Failing Kidneys and Different Treatment Options

Main ideas & lessons

Kidneys and why they matter (“kidney 101”)

• Kidneys maintain balance in the body 24/7 by managing:
  • Fluids
  • Electrolytes (e.g., potassium/sodium)
  • Blood pressure
  • Waste removal
• When kidneys fail/shut down, people may feel unwell due to:
  • Fluid or waste buildup
  • Abnormal potassium/sodium
  • Rising blood pressure
• This increases risk of serious illness and creates the need for a new way to filter blood and manage fluid/electrolyte balance.

When to start dialysis (timing)

• Doctors often begin planning when GFR (glomerular filtration rate) ~20 (about 20% kidney function).
• Dialysis is not automatically required at GFR 20.
• Historically, many started dialysis when GFR drops below ~12, but doctors are moving away from relying on a number alone because starting earlier didn’t improve outcomes.
• Canadian guidelines emphasize starting dialysis when symptoms develop, such as:
  • Severe fatigue
  • Nausea
  • Decreased appetite
  • Shortness of breath
• Symptom assessment can be tricky if other illnesses exist—patients should work with their kidney team / nephrologist to identify symptoms that will improve with dialysis.
• Treatment planning should begin at least 1 year before dialysis is needed because dialysis setup can take 3–6 months.

Treatment options for failing kidneys

1) Conservative care (“do nothing” / non-dialysis approach)

• Goal: preserve remaining kidney function as long as possible using:
  • Diet
  • Medications
• Reality: this approach does not stop gradual decline; it ultimately leads to death.
• Often chosen when:
  • People have other major medical conditions
  • They’re not candidates for transplant
  • They feel the burden/discomfort of dialysis outweighs the benefits

2) Kidney transplant (best option for many)

• Sources of donor kidneys:
  • Living donor (relative or friend)
  • Deceased donor (kidney from someone who died suddenly)
• Key points:
  • Deceased donor kidneys aren’t immediately available.
  • In Canada, about 20% of people on dialysis are waiting for a deceased donor transplant.
  • Average wait time: 5–8 years
  • If eligible and able to get a transplant, it’s often associated with living longer and better than staying on dialysis.
  • Living donor kidneys typically last longer and transplant may be possible earlier (even before dialysis starts).
• Practical lesson: patients should discuss potential donation with family and friends.

3) Dialysis (blood-filtering with machines/equipment)

Dialysis replaces kidney function by cleaning blood.

A) Hemodialysis (HD)

• Where it happens: outside the body
• Process:
  • Blood is passed through an artificial kidney (dialyzer)
• Lifestyle/diet:
  • Requires diet changes
  • Requires fluid restriction (drink less)
• Typical schedule:
  • About 4 hours per session
  • 3 times per week
• Access to blood (required connection):
  • IV line inserted in the neck, or
  • Fistula: surgically connect an artery and vein in the arm
    • Fistula can take ~3 months to be ready → requires planning
• Home option:
  • Some do HD at home, even at night while asleep, which may free daytime time and change diet/needs.
• Most commonly described setting: go to a clinic/hospital

B) Peritoneal dialysis (PD)

• Where it happens: inside the body
• Core idea: the lining of the abdomen (peritoneum) acts as the filter.
• Process of exchanges:
  • A tube is placed near the belly button into the peritoneum
  • A special solution called dialysate is infused
  • The solution diffuses waste products out of the blood
  • The fluid is then drained back out through the tube
  • The abdomen is refilled—this cycle is called an exchange
  • Typical exchange time: ~20–30 minutes
• Two timing approaches:
  • Continuous ambulatory peritoneal dialysis (CAPD)
    • Manual exchanges by the patient every day
    • Usually allows normal activity between exchanges
  • Automated peritoneal dialysis (often termed APD in practice)
    • A machine runs exchanges overnight while the patient sleeps (7–10 hours)
    • During the day, patients may have some fluid in the abdomen but can usually move around normally

Choosing where/how dialysis is done (clinic vs home): factors and constraints

Reasons to do dialysis in a clinic/hospital

Hospital/clinic dialysis can be appropriate if:

• Home dialysis would be difficult to self-manage reliably.

Specific barriers to reliable self-care at home include:

• Alcohol/drug addiction
• Cognitive impairment
• Other medical conditions
• Feeling things are “hard” right now
• Lack of a reliable helper
• History of many abdominal surgeries (can make PD difficult/impossible)

Reasons home dialysis might be better (when feasible)

Home dialysis may fit better if:

• You live far from a clinic
• You have a fear of needles
• You struggle with fluid restriction/diet required for in-center HD

Practical needs/support for home dialysis

Barriers can often be overcome with support/training:

• Limited vision or hearing
• Learning problems
• Physical limitations

Examples of mitigation/support mentioned:

• Use vibration alarms for hearing-impaired patients
• Train family members for frail patients
• Use mentorship from other patients experienced with overcoming barriers
• A visiting nurse can help set up the night-time cycler machine

General reassurance:

• Dialysis management may be achievable if someone can handle routine tasks (e.g., “operate an ATM” / manual dexterity for everyday activities).

How people decide between HD and PD (summary of decision logic)

Overall claims made

• There has never been a definitive trial directly comparing PD vs in-center HD.
• There’s some controversy, but the speaker suggests:
  • For patients who are candidates for either, outcomes like survival and quality of life are often similar across choices.

What tends to help patients do best

Patients tend to do best when they:

• Get information ahead of time
• Make a plan
• Choose the dialysis type that fits their lifestyle

Education appears important:

• Studies excluding people too sick for home dialysis suggest that with comprehensive education, many patients choose home dialysis—often PD.

Detailed bullet-point instruction list included in the video

• Plan early (recommended timeline)
  • Start considering treatment options at least 1 year before dialysis is likely needed
  • Aim to make the dialysis decision 3–6 months before starting, since setup/training/access preparation can take that long
• Monitor for “when to start dialysis”
  • Use symptom development (not only GFR):
    • Severe fatigue
    • Nausea
    • Decreased appetite
    • Shortness of breath
  • Work with the kidney team/nephrologist to determine which symptoms will improve with dialysis, especially if you have other illnesses
• Consider conservative care if appropriate
  • Preserve remaining kidney function with diet/medications
  • Accept that decline continues; the approach is often for patients who aren’t transplant candidates or don’t want dialysis burden
• Consider transplant if eligible
  • Assess whether you’re a candidate
  • Discuss living donor possibilities with family/friends
  • Recognize wait times for deceased donor kidneys (long)
• If dialysis is needed, choose between the two modalities
  • Hemodialysis (HD)
    • Plan for dialyzer sessions ~4 hours, 3x/week
    • Arrange access (IV line or arm fistula; fistula may need ~3 months)
    • Prepare for diet and fluid restriction
    • Consider home HD only if you can reliably self-manage (or have sufficient help)
  • Peritoneal dialysis (PD)
    • Arrange surgical tube placement in abdomen
    • Choose schedule:
      • CAPD: manual exchanges daily (~20–30 minutes each)
      • Automated/overnight PD: machine runs exchanges while asleep (7–10 hours)
    • Prepare for training and symptom monitoring
    • Consider whether abdominal surgical history affects eligibility

Speakers / sources featured

• Speaker: Dr. Mike Evans
• Referenced sources/authorities (not speaking directly):
  • Nephrologists / kidney team (clinical care team)
  • Canadian guidelines on dialysis initiation (noted as the basis for symptom-based starting recommendations)