1. Dialysis Options: What is the Best Choice for You. Ana C
Dialysis Options: What is the Best Choice for You? Ana C. Ricardo, MD University of Illinois Division of Nephrology

2. Where are the kidneys?

3. What do the kidneys do? Maintain fluid, salt and acid balance
Excrete end-products of the metabolism and foreign substances (urea, toxins and drugs)
Produce important enzymes and hormones
- Renin (Blood pressure)
- Erythropoeitin (Hemoglobin)
- 1,25-dihydroxyvitamin D (calcium, phosphorus, bone metabolism)

4. What is Chronic Kidney Disease (CKD)?
Syndrome characterized by a slow, progressive decline in kidney function (glomerular filtration rate or GFR <60 ml/min) or kidney damage (protein or albumin in the urine) that persists for more than 3 months.

5. Glomerular Filtration Rate or GFR

6. What are possible symptoms of decreased kidney function?
- There is no change in urine volume or “kidney pain”
Fatigue or weakness
Swelling
Bad taste in the mouth
Feel cold
Poor concentration
Shortness of breath
Itching skin
Cramping in hands and legs
Nausea and vomiting

7. What are the complications of chronic kidney disease? (1)
Low red blood count (anemia)
Elevated blood potassium levels (hyperkalemia)
Elevated blood acid levels (acidosis)
Fluid overload
High blood pressure (hypertension)
Swelling (edema)

8. What are the complications of chronic kidney disease? (2)
Mineral bone disease
Low blood calcium (hypocalcemia)
High blood phosphate (hyperphosphatemia)
Elevated PTH (hyperparathyroidism)
Renal osteodystrophy/bone disease
Vascular calcification/cardiac disease

9. What can be done when the kidneys fail?
No renal replacement therapy (RRT) also known as conservative management
Active medical care without RRT
Palliative care when necessary
Complications can be managed, but can’t compensate for uremia
End of life choices – living will – telling family
Can change your mind

10. What are the options for renal replacement therapy?
Dialysis (“artificial” kidney machine)
Hemodialysis
In-center: Thrice weekly, daily, nocturnal
Home: daily, short-daily, nocturnal
Peritoneal dialysis (PD)
Manual (Continuous ambulatory PD or CAPD)
Automated (Continuous cycling PD or CCPD)
Kidney transplant (new “real” kidney)
Deceased donor (brain death or cardiac death)
Living donor (related or unrelated)

11. What are the goals of renal replacement therapy?
Renal replacement therapies do:
Balance fluids
Remove waste products/toxins
Balance electrolytes/minerals
Renal replacement therapies do not:
Reverse prior kidney failure
Provide a cure for kidney failure

12. What are the reasons to start RRT?
Start discussion/preparing when kidney function (glomerular filtration rate or GFR) ~20 ml/min (CKD stage 4)
Historically dialysis started when GFR <15 ml/min (CKD stage 5)
End stage renal disease/end stage kidney disease (ESRD/ESKD)
Absolute indications
Refractory hyperkalemia, acidosis, hypertension, fluid overload

13. Hemodialysis Procedure

14. Hemodialysis access options: - Catheter - Graft - Fistula

15. Hemodialysis access options: - Catheter - Graft - Fistula

16. Hemodialysis access options: - Catheter - Graft - Fistula

17. Hemodialysis Advantages Disadvantages
Risk of low blood pressure, infection and/or bleeding In-center hemodialysis - Transportation to center - Schedule may not be flexible - May miss half day of work 2-3 times/week - Travel/vacation can be difficult - Don’t dialyze every day– can have significant fluid/waste buildup during off days Home hemodialysis Requires significant patient involvement and technical expertise
Works very fast, can be used for urgent issues
In-center hemodialysis:
- Total dialysis time per week ~12 hours/week
- Is social
Home hemodialysis
- Can do dialysis on your schedule
- Can do more dialysis
Less fluctuations of toxins/electrolytes
Linked to better long term outcomes
Less dietary restrictions
- Once monthly clinic visits

18. Peritoneal Dialysis

19. Peritoneal Dialysis REPEAT Connect Fill Dwell Start Dwell End Drain
30-90 minutes

20. Peritoneal Dialysis (PD)
CCPD: Continuous cycling PD
CAPD: Continuous ambulatory PD
Performed overnight
Done without electricity/machine

21. Peritoneal dialysis (PD)
Advantages
- Done at home or anywhere
- Can travel relatively easily – take cycler with or do CAPD
- Once monthly clinic visits
- Fluid removal is slower
- Better tolerated
- Less dietary restrictions
CCPD
- Done overnight
- Does not interfere with work
CAPD
- Can be done in resource-limited areas or areas without electricity
Disadvantages
- Requires PD catheter, risk of infection
- Requires significant patient involvement and technical expertise
- Fluid removal is done with dextrose (sugar)- can cause high blood sugars
- Filter is biologic – Success Requires favorable abdominal conditions
- Fluid in abdomen may be uncomfortable or feel strange
CCPD
- Requires machine and electricity
CAPD
- Need to do multiple exchanges through the day

22. Summary
Chronic kidney disease is a non-reversible, progressive disease with many complications
Timing of renal replacement therapy is variable with patient
There are several modalities of renal replacement therapy
Depend on patient preference and center

23. For more information… National Kidney Foundation
National kidney disease education program (NIH)

24. Questions?