Background

Whilst we fully support the need for early detection and prevention of kidney disease, we recognise that a significant minority of patients do, unfortunately, go on to develop established renal failure. For these patients, it is important that services are designed to ensure that they are fully involved in the treatment and management of their condition and that they are provided with the support they need to prepare them for renal replacement therapy.

Established Renal Failure

Patients with established renal failure (ERF) rely on renal replacement therapy in the form of dialysis or transplantation to survive.

Dialysis

There are two types of dialysis - Haemodialysis and Peritoneal Dialysis. The former is a process by which waste material and water are removed from the body pumping the blood through an artificial kidney linked to a dialysis machine. Patients usually receive this treatment at a hospital, but it can also take place at home. If generally carried out three times a week, with each treatment taking about four hours.

Peritoneal dialysis uses the natural membrane in the abdomen (the peritoneum) for dialysis. A sterile fluid is run into the abdomen. Waste products are drawn into the fluid. This fluid is then drained out and fresh fluid instilled. This process may be carried out manually (called CAPD – Continuous Ambulatory Peritoneal Dialysis) or using an automated machine overnight (APD). This form of dialysis only takes place at home and therefore gives patients greater freedom in their lifestyle.

Transplantation

Transplantation is the most effective form of treatment for those with established renal failure (ERF) and provides patients the best chance of restoring a normal lifestyle. Unfortunately, waiting lists for transplants of all types continue to increase in almost every country, including the UK. According to UK Transplant, the waiting list for a transplant in this country is currently around 3 years.

A key barrier to increasing the number of transplants carried out in the UK is the rate of organ donation, as the demand for kidneys exceeds the number which have been available. Moreover, it can be difficult to find a well-matched kidney for transplantation in some patients, as this is affected by a range of factors including blood group and genetic type.

More needs to be done to improve organ donation rates in the UK. A system of presumed consent for donation. There is also the need for more intensive care beds, transplant coordinators in every hospital, an efficient system in hospitals of identifying potential donors and effective public communication and education programmes to raise awareness of the benefits of organ donation.

We support the use of older donors, non-heart beating donors and living donors, both related and non-related.

Further information on our position with regard to dialysis can be found in our statements on Organ Donation, Consent and Modalities in Stage 4-5 CKD.
Dialysis or Transplantation?

Transplantation is the treatment of choice for patients with ERF, 30% of them are not suitable for a transplant, coupled with the acute shortage of available organs, around half require dialysis. It is therefore very important to ensure that patients have access to appropriate information, individually tailored, that informs them of the choices they have with regard to renal replacement therapy and enables them to work with a multi-disciplinary renal team to agree a care plan that best meets their needs.

When developing a care plan, the renal team should assess the patient's clinical, social and psychological suitability for both dialysis and transplantation, as well as take into account when they are likely to require renal replacement therapy. Transplantation is not appropriate for all patients and a full assessment of their suitability should be undertaken. This should take into account factors such as age, frailty, and general health, as some patients may not be physically up to transplant surgery.

If a patient is found suitable, then the renal team should discuss with them their options with regard to transplantation. There can be a benefit to patients in receiving a pre-emptive transplant (before they commence dialysis), so their timely assessment and preparation for transplantation is important.

Patients can be placed on the waiting list for a cadaveric organ transplant up to six months before the start of their dialysis. Given the long waiting time for a suitable organ and the difficulties in finding well-matched organs, it is key that patients are given the opportunity to be put on the list as soon as they have been assessed for their suitability. During this assessment, patients should also be invited to discuss other potential sources of organ donation, including live donation.

At the same time, preparations should be made for patients to receive dialysis treatment, regardless of whether or not they are on the waiting list for a transplant. This should include a full discussion between the renal team and patient of the options available with regard to the most appropriate form of dialysis, as well as liaison with surgical teams to ensure that the patient receives appropriate and timely vascular access surgery.

There may be a number of clinical factors that decide which form of dialysis is most suitable for a patient. For example, peritoneal dialysis may not be feasible in patients that have had extensive abdominal surgery, and the stage at which they present for dialysis may also restrict them to certain methods.

Moreover, the way in which different forms of dialysis are provided need to be taken into account. Some patients may not be able to tolerate the frequency of hospital visits required for haemodialysis, yet peritoneal dialysis can carry a risk of patients developing peritonitis and their ability to manage their dialysis to minimise this risk is important.

However, despite these clinical factors, the National Service Framework for Renal Services states that there is no robust evidence to show that one form of dialysis has better outcomes than the other. In our view, the key consideration in providing dialysis services is to ensure that where possible, patients are offered the choice between different modalities, based on an assessment of their suitability.

Kidney Research UK
April 2007