Whether or not a kidney transplant is the correct treatment for any specific patient is a changing question in terms of upper age or cause of kidney disease. When dialysis treatment was first introduced, being older than 45 meant absolute exclusion from therapy. Today, the average age of new dialysis patients in the United States is 64 years. Similarly, kidney transplants are now being performed in very old patients as well as in many instances when the cause of ESRD was considered reason to refuse a transplant.
The wait for a deceased kidney donor in New York, for example, is now nearly 10 years, meaning some dialysis patients on the wait list will not live long enough to get the desired transplant. Without question, the best choice, just about always, is to receive a well matched live donor kidney. In my experience, I care for kidney recipients who are cheerful and fully functional more than 30 years after their transplant.
It is unusual for those on dialysis to sustain a near normal life after 20 years. On the clearly positive side, the outlook for both dialysis and transplant patients is continuously improving.
In some cases of acute kidney failure, dialysis may only be needed for a short time until the kidneys get better. In chronic or end stage kidney failure, your kidneys do not get better and you will need dialysis for the rest of your life. If your doctor says you are a candidate, you may choose to be placed on a waiting list for a new kidney. Dialysis can be done in a hospital, in a dialysis unit that is not part of a hospital, or at home.
You and your doctor will decide which place is best, based on your medical condition and your wishes. In hemodialysis, an artificial kidney hemodialyzer is used to remove waste and extra chemicals and fluid from your blood.
To get your blood into the artificial kidney, the doctor needs to make an access entrance into your blood vessels. This is done by minor surgery to your arm or leg. Sometimes, an access is made by joining an artery to a vein under your skin to make a bigger blood vessel called a fistula. However, if your blood vessels are not adequate for a fistula, the doctor may use a soft plastic tube to join an artery and a vein under your skin. This is called a graft.
Occasionally, an access is made by means of a narrow plastic tube, called a catheter, which is inserted into a large vein in your neck. This type of access may be temporary, but is sometimes used for long-term treatment. A type of hemodialysis called high-flux dialysis may take less time. You can speak to your doctor to see if this is an appropriate treatment for you.
In this type of dialysis, your blood is cleaned inside your body. The doctor will do surgery to place a plastic tube called a catheter into your abdomen belly to make an access. During the treatment, your abdominal area called the peritoneal cavity is slowly filled with dialysate through the catheter. The blood stays in the arteries and veins that line your peritoneal cavity. Without life-sustaining dialysis or a kidney transplant, once a person with kidney disease reaches stage 5 end stage renal disease or ESRD , toxins build up in the body and death usually comes within a few weeks.
The decision to stop treatment should be an informed and voluntary choice. Experts recommend patients talk with their physicians and a social worker or therapist to understand their choices and know what to expect.
There are many reasons why someone with ESRD may not want to continue or start dialysis. Studies have shown that people most likely to withdraw from dialysis are older and living in nursing homes. They often have health problems in addition to kidney disease, and suffer more severe pain. They usually have physical limitations that restrict normal daily activities.
Planning for care and respecting the wishes of the patient makes end-of-life decisions easier. All adults should have an advanced directive. Having an advance directive lets everyone know what to do if you become unable to communicate those wishes.
If you have questions about an advance directive, please talk with your physician or an attorney. However, "not doing dialysis", is not, and should not be tantamount to "not doing anything". Nephrologists can still focus their efforts to treat symptoms of advanced kidney disease medically and do everything possible, short-of-dialysis, to make patients feel better. Diet can be modified to reduce uremic symptoms with a focus on optimal protein intake.
The patient and the physician might need to sit together to go over the expectations and chart a plan for care. But we do have more data available about life expectancy in patients who opt for dialysis. This is however the average, with wide fluctuations seen depending on the patient's age, nutritional status, and presence of other co-existing disease conditions like ischemic heart disease, cancer, etc.
I would also like to direct your attention to a graph that compares the expectancy of a normal year old male to a similar patient on dialysis, or one who has received a kidney transplant. All the patients were at least 75 years old. One might deduce from this data that kidney failure patients who opt for dialysis will generally tend to live longer.
Patients with advanced kidney disease will often have multiple other serious disease conditions like heart failure, diabetes, cancer, etc; what we physicians call.
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