Kidney failure

What is kidney failure?

Kidney failure, also known as end-stage kidney disease, occurs when the kidneys are no longer able to adequately remove waste from your blood and control the level of fluid in your body. Kidney failure can happen suddenly or gradually. People with kidney failure need dialysis or a kidney transplant to stay alive.

If you have kidney disease, it does not mean that you will develop kidney failure. One in ten Australians aged 18 and over (approximately 1.7 million people) has at least one sign of chronic kidney disease, and over 26,000 Australians receive dialysis or a kidney transplant for kidney failure.

You can lose up to 90 per cent of your kidney function before experiencing symptoms. In many cases, the signs of disease often aren’t noticed until the kidneys are close to failure.

Symptoms of kidney disease

In the early stages of kidney disease, people can have no symptoms. In fact, some people have no symptoms until over 90 per cent of their kidney function has gone. This is unfortunate because early detection of kidney disease and treatment is the key to preventing kidney failure.

Symptoms of kidney disease can include:

• tiredness
• loss of appetite
• difficulty sleeping
• headaches
• lack of concentration
• shortness of breath
• nausea and vomiting
• changes in the amount and number of times urine is passed
• changes in the appearance of urine or blood in the urine
• puffiness in the legs and ankles
• pain in the kidney area
• high blood pressure
• itching
• bad breath
• a metallic taste in the mouth.

These symptoms can be caused by other conditions, but if you are in a high-risk group for kidney disease, speak with your doctor.

Treatment for kidney failure

There are three treatment pathways for people approaching kidney failure:

• dialysis
• transplantation
• comprehensive conservative care

Dialysis or kidney transplantation is needed when there is less than 10 per cent of kidney function left. These options are also known as renal replacement therapy (RRT). Some people choose non dialysis comprehensive conservative care rather than dialysis or kidney transplantation.

Dialysis

There are two types of dialysis:

Haemodialysis - home or dialysis centre

Haemodialysis (HD) can be done by you at home. If you need access to special medical care or are unable to do HD at home you will need to have your HD at a dialysis centre. Dialysis centres are sometimes located in a hospital or in the community (called a satellite centre).

During HD, your blood travels through a special filter called a 'dialyser' before being returned cleaned to your body. The dialyser has many tiny fibres (tubes). Each fibre has tiny holes in its walls. A special fluid called dialysate washes around the fibres. The extra fluid and waste products travel from your blood through the fibres and into the dialysate. Clean blood flows back to your body and the dialysate goes down the drain.

Peritoneal dialysis

Peritoneal dialysis (PD) is done at home by yourself, or a family member can be trained to help you. Your health care team will organise training to show you how to manage at home. There are two types of peritoneal dialysis: the daytime bags Continuous Ambulatory Peritoneal Dialysis (CAPO) and the night-time cycler Automated Peritoneal Dialysis (APO).

Peritoneal dialysis uses your peritoneal membrane, a thin membrane or skin which surrounds and protects your organs in your abdomen (stomach) as a filter. During peritoneal dialysis, your membrane is used to filter waste products and extra fluid from your blood. A special catheter (tube) is used to move a special dialysis fluid called dialysate in and out of your peritoneal cavity all the time, so your blood is continually being cleaned.

Kidney transplant

A kidney transplant involves the transplantation of one kidney from either a living or deceased donor into the body of another person (recipient).

A kidney transplant is a treatment for kidney disease but it is not a cure. A transplant offers a more active life, without needing dialysis.

A kidney transplant requires ongoing care. You will need to take medications to stop your body rejecting the kidney (anti-rejection) for as long as you have the transplanted kidney. If a kidney transplant stops working, dialysis treatment will be necessary again. Another transplant may also be possible.

Comprehensive conservative care

Comprehensive conservative care is the treatment pathway you will be offered if you have decided that dialysis or transplantation are not right for you. People choose comprehensive conservative care for many reasons, and these include having other health issues, preferring an option that focuses on quality of life rather than extending life, or having tried dialysis choosing to stop this treatment.

With comprehensive conservative care you will still be monitored and supported by health professionals. You may have medications and a special diet to improve your quality of life. Comprehensive conservative care will not extend your life when your kidneys fail completely.

Causes of kidney failure

Some of the causes of kidney failure include:

• diabetes (diabetic kidney disease) – even if it is well managed, diabetes can cause kidney damage
• high blood pressure (hypertension)
• glomerulonephritis – swelling or inflammation of the tiny filtering units (nephrons) in the kidney. Also known as nephritis
• polycystic kidney disease – an inherited condition that causes thousands of cysts to form in the kidneys
• urinary reflux (reflux nephropathy) – a bladder-valve problem that allows urine to flow back into the kidneys, causing scarring
• medications – some drugs such as lithium and cyclosporin can cause kidney failure. Continued misuse of compound analgesic preparations (now banned) was once a common cause of permanent kidney damage. Non-steroidal anti-inflammatory drugs (NSAIDs), taken in normal therapeutic doses, may occasionally cause acute kidney failure
• medullary cystic kidney disease (MCKD) – an inherited kidney disease that leads to the kidneys gradually losing their ability to work properly due to cysts in the centre of the kidneys.

Chronic kidney disease (CKD)

Often, the development of kidney disease is gradual and kidney function worsens over a number of years. If you permanently lose more than 40 per cent of your kidney function, it is called ‘chronic kidney disease’ (CKD). This can lead to kidney failure.

You are more at risk of CKD if you:

• have diabetes
• have high blood pressure 
• are obese
• are over 60 years of age
• have a family history of kidney failure or hereditary kidney disease in a first or second degree relative
• have established heart problems (heart failure or a past heart attack) or have had a stroke
• smoke
• have a history of acute kidney injury
• are of Aboriginal or Torres Strait Islander origin and 18 years and older.

The risk of CKD resulting in kidney failure depends on your level of kidney damage. If kidney disease is found early, medication, combined with diet and lifestyle changes, can prolong the life of your kidneys.

If you have one or more of the risk factors for developing CKD, it is important to ask your doctor to perform a kidney health check which will include a blood test, urine test and blood pressure check.

Acute kidney failure

A sudden drop in kidney function is called acute kidney failure. This can be life threatening and requires immediate treatment. Causes of acute kidney failure can be divided into three groups:

• pre-renal (decreases to the kidney’s blood supply)
• renal (damage to the kidney itself)
• post-renal (obstructions in other parts of the urinary tract).

Acute kidney failure is often short-lived and many people with acute kidney failure need dialysis while they are waiting for their kidneys to recover. Sometimes, treatment is a matter of controlling blood pressure and blood chemistry, while waiting for kidney function to return.

The outcome for people with acute kidney failure depends on the underlying cause and presence or absence of other medical conditions. In cases where the cause is pre-renal or post-renal, the kidneys often recover well once the factor causing it is removed. Acute kidney failure is less common than chronic (ongoing) kidney failure.

Diagnosis of kidney failure

If kidney disease is suspected, you will have some kidney function tests (also known as a kidney health check) to measure how well your kidneys are working and help plan your treatment. This includes:

• Tests for albumin (a type of protein) and/or blood in your urine.
• A blood test to find out the level of waste products in the blood and calculate your glomerular filtration rate.
• A blood pressure test. Kidney disease causes high blood pressure, which can damage the small blood vessels in the kidneys. High blood pressure can also cause kidney disease.
• An ultrasound or Computed Tomography scan (CT scan) to take a picture of your kidneys and urinary tract. These tests show the size of your kidneys, locate kidney stones or tumours and find any problems in the structure of your kidneys and urinary tract.
• You may also visit a kidney specialist (called a nephrologist) to help manage your care and decide if a kidney biopsy is needed. During a kidney biopsy a small piece of kidney tissue is removed and looked at under a microscope to find out the type of kidney disease and check if your kidneys are damaged.

Where to get help

• Your GP (doctor)
• Kidney Health Australia helpline Tel. 1800 454 363 
• Kidney Health Australia - Dialysis: Key facts factsheet
• Kidney Health Australia - Comprehensive conservative kidney care factsheet