Which therapy option is right for me?
Your physician has discussed with you that your kidney function is severely impaired and that you will need to select a renal replacement therapy (RRT) option that is most suitable for you soon, to preserve both your life and quality of life. As there is more than one option available for therapy for many patients, it is important that you take the opportunity to learn more about your therapy options to make the right choice for you personally.
Choosing the right therapy for kidney failure may be difficult. Become familiar with the therapy options and, together with your physician, choose the therapy that best suits your health status and lifestyle.
The dialysis therapy you chose, is not set in stone. Your personal lifestyle and changing medical factors also play a role in your choice of therapy. Those factors may change during your life or there might be complications which require switching to another form of treatment. Many patients do not undergo just one form of treatment in their lifetimes.
Each therapy option has its own advantages and disadvantages and not every therapy is suitable for every patient, which may limit your choices. Together with your physician and your family, you can decide which therapy is best for you in terms of treatment results and your individual quality of life.
Supporting you on your way
We would like to support you on your path to the right therapy and have compiled the most important information about different therapy options.
- With some tips that support choosing the right therapy, we will provide you some guidance on the way to making a decision
- We want to introduce to you the most important therapy options:
transplantation, peritoneal dialysis, hemodialysis, home hemodialysis and conservative therapy
- The dialysis therapy you chose is not set in stone…
- Dialysis changes your everyday life. In the section My life with dialysis, we address the most relevant topics for choosing a therapy option: everyday life, exercising, vacation and nutrition
A major surgery during which a patient with kidney failure receives a new kideny - either from a living or deceased donor.
A kidney transplant is the transfer of a healthy kidney from a donor into a patient (recipient) with chronic kidney failure.
Whether a patient (recipient) is suitable for a kidney transplant depends on various medical considerations. Different laboratory tests are done to make sure that the donor kidney and the recipient are a match.
The time it takes to receive a donor kidney varies greatly. Unfortunately, there are not enough kidneys available for transplantation. For this reason, patients may often be on a waiting list for a long time.
Who can donate a kidney?
- A living blood relative (e.g. parents or siblings).
- A living unrelated donor (e.g. a life partner or very close friend)
- A deceased donor who agreed to donate before their death
How does a kidney transplant work?
The donor kidney is inserted into the lower parts of the abdomen. The diseased kidneys are usually not removed, mainly to benefit from the remaining functions of the kidney. If all goes well (i.e., the surgery is successful and appropriate medication to keep the kidney within the body is taken), the new kidney takes over the tasks of the diseased kidneys enough to partially restore the lost kidney function. A successfully transplanted kidney can work for many years. If the transplant is not successful, dialysis is still an option. Many patients with kidney disease go through different treatment modalities during their lifetime (e.g., start with peritoneal dialysis, then a kidney transplant, then switch to hemodialysis after the donor kidney may lose function or complications occur), so a failed transplant is not the last option.
What needs to be considered for a kidney transplant?
A successful transplant can help to achieve a better state of health without dialysis. To prevent rejection of the donor kidney, the patient (recipient) must take regular medications during and/or after the transplant. This medication is generally referred to as immunosuppresives. However, in some cases, even these medications cannot prevent the rejection of the kidney.
Since your immune system will be weaker compared to others, you should be aware of the potential side effects related to these medications, especially infections. Therefore, it is essential to follow the hygiene measures addressed by your physician. These medications can also cause other unwanted side effects, such as changes in your gums, increased blood pressure, high cholesterol levels, puffy face, anemia, unwanted hair growth, skin problems, and weakened bones. If any of these are present, inform your physician. For patients with a donor kidney, it is important that the anti-rejection and other medication is taken daily and that regular follow-up examinations take place.
Peritoneal dialysis (PD)
Peritoneal dialysis (PD) is named after the peritoneum. This is a thin, velvety tissue that lines the abdominal cavity and the internal organs. It is naturally present in every person’s body. This form of dialysis uses the peritoneum as a natural filter to replace kidney function. To do this, a fresh dialysis solution is introduced into the abdomen. Depending on your physician’s prescription, it remains there for a few hours and is replaced as soon as toxins and excess body water have been absorbed.
The PD catheter
- A catheter is a soft, flexible plastic tube that is about the thickness of a straw in diameter.
- In peritoneal dialysis, dialysis fluid flows in or out of the abdomen through the catheter.
- The catheter is placed into the abdominal cavity through a minor surgical procedure and permanently remains in place. It is usually ready for use two weeks after the surgery.
There are two types of PD
PD is performed either as continuous ambulatory peritoneal dialysis (CAPD) (manually) or as automated peritoneal dialysis (APD) (using a machine). In rare cases, a combination of two types can also be used. Both therapy options are normally performed independently at a patient's home or other suitable places, such as at work or at a hotel room during travel, generally by the patient or a caregiver. Don't worry! You will receive extensive training from your care team before performing dialysis on your own. All necessary steps will be communicated to you and afterwards you will be proud of yourself for being able to manage your therapy. The decision for one of the two PD options depends on the patient's lifestyle, health condition and personal preferences and is made together in consultation with your physician. You may find it helpful to involve relatives or other patients in your decision. Everything can be done together!
Facts about PD
- You perform the treatment independently, seven days a week, at home, as prescribed by your nephrologist.
- However, you are not alone: a physician will check on you regularly and a PD nurse is available for you on-call by phone.
- With PD, you are relatively flexible. That allows you to plan your daily life. This can be important for you if you work, go to school or travel.
- In addition, PD is possible almost anywhere, so you can dialyze at work, for example. However, talk to your physician about this beforehand!
- By not having to travel to a dialysis center, you have more time for yourself and only need to schedule check-ups with your physician.
- PD can help maintain residual kidney function.
- No needles (punctures) are needed to perform PD and the treatment is usually painless.
What you need to do to succeed at PD:
- You will receive detailed training at your dialysis center to ensure that you feel comfortable doing PD on your own. You will also learn proper catheter care.
- Be aware that it may take some time to get used to the fluid in your stomach. It is usually not a problem for an adult to have two to three liters of fluid in the abdominal cavity.
- Following certain precautions will help you avoid the risk of an infection called peritonitis. Hygiene control is one of the most critical aspects of PD therapy. Your nurse will give you instructions on how to avoid infection.
- You will need ample storage space for your supplies at home.
- If you have diabetes, be aware that your physician may need to adjust your dose of insulin. This is because the sugar in the dialysis may raise your blood sugar levels.
- You will perform your treatment every day, seven days a week, as prescribed by your nephrologist.
- You will visit your dialysis center once or twice a month for check-ins with your physician and your care team.
Continuous ambulatory peritoneal dialysis (CAPD)
Continuously done without a machine. Typically, three - five fluid exchanges are done per day at home.
With CAPD, dialysis takes place continuously. Dialysis solution is put into and taken out of the body via manual exchanges. Typically, three to five exchanges are done per day in a clean environment - at home, at work or while travelling. After a consultation with your physician, the exchanges can also take place in a suitable room at your workplace, for example. During dialysis, you are not connected to any machine, so you are able to move around during the treatment.
The dialysis solution is passed through the catheter into the abdominal cavity.
The dialysis solution remains in the abdominal cavity for several hours. Waste products and excess body water are absorbed by dialysis
After a predetermined time, the dialysis solution is drained from the abdominal cavity and replaced with fresh solution.
After applying hygiene measures, you connect the set of CAPD plastic bags filled with dialysis solution to your catheter. The CAPD set typically consists of two bags, one empty waste bag and one bag filled with 2-2.5 liters of cleansing fluid, or dialysate. You drain the used dialysis solution through your catheter, which takes about 20 minutes. After draining the used fluids flush the catheter with a small amount of fresh dialysate.
Now you can fill the fresh dialysis solution into your abdominal cavity. By hanging the plastic bag on the infusion pole at shoulder level, gravity pulls the fluid into your abdomen. This process is called filling and takes about 10 minutes. You can then disconnect the set and cap your catheter.
The whole process, which consists of the three steps filling, dwelling, and draining, is called a bag exchange. This process takes about 30 minutes and is typically done three to five times a day. Some patients prefer to do the bag exchanges before or after mealtime or at bedtime. All the necessary steps are taught and explained to you in advance in a detailed training session.
The dialysate remains in your abdominal cavity for several hours. This is called dwelling. During this dwell time, which is the time between two exchanges, waste products and extra fluid are removed from your blood through the peritoneum into the dialysate, which is removed from the body at the next bag exchange.
Automated peritoneal dialysis (APD)
Automated treatment that uses a machine to perform the fluid exchanges. ADP treatments are typically done at home.
For APD, the bag is exchanged with an automated process using a special machine called a cycler. The treatment is different for each patient and is adapted to your personal needs. Your physician will determine the number of bag exchanges and the length of stay. APD can be done as a longer single session while you sleep, as multiple shorter sessions during the day or night or as a combination of both. Typically, the time for treatment adds up to eight to twelve hours per day. You will receive detailed training on how to operate the machine.
As a PD patient, you will learn to carry out your therapy independently at home. This comes with a certain degree of personal responsibility. However, dialysis at home does not mean that you are alone! If you have any questions or need more support, you can contact your care team.
Learn about peritoneal dialysis in the following video:
During a hemodialysis treatment, your blood is filtered outside of your body through a dialyzer, also called a filter or artificial kidney, to remove unwanted waste, toxins, and excess body fluids. For the treatment, a specific access to the blood stream (vascular access) needs to be created that is used to access your blood vessels during treatment. There are three main vascular access types: a fistula, graft, or catheter. A surgeon will create this access, usually in the arm or sometimes in the leg, if it is a fistula or a graft. Catheters are generally inserted into the vessels in your neck. The preferred access for HD is a fistula, which is an access in the arm made by joining your vein and artery in a small surgical procedure and has been shown to have better outcomes compared to a graft or a catheter.
Hemodialysis uses a solution called dialysate to remove unwanted substances from your blood. Different from peritoneal dialysis, there is a special man-made membrane in the dialyzer that allows the cleaning of the blood. This restores your body and provides chemically balanced blood which is then returned to your body.
A typical hemodialysis treatment takes four to five hours and is repeated three times a week. However, the timing, duration and frequency of hemodialysis depend on your medical conditions and lifestyle as well as your insurance coverage.
If you choose in-center dialysis, you usually have three fixed appointments per week. With this treatment option, the dialysis team will prepare, carry out and monitor the dialysis for you.
Facts about hemodialysis
- The treatment is carried out by trained nurses and physicians.
- Your dialysis is in one place. You do not have to store dialysis machines or materials at home.
- During dialysis, you can read, relax, work on the computer, watch TV, listen to music or do anything else you enjoy.
- You may also want to talk to other dialysis patients. After all, it is good to know that you are not alone in this situation. For many patients, the dialysis treatment is a place to socialise and sometimes strong friendships develop between fellow patients.
Keep in mind:
- Stick closely to your dialysis schedule: usually three appointments per week, four to five hours a day, plus arrival and departure.
- Complete the entire session. Even stopping five minutes early can make dialysis less effective and harm your health.
- In the first few months of therapy, you may still be exhausted and wobbly on your feet after dialysis. If this is the case, ask a family member or friend to bring you to and pick you up from the sessions. Some dialysis centers may also be able to offer support.
Treatment is performed in the comfort of the patient's home, with the help of a care partner, if necessary.
If you choose home hemodialysis (HHD), you or a caregiver will perform the preparation, implementation, and monitoring of the treatment at home. The dialysis machine and the dialysis items are used in a home-based setting. Depending on the device system that you use, your electricity and water supply may need to be adapted. Some dedicated home machines also allow you to travel.
Home hemodialysis works similarly to in-center hemodialysis, but the treatment procedure is performed in the comfort of your home. Typically, hemodialysis is performed three to four times a week. For home hemodialysis, there may be the flexibility to add additional treatment sessions: frequent home hemodialysis. Frequent home hemodialysis is usually done five to six times a week and also allows you to perform shorter dialysis sessions, depending on the modality you decide together with your physician. Frequent HHD has been shown to provide different benefits to patients, which may improve flexibility and quality of life.
These benefits can be grouped as physical or mental benefits. For frequent HHD different benefits have been shown, such as typically the option for a more liberal diet,1 lowered blood pressure2,3 and connected medication reduction,1 and improved survival rates.4,5,6
For mental health, additional benefits of frequent HHD have been described. A short time daily hemodialysis session has been shown to improve mental health and lead to fewer depression episodes.
Moreover, if you are working, the work situation may be improved as the dialysis time is shorter.
Lastly, sleeping disturbances and restlessness in your legs may be lessened.
All those benefits may have a big impact on a patient’s individual situation and wellbeing. As a result frequent HHD could be a treatment option. Please talk to your dialysis team if this may also be an option for you as well.
HHD is proposed as a preferable choice for patients who want to continue to work, stay as flexible as possible, and perform dialysis in a familiar environment.
Facts about home hemodialysis
- You are more flexible in terms of work, school or other social activities, as you can choose your dialysis times yourself as recommended by your dialysis team, as compared to In-center HD.
- You stay in the familiar environment of your own home during dialysis, and have the possibility to always reach your dialysis team by phone.
- Typically, you can choose your diet more freely if your physician prescribes more frequent dialysis sessions.
- You do not have to leave the house for dialysis, which saves travel time and transportation costs and you do not need to worry about arrival and departure times.
- You may be able to do the HHD completely on your own. You or your care partner insert the needles yourself, which is preferred by some patients.
Keep in mind:
- Generally, in the first weeks, you go through a training phase, together with a partner or a friend whom you trust, if necessary.
- If you have a family member or friend to help you with dialysis, this person must be reliable. The person must agree to assist with your HHD or stay with you to monitor the treatment.
- You or your loved one must be ready to prepare for dialysis and clean the equipment afterwards.
- It must be checked whether your water and electricity supplies need to be renovated or converted. Make sure there is someone who can organize this.
- You also need to create some space at home to store materials and equipment.
- If you are frightened of needles, this is one point to consider when making your decision. Talk to your physician about it!
Dialysis in a center
Treatments are taken place in a dialysis center. The medical staff will prepare, perform an monitor.
If you choose in-center dialysis, you usually have three fixed appointments per week, typically for a four hour treatment in your dialysis center. With this treatment option, in general the dialysis team will prepare, carry out and monitor the dialysis for you.
Focus on sustaining the quality of life, not extending life. Therapy is based on relief from discomfort ant the pain of kidney failure symptoms, such as swelling and shortness of breath.
Depending on your (medical) conditions, dialysis might not prolong your life and the best option might be to let nature take its course. Regardless of medical conditions, based on individual situations and preferences some patients decide not to start or also discontinue renal replacement therapy.
You have the option of not receiving renal replacement treatment and life-prolonging treatment at all. The kidney function will then not be replaced, and your kidneys will fail, resulting in natural death. Your health care team will still support you and treat your symptoms with medication and, if necessary, give supportive form of nutrition. Conservative therapy is more about maintaining quality of life.
Your health team will talk with you to help you make an informed and considered decision.
Make a choice
Keeping and going to your appointments and following your treatment plan is critical to your health. Therefore, it is important to choose a therapy that suits to your personal situation. Always remember: The return for the time you invest can be a fuller, more active, and healthier life.
You have now learned an overview of, what treatment options are available. Together with your medical team, you can discuss and decide which of those treatment options would be the most suitable for you.
Read more about making the right decision in the next section.
1 Mucsi I, Hercz G, Uldall R, Ouwendyk M, Francoeur R, Pierratos A. Control of serum phosphate without any phosphate binders in patients treated with nocturnal hemodialysis. Kidney Int. 1998;53(5):1399-1404. doi:10.1046/j.1523-1755.1998.00875.x
2 Culleton BF, Walsh M, Klarenbach SW, et al. Effect of frequent nocturnal hemodialysis vs conventional hemodialysis on left ventricular mass and quality of life: a randomized controlled trial. JAMA. 2007;298(11):1291-1299. doi:10.1001/jama.298.11.1291
3 Chan CT, Shen SX, Picton P, Floras J. Nocturnal home hemodialysis improved baroreflex effectiveness index of end-stagerenal disease patients. J Hypertens. 2008; 26(9):1795-1800. doi: 10.1097/HJH.0b013e328308b7c8
4 Marshall MR, Polkinghorne KR, Kerr PG, Hawley CM, Agar JW, McDonald SP. Intensive Hemodialysis and Mortality Risk in Australian and New Zealand Populations. Am J Kidney Dis. 2016;67(4):617-628. doi:10.1053/j.ajkd.2015.09.025
5 Rydell H, Ivarsson K, Almquist M, Segelmark M, Clyne N. Improved long-term survival with home hemodialysis compared with institutional hemodialysis and peritoneal dialysis: a matched cohort study. BMC Nephrol. 2019;20(1):52.
Published 2019 Feb 13. doi:10.1186/s12882-019-1245-x
6 Marshall MR, Walker RC, Polkinghorne KR, Lynn KL. Survival on home dialysis in New Zealand. PLoS One. 2014;9(5):e96847. Published 2014 May 7. doi:10.1371/ journal.pone.0096847