Treatment options for patients with kidney failure.

Abstract

Nurses need to help patients with chronic kidney disease make informed decisions about future interventions. KEYWORDS: chronic kidney disease, continuous ambulatory peritoneal dialysis, continuous cycler-assisted peritoneal dialysis, dialysis, end-stage renal disease, hemodialysis, kidney failure, kidney transplantation, palliative care, peritoneal dialysis, renal replacement therapy.

Full text

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Treatment Options
for Patients with
Kidney Failure
Nurses need to help patients with chronic kidney disease make
informed decisions about future interventions.
K
several hours a day, several times a week, in an outpa-
tient facility. Many people have no idea that hemodial-
ysis may be performed in a patient’s home as well as
in a hemodialysis center, or that there’s any other type
of dialysis, namely peritoneal dialysis. Even some nur-
ses aren’t familiar with the various dialysis options,
which may be why some patients who require renal
replacement therapy don’t learn about the different
treatment options or the risks and benefits associated
with each.
To make informed choices about future inter-
vention, patients with chronic kidney disease need
to understand the full range of treatments available
to patients with kidney failure—and to understand
these treatment alternatives long before they progress
to that disease stage. For this reason, nurses must be
prepared to teach them about the advantages of pre-
emptive and early kidney transplantation; the basics
of both hemodialysis and peritoneal dialysis; the range
of environmental, procedural, and scheduling options
available to patients undergoing either type of dialy-
sis; and the circumstances under which to consider
palliative care.
Table 1).2 Patients whose chronic kidney disease has
progressed to ESRD qualify for Medicare-reimbursed
health care.2 According to the U.S. Renal Data System,
in 2008, the prevalence of ESRD in the United States
was 1,699 patients per million population, or nearly
By Susan LaRocco, PhD, RN
idney failure brings to mind two pos-
sible treatments: kidney transplanta-
tion, the treatment of choice for eligible
patients, and dialysis. For most people,
the term dialysis conjures up images
of a patient attached to a hemodialysis machine for
THE SCOPE OF THE PROBLEM
Cardiovascular disease, diabetes, hypertension, and
obesity, all ubiquitous in the United States, are major
risk factors for chronic kidney disease, which affects
nearly 17% of U.S. adults over the age of 20.1 Kidney
failure, also called end-stage renal disease (ESRD),
the fifth stage of chronic kidney disease, is defined
as having a glomerular filtration rate below 15 mL/
min/1.73 m2 or requiring dialysis to sustain life (see
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A patient talks with the hemodialysis technician while being connected
to a dialysis machine at a local hemodialysis facility. Photo by Robert
McLeroy / San Antonio Express / ZUMA Press / Newscom.
CLINICAL FEATURE

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548,000 patients.3 The median age of these patients
was 64.
For patients with ESRD, renal replacement therapy
options include preemptive kidney transplantation
(performed prior to any dialysis), postdialysis kidney
transplantation, home- or center-based hemodialysis,
and continuous ambulatory or cycler-assisted perito-
neal dialysis. Because renal replacement therapy af-
fects all aspects of a patient’s life and that of her or
his family, it’s important when selecting a modality
for patients to consider their lifestyle, social environ-
ment, and personality, as well as their clinical condi-
tion.
KIDNEY TRANSPLANTATION
The first successful kidney transplantation was per-
formed in 1954.4 As with all of the early, successful
procedures, the donor and recipient were identical
twins.4 Until 1962, when immunosuppressive drugs
were incorporated in postprocedural care, transplan-
tations involving relatives who weren’t twins and unre-
lated donor-recipient pairs were unsuccessful be cause
of organ rejection.
Initial attempts at immunosuppressive therapy of-
ten resulted in patient death, but during the 1960s,
advances in that area, as well as in organ preserva-
tion and tissue typing, greatly improved the success of
transplantation.4 In fact, a Scottish study, conducted
between 1989 and 1999, involving 4,532 adults with
kidney failure who had recently started dialysis treat-
ment, found that the 1,095 participants who under-
went a first cadaveric transplant during the study
pe riod had a projected life expectancy that was three
times as long as that of their counterparts who con-
tinued with dialysis treatment.5
The one-year patient survival rate for transplanta-
tions performed between 1997 and 2004 was 94.4%
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when the kidney was from a deceased donor and
97.9% when it was from a living donor.6 In a single-
center, U.S. study of 2,540 living-donor kidney trans-
plantations, patients whose procedures were perfor med
preemptively (before the patient had started dialysis)
or within the first year of dialysis had significantly
better five-year survival rates (93% and 95%, respec-
tively) than patients whose transplantations were per-
formed after at least one year of dialysis (81%).7 In
addition, patients who received preemptive transplan-
tations had significantly higher five-year graft survival
rates and returned to full-time employment more of-
ten than did patients whose transplantations were per-
formed within the first year or after at least one year
of dialysis. Despite the encouraging statistics, post-
surgical infection remains a significant risk with all
kidney transplantations.
While transplantation is considered the treatment
of choice, it’s not an option for many patients. Bar-
riers include
• comorbid conditions (such as severe cardiovas-
cular or peripheral vascular disease or metastatic
cancer) that put patients at higher risk for surgical
complications or significantly reduce estimated
patient survival.
• a limited supply of kidneys.
• higher out-of-pocket expenses for transplant re-
cipients.
The U.S. waiting list for kidneys currently includes
about 89,700 candidates.6For patients placed on the
list in 2005, the median wait time to receive a trans-
plant was three years, and it’s projected that patients
listed in 2010 will have a median wait time of 3.6
years.3 The cost of postsurgical medication, primar-
ily immunosuppressants, is estimated to be between
$5,000 and $13,000 annually.8 Although patients un-
dergoing dialysis receive Medicare coverage for the
duration of treatment, patients who undergo transplan-
tation receive coverage for transplantation-related
treatment and medications for only three years fol-
lowing surgery.9
TYPES OF DIALYSIS
In one form or another, dialysis has been used to treat
kidney failure for more than 70 years (see The His-
tory of Dialysis4, 10-13). For both hemodialysis and peri-
toneal dialysis, the treatment goals are the same: to
remove metabolic wastes and establish normal fluid
and electrolyte balance. Neither form of dialysis can
cure kidney failure; patients using either one must con-
tinue treatment to sustain life, unless they undergo
successful kidney transplantation. At the end of 2008,
93% (354,600) of the U.S. dialysis population were
receiving hemodialysis, and 7% (26,517) were receiv-
ing peritoneal dialysis.3
Health factors may limit a patient’s dialysis choices.
For example, some patients with ischemic or conges-
tive heart disease and others in whom vascular access
is limited may not tolerate hemodialysis.14 Similarly,
A patient undergoes continuous ambulatory peritoneal dialysis at home
in her kitchen. Photo by Life in View / Science Photo Library.

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patients with documented peritoneal dysfunction or
extensive abdominal adhesions may be unable to per-
form peritoneal dialysis effectively.14 Researchers have
found, however, that the limited use of peritoneal
dialysis in the United States is independent of co-
morbidity, patient age, and body size, and may be
explained by limited trainee education and relative in-
experience of health care providers.15
Hemodialysis uses a synthetic, semipermeable
membrane and the principles of diffusion, osmosis,
and ultrafiltration to remove toxins and excess water
very gradually from the blood. The patient’s vascu-
lar system must be accessed through an arteriove-
nous fistula (the preferred method), an arteriovenous
graft (if the patient’s vasculature can’t accommodate a
fistula), or a double-lumen central line (for immediate
or temporary access). The fistula, created by anas-
tomosing an artery to a vein, usually in the forearm,
typically takes two to three months to mature; in the
interim, a central line can be used for access.
Most patients undergoing hemodialysis are treated
three times a week for three to four hours, either in
their home or in a dialysis center. Vascular access fail-
ure, which may occur with clotting or infection, is a
common reason for hemodialysis-related hospital ad-
mission. Other potential complications include sleep
disturbance, episodic shortness of breath (due to fluid
accumulation between treatments), and muscle cramp-
ing during treatment. More serious but less common
complications include hypotension during treatment,
dysrhythmias, chest pain, blood loss (if needles be-
come dislodged), and dialysis disequilibrium (signaled
by headache, nausea, vomiting, restlessness, decreased
level of consciousness, and seizures). Dialysis disequi-
librium is most likely to occur in patients treated for
acute renal failure or in those whose blood urea ni-
trogen levels are greater than 150 mg/dL.
Home hemodialysis in the United States has seen
modest growth in popularity over the past four years,
although it’s unclear how recent changes in Medi-
care reimbursement for intravenous and prescription
drugs may affect this trend.3 In 2008, about 1% of the
U.S. hemodialysis population (3,826 patients) used
home hemodialysis, with Illinois accounting for 17%
of these patients.3 Home hemodialysis is an appro-
priate renal replacement modality for highly moti-
vated patients and usually entails significant caregiver
support.
To perform home hemodialysis, the patient and
caregiver must learn how to prepare equipment and
supplies; insert the needle in the vascular access; op-
erate, monitor, clean, and disassemble the dialysis ma-
chine; monitor blood pressure and heart rate; maintain
treatment records; and keep supplies on hand. In ad-
dition, they assume responsibility for administering
medications and handling emergencies during dialy-
sis. Training generally requires three to eight weeks.
Nocturnal dialysis is performed during the night,
either at home or in a dialysis center, and each session
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typically takes about eight hours. Dialysis equipment
includes sensors that sound an alarm if a problem oc-
curs, so patients can feel free to sleep during the treat-
ment. Within the home, nocturnal dialysis, like home
dialysis in general, can be performed as often as ev-
ery day, if desired. Center-based nocturnal dialysis is
usually performed three times a week.
Peritoneal dialysis also incorporates the principles
of diffusion, osmosis, and ultrafiltration, but it relies on
the peritoneal membrane instead of a synthetic semi-
permeable membrane to serve that purpose. Two to
three liters of warmed sterile dialysate fluid are in-
troduced into the abdominal cavity through a perma-
nently implanted silicone catheter—a process called
the fill, which normally takes about 20 minutes. Di f-
fusion and osmosis occur over the several hours the
fluid remains in the abdominal cavity, a period called
the dwell time. Drainage by gravity typically takes an-
other 20 minutes. The process of draining and fill ing
the abdomen is called an exchange. Patients usually
need to perform four or five exchanges a day, seven
days a week. Generally, the procedure can be learned
in several days. With peritoneal dialysis, diet is less
restrictive than with hemodialysis because waste re-
moval is continuous rather than intermittent. Nev-
ertheless, it’s important for all patients with kidney
disease to avoid salt, limit foods that are high in phos-
phorus (such as milk, cheese, nuts, and dried beans)
and potassium (such as bananas, oranges, vegetables,
chocolate, and nuts), and restrict their intake of flu-
ids.
The two common forms of peritoneal dialysis are
con tinuous ambulatory peritoneal dialysis and con-
tinuous cycler-assisted peritoneal dialysis. Neither
Table 1. The Stages of Chronic
Kidney Disease2
Stage Description
GFR (mL/
min/1.73 m2)
1
Kidney damage with
a normal or elevated
GFR
Kidney damage with
a mildly decreased
GFR
A moderately
decreased GFR
A severely
decreased GFR
>– 90
2 60–89
3
30–59
4
15–29
5 Kidney failure
< 15 (or
dialysis)
GFR = glomerular filtration rate.
Adapted with permission from the National Kidney
Foundation.

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re quires the patient to visit a dialysis center; both
can be performed at home, at work, or while travel-
ing.
The ambulatory form, as its name suggests, en ables
the patient to move freely and continue with normal
daily activities because it requires no machin ery and
no restraints. By contrast, the automated form uses a
machine called a cycler, which is programmed to per-
form several exchanges during the night while the pa-
tient sleeps. In the morning, patients begin an exchange
with a prolonged, often day-long, dwell time.
Peritonitis is the most serious and most common
complication of peritoneal dialysis. Cycler-assisted
peritoneal dialysis provides a little more protection
against peritonitis than the ambulatory form because
it requires the closed, sterile dialysis system to be in-
terrupted less frequently. To reduce the risk of peri-
tonitis, patients using either form of peritoneal dial ysis
should practice meticulous hand hygiene and wear
a mask when the catheter is disconnected from its
tubing. Other complications of peritoneal dialysis in-
clude leaking around the catheter insertion site, which
usually resolves spontaneously within the first few
days after catheter insertion; abdominal hernias; ag-
gravation of hiatal hernias; low back pain; and loss
of appetite (due to fluid in the abdomen).
LIFESTYLE CONSIDERATIONS IN DIALYSIS SELECTION
Because both hemodialysis and peritoneal dialysis af-
fect all aspects of a patient’s life, nurses need to help
patients make the choice that’s compatible with their
lifestyle. It’s also important to let patients know that,
in choosing a method, they’re not necessar ily commit-
ting to that method for life. As patients’ health status
or social situation changes, it may be ap propriate for
them to reconsider their options and make a differ-
ent dialysis choice.
Travel concerns. For patients treated by hemodi-
alysis, travel requires planning. They must schedule
dialysis sessions in advance of travel and arrange for
medical records to be exchanged between home and
remote centers. Of note, some cruise ships have on-
board hemodialysis facilities and offer treatment at
night so as not to interfere with port activities. Patients
using peritoneal dialysis must either bring dialysis sup-
plies with them or have them delivered to their desti-
nation in advance of their arrival.
Independence vs. security. Coordinators of home
hemodialysis and peritoneal dialysis programs point
out that patients who perform dialysis within the home
are at less risk for nosocomial infection, can avoid pro-
longed travel and waiting times, and undergo fewer or
less pronounced chemical or hemodynamic changes.16
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Hemodialysis began in 1943 when Willem Kolff
of Holland developed an “artificial kidney” that
used diffusion to remove waste products from the
blood of patients with kidney disease.4 His earli-
est patients had such advanced kid ney failure that
they died despite treatment, but when he tried his
dialysis procedure on patients with acute renal
failure, he had some success.4 The first hemodial-
ysis in the United States was performed in 1948
in New York City. It was considered a treatment
for acute renal failure only until 1960, when the
development of the arteriovenous shunt made long-
term circulatory access feasible, and hemodial-
ysis was es tablished as a treatment for chronic
kidney failure.4
In the mid 1960s, the cost of hemodialysis was
about $10,000 per year.10 Since the treatment
wasn’t yet covered by Medicare, very few patients
could afford it.11 Those who had the means for
treatment visited a dialysis center twice weekly for
sessions rang ing from 10 to 16 hours.10 To lower
the cost of treatment and give the patient more inde-
pendence, the Univer sity of Washington Hospital,
one of the first hospitals to perform hemodialy-
sis, began a home-based program through which
nurses provided extensive train ing for the patient
and family.10
By the 1970s, improvements in equipment had
shortened dialysis time. In 1972, an amendment
to the Social Security Act provided federal reim-
bursement for dialysis care for patients with end-
stage renal disease (ESRD) through the Medicare
ESRD Program.12 With the new federal regulations
in place, many dialysis centers opened, giving new
hope to patients with ESRD.
Peritoneal dialysis was used with limited suc-
cess to treat acute renal failure in the late 1930s
and to treat ESRD in the early 1950s.4 The time
frame over which the procedure was performed
varied widely, ranging from daily to once a week
to continuously for one week.4 Then, as now, a
major complication was peritonitis.4
Peritoneal dialysis was seen as a viable option
for community hospitals because the need for spe-
cialized equipment was not nearly as great as with
hemodialysis.4 Long-term peritoneal dialysis began
in 1972 with Dr. Henry Tenckhoff’s development
of a soft, pliable dialysis catheter that could be sur-
gically im planted and function for many years.13
The History of Dialysis
The technological and legislative advances that have revolutionized the treatment of kidney failure.

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scored significantly lower on a standard quality-of-life
index than did a reference sample from the general
Irish population, with patients feeling that their im-
paired physical health particularly limited their par-
ticipation in normal daily activities.22 By contrast, a
cross-sectional, correlational study of 73 patients un-
dergoing in-center hemodialysis in the southeastern
United States for three months to 25 years (mean time,
56 months) found that patient scores on a subjective,
self-reported, quality-of-life index designed for pa-
tients using dialysis were similar to those of healthy
people who’d been given the general population ver-
sion of the index in a previous study.23
PALLIATIVE CARE
Palliative care is an option for patients with kidney
failure, particularly if they have multiple comorbi di-
ties.24, 25 Palliative care would include providing symp-
tom management and comfort measures for patients
who withdraw from or don’t start dialysis treatment.
According to the Renal Physicians Association, such
decisions to forgo dialysis may be appropriate under
the following conditions25:
• The patient is fully informed and makes the deci-
sion voluntarily.
• The patient lacks decision-making capacity and
the patient’s legal agent makes the decision.
• The patient lacks decision-making capacity and
has indicated in an oral or written advance direc-
tive a desire not to receive dialysis.
• The patient has severe, irreversible neurologic im-
pairment and shows no sign of thought, aware-
ness, or purposeful behavior.
THE NURSE’S ROLE
One of the nurse’s most important roles is to partner
with patients, providing information that enables them
to make informed choices. Since patients often use the
Internet to learn about their condition and explore
treatment options, nurses can guide them to reliable
Web sites and help them interpret the material they
find there (see A Web of Support). In addition, nurse-
Center-based hemodialysis, on the other hand,
does n’t require that the patient take responsibility
for the treatment. Once inside the dialysis center, the
pa tient is in the competent hands of specially trained
nur ses and technicians. For many patients, this pro-
vides a feeling of security.
Related costs. Of the 547,982 patients with ESRD
who resided in the United States, Puerto Rico, or U.S.
territories in 2008, more than 400,000 were insured
by Medicare.3 The total Medicare expenditure for
ESRD treatment that year was $26.8 billion, which
included $19.4 billion for hemodialysis, representing
an increase of 9.3% from the previous year (when he-
modialysis rose by 3.8%) and a per patient annual
cost of $77,506.3 That same year, costs for peritoneal
dialysis rose 8.3% to $1.04 billion (following a slight
cost reduction in 2007), representing a per patient an-
nual cost of $57,639.3
These statistics don’t take into account patients’
health status; but a study using a non-Medicare claims
database compared the costs of treating patients
(matched for sex, comorbidities, and pretreatment
health care use and costs) by whether they used hemo-
dialysis or peritoneal dialysis.17 Patients using perito-
neal dialysis had significantly lower total health care
costs and were significantly less likely to be hos pital-
ized during the year following dialysis initiation than
were their counterparts using hemodialysis. In this
study, all health care costs were considered, includ ing
ED visits, outpatient office visits, inpatient hospi tal
costs, and outpatient (retail) pharmacy costs, as well
as costs of renal replacement therapy. Over the course
of one year, median interquartile per-patient health
care costs were $43,510 higher for pa tients us ing hemo-
dialysis than for patients using peritoneal dialysis.
HOW DIALYSIS AFFECTS QUALITY OF LIFE
Patients may consider quality of life more important
than such easily quantified measures as frequency of
hospitalization or mortality rates.18 Accordingly, the
Centers for Medicare and Medicaid Services requires
all participating dialysis facilities to assess patients’
quality of life, using a standardized mental and phys-
ical assessment tool.19
Several studies have investigated the effects of dial-
ysis and dialysis modality on health-related qua l ity
of life with varying results. Having studied 192 pa-
tients who had self-selected treatment by either hemo-
dialysis or peritoneal dialysis, researchers in Alberta,
Canada, concluded that, after controlling for patient
comorbidities, health-related quality of life was inde-
pendent of dialysis method.20 A U.K. study that assessed
the quality of life of 36 patients starting treatment
with peritoneal dialysis, as well as that of their care-
givers, found that quality of life was im paired for
both patients and caregivers at the beginning of dial-
ysis, but improved after one year, with social function-
ing improving significantly.21 Ninety-seven patients
receiving hemodialysis treatment at an Irish hospital
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A Web of Support
The following Web sites provide information of
interest to patients with chronic kidney disease
and the clinicians who care for them.
• American Association of Kidney Patients
www.aakp.org
• American Nephrology Nurses’ Association
www.annanurse.org
• National Kidney Foundation
www.kidney.org
• National Kidney and Urologic Diseases Infor-
mation Clearinghouse
http://kidney.niddk.nih.gov