When a person’s kidneys can no longer filter blood the way they should, the person is diagnosed with Chronic Kidney Disease (CKD), which affects more than 30 million adults in the United States.
Doctors recommend staying well hydrated, stopping smoking and managing other conditions like diabetes, hypertension and heart disease as a way to offset the issues associated with CKD, but when that isn't enough, dialysis and/or an organ transplant are the next considerations.
When most people think of dialysis they picture hemodialysis, a common method where patients are connected to a machine that filters their blood and removes unwanted waste products. It also helps balance electrolytes and minerals in the body.
How “bad” does kidney function have to get for a person to be put on dialysis? Rather than a measurement of kidney function, secondary problems with a person’s chemical balance in the blood can impel doctors to consider dialysis.
“The issue with kidney dysfunction is, what does it cause secondarily?” said Dr. Anuj Chopra, urologist at UPMC Susquehanna Sunbury. “One of the things that we see is abnormal potassium levels, which can lead to heart issues. So when we start seeing that there’s electrolyte or fluid imbalance, that’s when we start considering dialysis.”
Dialysis can be a temporary treatment. For example, if someone damages their kidneys, as kidney function improves, they may discontinue dialysis, Dr. Chopra said.
Typically, however, it is a permanent diagnosis that requires treatment three hours a day, three times a week. Nevertheless, it can be a lifesaving method of controlling CKD. It makes people feel better, sometimes within the first week of treatment, sometimes after a few months.
Dr. Manzoor Shah, internal medicine of Evangelical-Lewisburg, once visited a man whose walls were covered with trophies and certificates celebrating the 25 years he had thus far completed on dialysis.
“That is not the rule. That is the exception,” Shah said. “But people can be on dialysis for a long, long time.”
Peritoneal dialysis (PD), done at home, is another possibility. It uses the inner lining of the belly to filter blood. A catheter is inserted in the abdominal cavity, and the patient adds dialysate fluid through the catheter while waste fluid is removed, either through a cycler machine or by hand. Depending on the type of PD, it can be done overnight while the patient sleeps.
“All in all, it gives you more control of your life,” said Dr. Prince Mohan, Geisinger’s medical director of transplant nephrology. “You can just take your machine wherever you go.”
Shortage of organs
A kidney transplant, found by matching blood types with a potential donor, can give a patient a new life untethered to dialysis.
“Unfortunately there is a shortage of organs in the United States,” Chopra said. “You can be on a waiting list for years.”
“At this moment, 100,000 people are living in this country with a kidney transplant,” Dr. Shah said. “Fifty thousand are waiting for a transplant.”
Organ transplants come with three basic risks: rejection, infection and complications, said Dr. Michael Marvin, chairman of Geisinger’s department of transplantation and liver surgery. All drugs have side effects. Minimalizing the dose of any drug helps lower the degree of complication.
“We must customize care for each individual,” Marvin said, adding that Geisinger works with teams of doctors and nurses from different departments to create the best results for their patients.
Living donors can shorten the waiting time, and a relative’s organ tends to be a better match. Donated organs are gauged by their half-life, the time that 50 percent of the organs are working, Dr. Mohan said. Kidneys from a living donor have a half-life of 12 to 15 years. The kidney from a cadaver has a half-life of 8 to 10 years.
“All kidneys are not the same in terms of quality,” Marvin said, pointing out variabilities such as blood match and age of the organ donor.
Survival rate improved
Survival rate for kidney transplants is “actually very good now,” Chopra said. Patients still need immunosuppressants, which lower the chance of organ rejection but also lower a person’s natural immunities to infections. There is also a slightly higher risk of cancer with transplant patients.
“So everything has a price,” Shah said.
“I’ve seen patients that are 10 years past transplant and have pretty much normal kidney function.” Chopra said.
Kidneys have a greater capacity to do their job than is needed to keep us healthy. This accounts at least in part for the reason patients with CKD don’t always notice their kidney function is deteriorating; the kidney steps up its job to keep the patient going.
This capacity also allows both patients and living donors with one kidney to have a normal life.
“Kidneys have a lot of reserve capacity,” Shah said.
“One kidney can and does do the work of two kidneys,” Marvin said.
In 2015, Geisinger performed 38 kidney transplants. Last year they performed 81, largely because they have started accepting donor kidneys from people who have been exposed to hepatitis C, often through opioid use, Marvin said. Out of 35 transplants with an organ exposed to hepatitis C, no one has gotten the virus.
Geisinger has now begun accepting kidneys from donors who were actually diagnosed with hepatitis C. Of the patients receiving those kidneys, 100 percent did get the virus, but all were given medications that cured them of it within four weeks.
“This has enabled us to really grow our ability to perform transplants in our area,” Marvin said.
Comparing dialysis to transplants, Mohan said, “Transplant is the best treatment for kidney failure. I say treatment, not cure.”
Transplant patients live longer than dialysis patients and have a better quality of life.
“That’s why we try to get patients a transplant (even) before dialysis,” Mohan said.
Living donors are put through a slew of tests to make sure no harm will come to them after donor surgery, Mohan said. Donors can live well on one functioning kidney over a period of time.
“We can’t do anything in the world of transplants without the donor,” Marvin said, acknowledging that in the case of a cadaver donor, the surviving family members must make a gut-wrenching decision at a difficult time. “We’re very thankful to our donors and their families.”
Geisinger has had “a rash of altruistic donors” who want to donate a kidney to anyone in need, Marvin said.
“And,” Mohan added, “we are thankful for those donors.”