Saturday, March 26, 2011

My list of preferences for renal replacement therapies

I have seen pretty much all modalities of renal replacement in my almost 14 years of experience with kidney disease. Here is the list of modalities in order of my preference:

1. Kidney Transplant: Top there is the indisputable king, a renal transplant. Despite all the risks, the costs, the possible complications, a kidney transplant continues to offer the best outcomes. For me, the most important benefits of a transplant are the freedom from dialysis and the freedom from fluid restrictions. Despite all what people say about daily nocturnal offering outcomes equivalent to cadaveric transplants, I still find dialysis and its attendant problems, both physical and mental, too overwhelming. I would take a transplant any day.

I would go so far to say that once you are diagnosed with kidney failure and are going to need some form of replacement 'soon', do all you can to get a transplant without having to get on to dialysis at all. Try not to know fluid restrictions at all. This is possible and is happening quite often these days. All it needs is swift, prompt, proactive action.

2. CCPD: Second would be Peritoneal Dialysis connected to a cycler at night. This would free up your days and give you the benefits of minimal fluid and diet restrictions. With portable cyclers already available, travel would also not be an issue.

3. CAPD: Third would be manual Peritoneal Dialysis. Three to four exchanges every day. This offers the advantages of minimal diet and fluid restrictions. The only hassle being the 30-35 minutes three to four times a day that you need to spend on the exchanges. Travel is also possible because most providers nowadays have the facility of supplying bags wherever you go. Ideally the patient should self-administer the exchanges to realize the true flexibility and independence of PD.

4. Daily nocturnal home hemodialysis:  The best hemodialysis modality. 7 to 8 hours, 6 to 7 nights a week. The problem is you still need to suffer the needles. There is also a certain element of risk. Blood leaks can happen. Hypotension and cramps can happen. Despite all this, the benefits far outweigh the risks. The full advantage of the modality can be realized only if you self-dialyze. It is difficult but can be achieved with proper training available in some countries (not in mine).

5. Short daily home hemodialysis:  Two to three hours everyday at home. The problem with this is the fluid removal rates can still be high. Fluid restrictions will still apply. Risks are reduced because you are most likely awake.

6. In center nocturnal hemodialysis: 4 to 6 times a week, 7 to 8 hours in center. Offers the benefits of longer duration dialysis but you need to go in-center. Cross infections, inflexibilities.

7. Twice/Thrice a week home hemodialysis: Regular hemodialysis except that its at home. The problems of the modality remain. However at least you are saved from the danger of cross infections with viruses such as Hepatitis B, C and HIV.

8. Regular, in-center hemodialysis:  Regular hemodialysis in a center. My least favored option. The default for most people. The only option most people are told about.

5 comments:

Madras Hash said...

Nice, neat guide setting out the options. All nephros should give a printout of this Post to all CKD newbies and that will be the beginning of a meaningful discussion on planning for the way forward.

Madras Hash said...

Is http://www.dialysis.org.in/ updated with this info?

Kamal D Shah said...

Thanks Vinod! Glad you liked it.

Well, after reading your comment, I updated the http://dialysis.org.in site too.

vishal goyal said...

Thanks Kamal for bringing this information. About CCPD or CAPD I understand the benefits, but according to Dr. Gopal Rabindranath "PD is good for the first 3 years and variably longer and depends on comorbidity, infections"
"When compared to Hemodialysis, PD is less efficient as the years go by.".
Please check the following link for details
http://homehaemodialysistraininginindia.page.tl/CAPD-s-HHD.htm
Please bring out the more enlightened comparison. Thanks again.

Kamal D Shah said...

Hi Vishal,

Firstly, dialysis modality is purely personal preference! I know some people who hate PD and swear by hemo. I cannot comprehend this though! This list is my personal choice. It may not necessarily represent that of everyone.

Having said that, I can safely say that most people prefer PD simply because it can be done at home, imposes less fluid and dietary restrictions and does not have needles of blood coming out of the body.

Dr. Rabindranath is correct when he says that over the years PD is less efficient than hemo. My point however is do PD as long as it lasts. At least for that period of time, you have a great life!

There are people who have done PD for many years. The key of course, is to be very careful while doing exchanges and the exit site dressing in terms of infection prevention.

-Kamal