Kidneys - dialysis and 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.

Types of kidney dialysis

There are two forms of dialysis – peritoneal dialysis and haemodialysis. Peritoneal dialysis is further broken down into two main types: continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD).

Peritoneal dialysis

Peritoneal dialysis occurs inside your body using your body's peritoneal membrane as a filter. This membrane is a fine layer of tissue that lines your peritoneal (abdominal) cavity, covering organs such as your stomach, liver, spleen and intestines. It has a fine layer of tissues and a rich blood supply.

The two main types of peritoneal dialysis are:

• continuous ambulatory peritoneal dialysis (CAPD)
• automated peritoneal dialysis (APD).

Access for peritoneal dialysis

Peritoneal dialysis uses a soft tube called a catheter. A surgical operation is required to insert the catheter into the peritoneal cavity. The catheter is about 0.5 cm wide and remains in your body until dialysis is no longer needed. One end of the catheter sticks a few centimetres out of your body, so that it can be connected to a bag containing a special fluid. The catheter allows the fluid to enter and leave your peritoneal cavity.

Waste and extra fluid move from your blood into the special fluid, which is then drained from the body. Each time 'used' fluid is replaced by fresh fluid, the cycle is called an 'exchange'. The number of exchanges needed differs from one person to the next.

Continuous ambulatory peritoneal dialysis (CAPD)

Four exchanges are usually done each day. Each exchange includes connecting a new bag of fluid, draining out the old fluid and putting the new fluid in. It takes about 30 minutes and can be done almost anywhere, with a few sensible precautions. In between exchanges, the person is free to go about their daily activities.

Exchanges are typically done on waking, at lunch time, at dinner time and before going to bed. Some flexibility is available for busy days. CAPD works by gravity. When the drain bag is placed at floor level the fluid drains out. By raising the new dialysate bag above shoulder level, the new dialysate flows into the peritoneal cavity.

Automated peritoneal dialysis (APD)

During APD, a machine called a cycler does the exchanges. Each night, the catheter is attached to the tubing of the cycler. It does several exchanges, moving the dialysate in and out of the body while the person is asleep. APD is done every night and usually takes between eight to 10 hours. During the day, dialysate is usually left in the body so that dialysis continues.

Training for peritoneal dialysis

If a person chooses to have peritoneal dialysis, they will be taught to:

• minimise the risk of infection
• perform the exchanges
• care for the site where the catheter leaves their body
• manage their general health
• manage any problems with dialysis
• order and look after dialysis supplies.

Haemodialysis

Haemodialysis involves making a circuit where blood is pumped from your bloodstream to a machine that filters waste and excess water. The filtered blood is then pumped back into your bloodstream. Only a small amount of blood is outside your body at any one time. The process is not painful and takes four to five hours.

Access for haemodialysis

For haemodialysis to occur, access to your blood stream is needed. A 'vascular access’ is made during surgery. Vascular is a term that means blood vessels and it can refer to both arteries (which take blood away from the heart) and veins (which take blood to the heart).

The surgery is usually done as a day case, so an overnight stay is not needed. It can take up to two months for the access to 'mature' so that it is ready to use for dialysis.

The three types of vascular access are:

• fistula – joins one of your arteries to a vein. The vein enlarges and is known as the fistula. It is usually in your lower or upper arm. A fistula generally needs six to eight weeks to develop after surgery before it can have needles put into it
• graft – uses a piece of tubing attached between one of your arteries and a vein, and again cannot have needles put into it until a few weeks after the surgery
• catheter – usually a temporary tube put into a large vein until a fistula or graft is ready to use. Catheters can be used immediately.

People with a vascular access need to take care of it and practice careful hygiene to prevent infection. It is important that you talk to your doctor and healthcare team about how to look after your graft or fistula, because it is your lifeline for treatment for kidney failure.

Treatment locations for haemodialysis

Haemodialysis can be done by you at home. Or, for people who need extra medical support, it can be performed at a dialysis unit in a hospital or a satellite centre. Your healthcare professionals will advise you of your available options. Haemodialysis is needed at least three times a week. At a dialysis unit, you will have permanent regular appointments for a four-to-five-hour dialysis session.

If you are dialysing at home, your schedule will be tailored to your needs and may include shorter or longer sessions, with three to six treatments each week. The extra treatments will help you to feel better.

If you choose to have haemodialysis at home, special plumbing will be installed and the machine will be provided, along with all the supplies you need. You will learn to manage your own dialysis. A spouse, friend, carer or partner can be trained to help you, but some people dialyse by themselves.

Having dialysis at home means you can choose to dialyse when it suits you – at any time during the day, or overnight while you sleep. At home, it is also possible to dialyse more often, which has health benefits.

Making a kidney dialysis choice

The type of dialysis treatment you choose to have may be influenced by a number of factors including:

• personal lifestyle (including work, family responsibilities, travel, leisure activities)
• personal preference
• health and medical suitability.

If you need to have dialysis, your healthcare professional will discuss the pros and cons of the different options with you, your family, and your healthcare team. It is usually possible to change between dialysis options if one treatment no longer suits.

Kidney transplant

A kidney transplant is a treatment for kidney failure, but it is not a cure. A transplant offers:

• a more active life
• freedom from dialysis
• freedom from restrictions on fluid and dietary intake.
• It is important to remember that a transplanted kidney requires a lifetime of management and care.

Kidney transplants can come from living or deceased donors. The person receiving the kidney is called the recipient and the person giving the kidney is called the donor. Living donors can be relatives, as well as partners and close friends. Occasionally they are also people unknown to the recipient. Deceased donors are people who have given permission for their organs to be donated after their death.

A transplant from a deceased donor is available to medically suitable people who have been stabilised on dialysis. If the transplant is from a living donor, the operation can be done when the kidneys are close to failing, but before dialysis starts. This is called a pre-emptive transplant.

The survival rate following a kidney transplant is high – 97 per cent of recipients from deceased donors are alive at one year, and 90 per cent are alive at five years. The survival rate following a kidney transplant from a living donor is even higher – 99 per cent at one year, and 96 per cent at five years.

Kidney transplant as an option

Not everyone is suitable for a transplant. Sometimes, other medical problems make dialysis or comprehensive conservative care better treatment options.

Factors that affect the suitability for a transplant include:

• agreement with the idea of transplantation and acceptance of the risks involved
• general good physical health, apart from kidney failure
• willingness to go through with the tests and operation
• willingness to take lifelong anti-rejection medication.

Transplant procedure

Surgery takes about two to three hours. A cut is made in your lower abdomen (stomach), on the right or left side. The new kidney is placed in your pelvis. The renal artery and vein of the transplant kidney are connected to an artery and vein in your pelvis. The ureter of the transplanted kidney is connected to your bladder so urine can flow.

Your failed kidneys are not removed. They are left in your body to continue to provide whatever amount of function it may still have. Sometimes it may be necessary to remove your failed kidneys if they are very large or in the case of chronic infection. If this is needed, your failed kidneys will be removed in a separate surgical procedure before your transplant surgery.

After transplant surgery

After the transplant surgery, it is normal to feel some pain around your wound. You will be given medication to help with this.

Your transplanted kidney may start to make urine immediately, or you may need dialysis for a few days whilst your kidney recovers from surgery. A catheter will be placed in your bladder for around five days to drain your urine into a bag.

You will have blood tests every day to check the function of your transplanted kidney, to measure medication levels and to detect any problems early so they can be treated quickly. The amount of fluid you take in is important. If your kidney is working you may find yourself having to drink lots of fluid.

A physiotherapist may assist you with an exercise plan. It is important to do coughing, breathing and leg exercises while you are restricted to bed rest.

The length of time that you will need to stay in hospital after the transplant surgery will depend on how well your body responds to the new kidney and whether you have any complications. Most people are in hospital between six and ten days. You may feel better immediately after your surgery or you may take longer to adjust.

Are kidney transplants successful?

Kidney transplants are very successful. 95% of transplants are working one year later. If the transplant works well for the first year, the chances are good that it will function very well for many years.

Success rates are higher with living donor kidneys than for deceased donor kidneys.

To give your transplant the best chance of success, it is important that you look after yourself while you are on the transplant waiting list. You will have regular reviews where you can discuss any concerns about your transplant preparation.

Kidney rejection

In the early period after your transplant, you may have some rejection episodes. These may only be picked up by your regular blood tests. These episodes can usually be managed with changes to your medications. Some rejection episodes may require extra treatments such as plasma exchange or special infusions.

In the early weeks of your transplant, you may experience a number of acute rejections. An increasing eGFR or creatinine is usually the first sign of acute rejection. A biopsy of the kidney transplant is often used to diagnose rejection and to decide on the best treatment.

Chronic rejection refers to a gradual process, which leads to scarring and damage in the transplanted kidney. This usually occurs over several years and can be very difficult to treat.

Well being after a transplant

Having a transplant should have a positive effect on your life. However, it is still a major life event causing a range of emotions before and after the operation. You may have mood swings and feel stressed or depressed as you adjust to your transplant, and as your body responds to the anti-rejection medication.

Comprehensive conservative care for kidney failure

Comprehensive conservative care is the treatment choice for kidney failure for people who have decided that dialysis and transplant are not appropriate for them. For many, this is because they are already very frail and they do not want complex treatments. Some people have the complex treatment for a while and then wish to stop.

For many who are already frail, their lifespan with kidney failure, with or without dialysis, is very similar. Comprehensive conservative care means that the person's care continues to be supervised and supported by health professionals. They may have medication and a restricted diet to improve their quality of life. Supportive care, however, will not artificially prolong life when your kidneys fail completely.

If a person is unsure about choosing a treatment option, it is always possible to try dialysis for a short while to see how things go.

Where to get help

• Your GP (doctor)
• Kidney Helpline Tel. 1800 454 363
• Kidney Health Australia - Kidney transplants factsheet