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Life: The Ultimate Gift (Part 3)

Reprinted from PN February 2002

This is the third of four articles describing renal function and failure in people with spinal-cord injuries, and therapeutic options after renal failure. To read Part 1, click here. To read Part 2, click here.

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When you hire a nephrologist, you should begin looking at your options and making plans about how you want to proceed. You essentially have four options:

Peritoneal dialysis when your kidneys fail completely and you need to be dialyzed

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Hemodialysiscleaning of the blood by an artificial kidney

Transplantation, either from a live donor or a cadaver

Do nothing, and you will probably die from renal failure within the next few years


"In the U.S., almost 100,000 persons are on dialysis, not counting those with acute kidney failure who are on dialysis only temporarily." Mayo Clinic Family Health Book
It is important to understand whether your nephrologist has biases against your choicei.e., some are not comfortable with transplantation. Whether or not you decide on this procedure, your nephrologist will put you on the donor list (awaiting a donated kidney) as soon as you begin treatment for renal failure.

Contrary to what you may hear, even from some physicians, only two weights are put on those on the list to receive cadaver kidneys: (1) length of time on the list and (2) if you are a child, you are placed higher on the list. Your physical condition, prior injuries such as SCI, and/or your age are not taken into consideration when you are on the waiting list for a cadaver kidney.

All end-stage renal disease is covered by Medicare, no matter what your age, the insurance you have, or whether you are a VA patient. You can choose any hospital or physician you want, and Medicare will pay. It is one of the few diseases totally covered by Medicare including dialysis, transplantation, andif you have a live donorall the donor's medical costs.

If you are planning to have a transplant, even if it is imminent, there is some motivation to try skipping dialysis and "toughing it out" until your transplant. However, if you try to delay dialysis too long, you may become too ill to transplant.

One of dialysis's values is that it often keeps people healthy enough to receive a transplant. (Malnourishment is one of the largest morbidity factors in many diseases, including renal. It is often as great a cause of death in a patient as the disease itself.) Renal disease is insidious in the sense that people do not realize how ill they are until they have some relief of symptoms from adequate dialysis or a transplant. Your nephrologist can use many interventions to increase your general health. The first is to make sure you are adequately nourished and anemia is taken care of with epogen and perhaps iron. If you are on hemodialysis, you will often receive large doses of iron and epogen at the same time.

Peritoneal dialysis (PD) is the least invasive of all treatments for renal failure. Several different PD types exist. The major one is a manual, self-care therapy called continuous ambulatory peritoneal dialysis (CAPD). Essentially, CAPD is infusing a liquid called dialysate into the peritoneal cavity, which functions much the way the kidneys did, constantly cleaning the blood as long as dialysis fluid is present. In a minor surgical procedure, a small catheter is permanently placed in the peritoneal cavity. Wastes are drawn into the peritoneal cavity and removed by exchange. An "exchange" refers to clean solution going into the peritoneal cavity and, as it collects contaminants, it is drained out and discarded. The catheter is left in so PD can occur continuously and often lasts for many years. Once the site heals you can clean it in the shower.

Usually, you have four exchanges a day. An exchange usually takes about 30 minutes. The blood is cleaned and filtered of wastes and excess water. No blood is removed, and the dialysis procedure occurs gently inside your body. No needles are needed to gain access to the blood as in hemodialysis.

Another type of PD is automated peritoneal dialysis (APD), performed at home with the help of a peritoneal dialysis cycler machine connected to a long tube. The cycler performs several exchanges while you sleep. APD, also called IPD (intermittent peritoneal dialysis), is good for people with busy daily schedules or those who need help with dialysis. This treatment lasts about 10-14 hours, and fluid is not left in the peritoneal cavity between treatments. IPD has a definite beginning and ending and is considered intermittent treatment like hemodialysis. Few people use this as a chronic form of PD.

PD advantages include greater independence, no needles, flexible schedules and diet, blood pressure and sugar control, and less stress on the body. Among disadvantages are four exchanges a day or being on a machine every night with no off days, a permanent catheter, and some risk of infection. Because of the amount of fluid involved in these exchanges, there may be a possible weight-gain period. A big disadvantage is that PD can only be done for a limited time, differing according to the individual.

Hemodialysis is more invasive than PD, yet not quite as much as a transplant. If you are going to be on dialysis for more than a few months or have decided to stay on hemodialysis and not get a transplant, a few months prior to beginning dialysis you will see a surgeon who will install one of three access methodsa fistula, a graft, or a catheter.

An arteriovenous fistula usually produces the best results for dialysis and is created by directly connecting an artery and a vein. An arteriovenous graft is created by connecting the artery and vein with an artificial tube. In both cases, to initiate dialysis a needle is inserted through the skin into the fistula or graft. A permacatheter is often an emergency technique used while the fistula is healing. The fistula is usually considered for long-term dialysis.

If you're looking at a year or less or have a more acute need and require dialysis quite soon, the surgeon will put in, under local anesthetic and hypnotic drug, a permacatheter. This is placed in the chest, again going through the vein and returning the blood to the same vein.

The permacatheter will have two tubules coming out of the chest, usually just above the right nipple line, toward the center of the chest. These two lines are then hooked up to the hemodialysis machine; one removes blood, and the other puts it back in (the process is often reversed if one of the lines does not seem to draw blood out easily).

Going into a dialysis center for the first time can be intimidating, frightening, and depressing. The first step is triaging, where you are weighed, answer a series of questions about general health, and have blood pressure and temperature taken. You are escorted to your "slot," where many other patients receive dialysis at the same time.

The machine is basically a pump that moves blood through an artificial kidney called a dialyzer. The staff will reuse your dialyzer, so you need to check for your name each time since it is changed for every patient who comes in.

As you settle into your slot, the first event is to clean the tubes on your chest. Then one of the staff hooks up the blood-flow instrument, and blood cleaning begins.

The dialyzer's purpose is to remove excess fluid and the toxic waste. It also takes out some protein if you have too much in your body. Immediately after the four hours, you may feel hunger for the first time in a day or two, and it is important then to ingest as much protein as you can before the next dialysis period. Many people continue to produce urine and take diuretics in order to keep fluid retention to a minimum.

Occasionally, the machine sounds an alarm. It simply means the machine is not working as well as it needs to, so the technician makes adjustments and the dialysis continues. Prior to beginning dialysis the technician takes blood to measure your pre-serum urea nitrogen as well as many other blood values, and then again after the procedure.

Occasionally, you get liquid iron, as much as 250-300 cc, during your dialysis. Additionally, epogen usually is administered during dialysis, also to build red-blood cells.

You need to check two numbers to see if your dialysis is adequate. These are URR (urea reduction ratio) and KT/V. The URR test measures how much urea was removed from your body during one dialysis treatment; the minimum guideline for adequate dialysis is 65%. KT/V begins with your URR number and adds other factors, such as your weight. The minimum guideline for KT/V is 1.2.

At the end of dialysis, the technician unhooks one of the tubes and flushes the one in your body from which he or she unhooked it. He/she then fills that tube with heparin, an anticoagulant, so no clots form in the tubes or in your body. He/she then returns all the blood to your body through the other tube and seals it with heparin also. The whole process begins again 48 hours later and continues until some other event occurs (i.e., transplant or death).

You must watch potassium intake; potassium is found in bananas, tomatoes, and many other fruits and vegetables. A weekly blood test indicates the concentration of potassium, and your nephrologist will warn you if levels begin to get too high so you can cut back quickly. If you are not producing urine with diuretics, you must also restrict fluid intake to keep water retention at a minimum. Too much fluid in the body affects breathing, the heart, and skin.

Next month: "Being transplanted after having been on dialysis is a Lazarus-like experience, reversing the process of dying to one of living," Dr. Gruver says. He describes what leads up to the transplantation procedure and tells what happens if people with renal failure do nothing.

Dr. Gene Gary Gruver is a board-certified clinical psychologist who has practiced in Tucson, Ariz., for more than 30 years. This article is based on his research as well as edited commentary by researchers and physicians, and his personal experience with renal failure and transplantation.

 

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Life: The Ultimate Gift (Part 3)

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