Early in the course of kidney failure (also called renal failure), treatment is required to preserve kidney functions as much as possiible. However, as the kidneys progressively lose their ability to function, fluid and waste products begin to build up in the blood. Complications such as malnutrition, bone disease, and anaemia can occur as a direct result of kidney failure. Finally, when more than 90 per cent of the kidney functions are lost, these problems reach a critical stage and artificial replacement of kidney functions will be required. This artificial replacement of kidney functions is called renal replacement therapy. There are three types of renal replacement therapy each designed to take over the function of the failing or nonfunctioning kidneys.

WHAT ARE THE DIFFERENT TYPES OF REPLACEMENT THERAPY?

There are three main types of renal replacement therapy: kidney transplantation, hemodialysis, and peritoneal dialysis.
1.Hemodialysis
In hemodialysis, the patient’s blood is passed through a dialysis machine to remove waste products and fluids.
2.Peritoneal dialysis
In peritoneal dialysis, dialysis fluid (usually glucose in high concentration) is placed into the abdomen through a tube, or catheter. It stays in the abdomen for a given time, drawing extra water and waste products from the blood. After a prescribed period, it is drained out and discarded. Several such cycles are repeated everyday.
3.Kidney transplantation
In kidney transplantation, a healthy kidney from another human being is put in the patient. This provides better quality of life and survival as compared to dialysis
Some patients with renal failure are not candidates for a kidney transplant.

Generally accepted conditions that would exclude a person from being eligible for transplantation include:
• Active cancer with a short life expectancy
• Another chronic illness that results in a life expectancy of less than one year
• Poorly controlled psychosis
• Active substance abuse
• HIV infection
Although patients with HIV infection have been expressly excluded from consideration, some centers are reevaluating this policy on a case by case basis, in light of the current availability of effective treatments for HIV. Patients with other medical conditions are also evaluated on a case by case basis to determine suitability for transplant.

WHICH TYPE OF RENAL REPLACEMENT THERAPY IS RIGHT FOR ME?

Choosing the most appropriate method of renal replacement therapy is a complex decision that is best made by the patient and doctor after careful consideration of a number of important factors.

For example, hemodialysis involves rapid changes of the fluid balance in the body and is not tolerated well by some patients. Some patients are not suitable candidates for transplant, while others may not have the home supports needed to do peritoneal dialysis. The patient’s overall medical condition, personal preferences, and home situation are among the many factors that will be considered in examining the options for renal replacement. It is common for patients to switch from one modality to another when preferences or conditions change over time.

HOW WILL MY DOCTOR KNOW WHEN I NEED RENAL REPLACEMENT THERAPY?

As kidney disease progresses, the decision to begin dialysis is made by the patient and doctor after considering a number of factors, including the patient’s kidney function (as measured by blood and urine tests), overall health, quality of life, and personal preferences. Doctors recommend that dialysis begin well before kidney disease has advanced to the point where life-threatening complications might occur. There are also data that suggest it is beneficial to begin dialysis before signs of malnutrition, which is a complication of kidney disease, are evident.
Certain clinical signs indicate that dialysis must be started immediately. If blood tests measuring kidney function fall outside certain parameters, or if the patient has symptoms such as mental confusion or bleeding that is related to kidney disease, dialysis should be started immediately.

WHEN SHOULD I TALK TO MY DOCTOR ABOUT RENAL REPLACEMENT THERAPY?

Some patients with chronic kidney disease can expect their disease to progress over time. While the goal of early treatment is to preserve kidney function for as long as possible, some will eventually need renal replacement therapy.
Patients with kidney disease should find out early in their treatment whether it is likely that they will eventually need renal replacement therapy. Advance planning can help reduce complications and may improve the overall outlook for the patient. First of all this will give enough time for arranging adequate finances required for the treatment. If hemodialysis will be used, advance planning might allow time for the placement of an AV fistula (the ideal form of vascular access for dialysis), which requires at least two to four months to heal before it can be used. Similarly, allowing sufficient time to train the patient and/or family to perform home hemodialysis or peritoneal dialysis will help ensure that the those involved feel prepared at the time that dialysis treatments must begin.