your doctor, and often other family members or caregivers, after careful consideration of a number of important factors.

For example, hemodialysis involves rapid changes of the fluid balance in the body and cannot be tolerated by some patients. Some patients are not suitable candidates for kidney transplantation, while others may not have the home supports or abilities needed to do peritoneal dialysis. Your overall medical condition, personal preferences, and home situation are among the many factors that should be considered. It is possible to switch from one type of dialysis to the other if preferences or conditions change over time.

REFUSING DIALYSIS

In the United States, dialysis is available to everyone who needs it. However, some people choose to refuse dialysis. You and your family should discuss the risks and benefits of long-term dialysis early and often.

Most people with kidney disease who have no other chronic illnesses are encouraged to pursue aggressive treatment of their disease; the chance of having a high quality of life for an extended period of time is usually excellent. However, you may have compelling reasons for refusing treatment. Try to feel comfortable discussing your wishes with your family and healthcare team with the goals of death with dignity and life with quality.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Hemodialysis
Patient information: Chronic kidney disease
Patient information: Peritoneal dialysis

Professional Level Information:
Adequacy of continuous peritoneal dialysis
Choosing a modality for chronic peritoneal dialysis
Dialysis modality and patient outcome
Evaluation of the kidney donor and risk of donor nephrectomy
Evaluation of the potential renal transplant recipient
HLA and ABO sensitization and desensitization in renal transplantation
HLA matching and graft survival in kidney transplantation
Indications for initiation of dialysis in chronic kidney disease
Kt/V and the adequacy of hemodialysis
Patient survival after renal transplantation
Renal replacement therapy (dialysis) in acute kidney injury (acute renal failure): Indications, timing, and dialysis dose
Renal transplantation and the elderly
Solid organ transplantation in HIV-infected individuals

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• National Institute of Diabetes and Digestive and Kidney Diseases

      (www.niddk.nih.gov)

• National Kidney Foundation

      (800) 922-9010
      (www.kidney.org)

• United Network for Organ Sharing (UNOS)

      (888) 894-6361
      (www.unos.org)

• American Kidney Fund

      (www.akfinc.org)

• Home Dialysis Central

      (www.homedialysiscentral.org)

• Kidney School

     (www.kidneyschool.org)

[1-3]