When the GFR (Glomerular Filtration Rate, a measure of kidney function) drops below 10 mL per minute, various symptoms may develop, not necessarily unique to the kidney condition. These symptoms include excessive fatigue, disturbances in attention and concentration, reduced appetite, nausea, vomiting (especially in the morning), itching, and shortness of breath. The symptoms worsen as kidney function declines, indicating the need for alternative kidney treatment. Additionally, there may be disturbances in the concentration of minerals in the blood, particularly potassium, phosphorus, and calcium.
Alternative treatments include dialysis and kidney transplantation. To initiate alternative kidney treatment in advance, the nephrologist and the multi-disciplinary team (nurses, social worker, dietitian) will guide you on treatment options when the GFR drops below 15 mL per minute. At this stage, you may not experience symptoms, but it is essential to prepare for alternative treatment as the preparation process can take about 3-6 months. Why is early referral important? Numerous studies have shown that preparedness for alternative treatment is associated with higher survival rates and fewer hospitalizations after initiating alternative therapy.
The best treatment is a living donor kidney transplantation, and it is advisable to plan this treatment in advance. If there is no suitable living donor, you should be prepared concurrently for dialysis and register on the waiting list for deceased donor kidney transplantation. Since the preparation process for transplantation takes at least 3 months, it is recommended to start the process parallel to the preparation for dialysis.
There are two types of dialysis: peritoneal dialysis (home-based) and hemodialysis.
Both methods require a minor surgery initially. For peritoneal dialysis, a flexible tube is implanted into the abdominal cavity. About two weeks after the surgery, you will start receiving training on how to perform peritoneal dialysis. In summary, a special fluid is infused through the tube into the abdominal cavity, where it remains for several hours during which waste products are exchanged between the blood vessels in the abdominal cavity and the fluid. At a pre-determined time, in coordination with the dialysis nurse, the fluid will be drained from the abdominal cavity through the tube, and after the drainage, fresh fluid will be infused. This exchange is performed four times during the day or overnight using automated exchanges.
* This explanation does not replace individual guidance on how to perform dialysis.
The second method, hemodialysis, is carried out using a machine that filters the blood and removes excess salt and water. The procedure requires convenient access to large veins. There are three ways to achieve this: fistula - a direct surgical connection between an artery and a vein in the arm or forearm; graft - a connection between an artery and a vein using a synthetic tube in the same locations; or a catheter in the central vein (usually in the neck).
The best access method is the fistula, followed by graft and the central catheter. For those who choose hemodialysis, the blood vessels in the upper limbs are mapped, and the surgeon determines which access type suits the patient. The next step is to set the date for surgery to construct the fistula or graft. Ideally, the timing of the surgery should be set two months before the estimated start of dialysis to allow for a few weeks for the fistula to mature and be ready for treatment. It should be noted that this schedule cannot be precise, and the waiting time for surgery may be two months or more. Therefore, close and constant communication between the patient and the nephrology team is vital for the success of the process. If the fistula is not constructed on time, you may urgently need a central catheter. As mentioned, this access carries a high risk of severe blood infections. Therefore, fistula surgery on time is the best approach.
Hemodialysis treatment is performed at least three times a week for at least four hours per session, and the amount of dialysis can be increased as needed.