Renal failure and treatment options

Dr Deepak Pathania
Chronic kidney disease is a state of irreversible kidney damage which is sustained for more than three months. The disease is progressive, irreversible and natural history involves worsening of kidney function over period of time. The marker of kidney dysfunction is glomerular filtration rate(GFR) which is derived from serum creatinine based equations. Patient with CKD progress over time to CKD 5 which is a stage with GFR of less than 15 ml/min. At this stage of disease patient start having symptoms related to accumulation of uremic toxins and need of RRT arise. The native kidneys are now unable to get rid of daily metabolic waste generated from food. The symptoms are variable and may range from decreased apetite, metallic taste in mouth, swelling over feet, weight loss and generalised asthenia. The need for RRT is dictated by symptoms rather than an absolute value of serum creatinine.
Forms of renal replacement therapies
When GFR falls below 15ml/min, need of RRT arises primarily dictated by patient’s symptoms. The function of kidney has to be replaced with either a functioning kidney or Dialysis.
Renal transplant: It is considered the best form of renal replacement therapy. It involves a surgery in which a kidney from donor is transplanted into the patient and this kidney performs the function in recipient. There is lot of misconception regarding the transplant procedure and its outcomes.
Myth: Transplant surgery is dangerous .
Fact: Transplant surgery is safe, risk of death from surgery is very low and is comparable to any other routine surgery.
Myth : Risk to donor is high
Fact: Extrusion of kidney from donor (Nephrectomy) is done through laparocopic surgery which is akin to many other minimally invasive surgeries. The surgical scar is very small and risk of surgery is very low. Donors are very extensively evaluated prior to being considered for donation.
Myth: Donor can have renal failure in future.
Fact: One functioning kidney is fully capable of supporting the body functions throughout life. World over data has shown that the risk of renal failure in donor post donation is very low and is comparable to general population. Paradoxically the studies have shown longer lifespan of donors as compared to normal population which is related to better lifestyle adopted by donor post donation. The experience of donation is psychologically very fulfilling to donors.
Dialysis is a process where toxins are removed from blood. In kidney patients these include urea, creatinine and various other uremic toxins. Dialysis can be done by two methods
Hemodialysis : In hemodialysis blood is circulated through a machine and dilayser (artificial kidney).The dialyzer performs the function of removing the toxins from body. The purified blood is reinfused into patient’s body. This procedure is performed three times a week ofr mantainance hemodailysis. In order to perform hemodailysis blood access is required. This can be a catheter (temporary or permanent) or Arteriovenous fistula (AVF) and graft (AVG). The best access amongst these is AVF which is usually constructed 3 to 4 months prior to anticipated need of dialysis. It involves connecting vein and artery in arm thorugh a small and short surgical procedure after which dilatation of vein occurs over 4- 6 week period which is subsequently used for dialysis.The risk of infection is minimal and it can be closed as well if required(like after successful transplant).
In case AVF is not constructed at the time of requirement of dialysis, dialysis is then done through catheters which can be temporary or permanent. However the risk of infection is higher in catheters as compared to AVF.
Concluding remarks
Renal replacement therapy is required when kidney functions are unable to support the metabolic needs of body. The best form of renal replacement is renal transplant.The candidates not suitable for transplant can opt for hemodialysis or peritoneal dialysis depending upon their lifestyle requirement. All the procedures are safe and easily accessible. Advanced planning can go a long way in improving patient outcomes.
(The author is consultant Nephrologist and Renal transplant physician at SMVD Narayana Superspeciality Hospital Katra.)