Your kidney treatment? Your choice!

How important is your lifestyle to you? Your quality of life? Income? Kidney failure is different from most types of illness. Unlike even cancer, once your kidneys fail, treatment is life-long. This means your treatment needs to be a good fit for your lifestyle, so you can work, travel, do hobbies, share meals with family and friends, and stay active in life.

Dialysis is not just a bridge to transplant, since you may need it for many years—and you have a life to live while you wait! You can learn about the types of dialysis in Kidney School™ and on Home Dialysis Central.

Know your options

In most cases, people can do any type of treatment they prefer. But having a number of abdominal surgeries can keep you from doing peritoneal dialysis (PD). Some health problems may rule out a treatment option or make one a better choice for you than another. Your doctor should be able to tell you if there is any medical reason why you should or should not do a certain treatment. And, you can always ask for a second opinion.

Sometimes, people are guided into a treatment option because the care team has certain opinions. For example, in the U.S., 91% of people with kidney failure use in-center hemodialysis (HD); only about 8% do PD.1 People who are white, working, have at least a high school education, and are married are more likely to be told about PD.2 But when people are educated about all of the options, 45% of 5,065 patients surveyed said they would prefer PD.3

Most people don't know about all of the options before they start treatment. In a recent study of new dialysis patients in California, lack of education about options was the main reason why patients did not choose home treatments: 66% did not know about PD, 88% did not know about home HD, and 74% did not know about transplant.4

You're in charge

When nephrologists were asked what factors should go into dialysis choice, their number one answer was patient preference, at a score of 4.54 out of 5.5 This suggests that once you learn about the treatments and decide, your doctor will value your opinion.

Making a treatment choice for yourself is key to how well you may do. One large study put 2,418 new dialysis patients into three groups, based on how they chose their treatment:6

  • Group 1 (636 patients) made their own choice.
  • Group 2 (922 patients) worked with their care team to decide.
  • Group 3 (860 patients) said their care team chose for them.

Five years later, those who made their own choice (Group 1) were significantly more likely to live longer and to get a transplant. This was true even after adjusting for age, sex, race, other illness, blood test levels, level of kidney function, education, work, and marital status.

You are the one who must live with the treatment from day-to-day. It makes sense that you'll feel better if the choice is yours.

Which treatment will help you live longest?

For years, studies have looked at whether PD or in-center HD helps patients live longest. And the answer is: we don't know. Which one might work best for you depends on your body size, other illnesses, and how good your treatments are.

  • Larger patients (BMI >30) tend to do better on HD than on PD.7
  • Malnourished patients (BMI <20.9) don't tend to do well on either treatment.7
  • One 1995-98 study found that patients were much more likely to survive a first year of PD than a second.8 But doctors were not routinely checking remaining kidney function back then, so those patients may not have had enough PD. Today, there are guidelines in place to help prevent this.

A study of 405 short daily HD patients found survival rates nearly 2/3 better than would be expected on in-center HD.9 No similar study has yet been done for nocturnal HD.

Which treatment will help you feel better?

You won't be surprised to learn that some people feel better on PD and some on HD. Most people become attached to the treatment they use, and don't want to change. In fact, more than 75% of patients would choose a higher dose of dialysis if it improved their survival by 20%. But nearly a third would not switch treatments even if they would live twice as long.10 This suggests that you need to take other patients' advice with a grain of salt, and choose what will work best for you.

Studies of quality of life on people using PD vs. standard, in-center HD also show that preferences vary. PD users were much more likely to rate their care as excellent than HD users, which suggests that they were happier with their treatment.11 Another study found that each treatment has pros and cons. After a year, HD patients felt better in some ways (general health, body image, sexual function), while PD patients felt better in others (mental health, travel, work, and diet).12

Compared to standard in-center HD though, a small (45 person) study found that patients on short daily or nocturnal HD had:13

  • Better fluid management - less cramping, fewer headaches, lower blood pressure, less weight gain between treatments, less shortness of breath
  • Better physical functioning - standard HD patients lost ground during the study

Every patient who switched to daily or nocturnal treatments chose to keep it. Studies also show that short daily or nocturnal HD can improve appetite and nutrition.14,15

Try treatments on for size

A long-time patient educator has some good advice about choosing a treatment. She suggests that you think through your day and how it might work with each type of treatment you are thinking about.16

  • Waking up - Would you want to get up earlier to get to an in-center HD treatment? To start or stop a PD treatment? Do you mind seeing dialysis equipment or supplies in our home, or would this be a deal-breaker for you?
  • Eating breakfast - What sort of diet and fluid limits are you willing to live with each day? In-center HD has the most limits, PD and short daily HD have fewer, nocturnal HD has the least.
  • Taking medications - How many pills will you want to take in a day? In-center HD has the most pills, nocturnal HD has the least (often no phosphate binders).
  • Going to work - Do you have a job? How will your treatment times fit your work life, and how much control will you have? How much will your income drop if you quit your job and take disability? Social Security Disability takes 6 months to start, and pays only about 38% of earned income.
  • Getting your treatments - If you live far from a center or don't have a car, in-center HD can be costly and inconvenient. Home treatments mean that after training you visit the center just once a month for clinic appointments. PD or short daily HD treatments can be done throughout the day—is that a plus or a minus for you?
  • Dealing with childcare - Do you have young or school-aged children? Who will care for them if you dialyze in a center? What will happen during school vacations or summer breaks?
  • Eating dinner - How much will family meals be affected by your diet limits? Will your treatment give you the energy to cook? If not, who will prepare meals?
  • Socializing with family and friends - Headaches, muscle cramps, and fatigue can keep you from making plans and having fun with your loved ones. Hooking up to a PD cycler can shorten your evening. What's important to you?
  • Going to bed - How well are you sleeping on your treatment choice? Could you sleep with a PD cycler or HD machine in the room? Could you sleep in a dialysis center for nocturnal in-center treatments? How will your body image and sex life be affected by your treatment choice?

There are no right or wrong answers to any of these questions—only what will or won't work for you. Your needs may change over time, too. People who have lived with kidney failure for decades often find that over the years they may try all of the dialysis options plus one or more transplants.

Every treatment for kidney disease has pros and cons. You are the only one who can decide what will best fit your needs and your lifestyle at any given time. The more involved you are in making a treatment choice, the better you are likely to feel.

References

  1. U.S. Renal Data System: USRDS 2005 Annual Data Report. The National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Bethesda, MD 2005.
  2. Stack AG. Determinants of modality selection among incident US dialysis patients: Results from a national study. J Am Soc Nephrol 13:1279-1287, 2002.
  3. Schreiber M, Ilamathi E, Wolfson M, Fender D, Mueller S, Baudoin M. Preliminary findings from the National pre-ESRD Education Initiative. Nephrol News Issues 14(12):44-6, 2000.
  4. Mehrotra R, Marsh D, Vonesh E, Peters V, Nissenson A. Patient education and access of ESRD patients to renal replacement therapies beyond in-center hemodialysis. Kidney Int 68:378-390, 2005.
  5. Mendelssohn DC, Mullaney SR, Jung B, Blake PG, Mehta RL. What do American nephrologists think about dialysis modality selection? Am J Kidney Dis 37(1):22-29, 2001.
  6. Stack AG, Martin DR. Association of patient autonomy with increased transplantation and survival among new dialysis patients in the United States. Am J Kidney Dis 45(4):730-742, 2005.
  7. Stack AG, Murthy BVR, Molony DA. Survival differences between peritoneal dialysis and hemodialysis among "large" ESRD patients in the United States. Kidney Int 65:2389-2408, 2004.
  8. Jaar BG, Coresh J, Plantinga LC, Fink NE, Klag MJ, Levey AS, Levin NW, Sadler JH, Kliger A, Powe NR. Comparing the risk for death with peritoneal dialysis and hemodialysis in a national cohort of patients with chronic kidney disease. Ann Intern Med 143:174-183, 2005.
  9. Kjellstrand C, Buoncristiani U, Ting G, Traeger J, Piccoli GB, Sibai-Galland R, Young B, Blagg CR. Survival in 405 patients treated by short daily hemodialysis (DHD) for 948 patient years rivals renal transplant survival. J Am Soc Nephrol 16:733A, SA-PO809, 2005.
  10. Bass EB, Wills S, Fink NE, Jenckes MW, Sadler JH, Levey AS, Meyer K, Powe NR. How strong are patients' preferences in choices between dialysis modalities and doses? Am J Kidney Dis 44(4):695-705, 2004.
  11. Rubin HR, Fink NE, Plantinga LC, Sadler JH, Kliger AS, Powe NR. Patient ratings of dialysis care with peritoneal dialysis vs hemodialysis. JAMA 291(6):697-703, 2004.
  12. Wu AW, Fink NE, Marsh-Manzi JVR, Meyer K, Finkelstein FO, Chapman MM, Powe NR. Changes in quality of life during hemodialysis and peritoneal dialysis treatment: generic and disease specific measures. J Am Soc Nephrol 15:743-753, 2004.
  13. Heidenheim AP, Muirhead N, Moist L, Lindsay RM. Patient quality of life on quotidian hemodialysis. Am J Kidney Dis 42(1, Suppl 1):S36-S41, 2003.
  14. Spanner E, Sun R, Heidenheim AP, Lindsay RM. The impact of quotidian hemodialysis on nutrition. Am J Kidney Dis 42(1, Suppl 1):S30-S35, 2003.
  15. Galland R, Traeger J. Short Daily Hemodialysis and Nutritional Status in Patients with Chronic Renal Failure. Sem Dial 17:104-8, 2004.
  16. Campbell A. Strategies for improving dialysis decision making. Perit Dial Int 11:173-178, 1991.

Copyright © 2006 Medical Education Institute, Inc. All rights reserved.

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