Chronic Kidney Disease #4: Updated Information on Dialysis

Doctor's Insight.

Chronic kidney disease or CKD involves a gradual decline in kidney function.

When you reach the end-stage kidney disease, you will require a treatment that replaces the functions of your kidneys.

The most common type of treatment is hemodialysis which involves frequent hospital visits.

There is also peritoneal dialysis, which is done at home.

Another type of treatment is a kidney transplant, which is relatively common in Europe and the United States.

Welcome to Doctor's Insight.

Approximately four million people worldwide suffer from End-stage kidney disease, a condition in which the kidneys lose their function.

Here is the breakdown of the treatment worldwide.

71% receive hemodialysis, 9% get peritoneal dialysis and 20% undergo a kidney transplant.

In Japan, 96% receive hemodialysis, 3% for peritoneal dialysis and less than 1% get a kidney transplant.

Each of these methods has its own advantages and disadvantages.

The accessibility of these treatments varies by country and region.

Today, we will focus on the various treatments available for end-stage kidney disease.

Today's expert is Dr. Masaomi Nangaku, President of the International Society of Nephrology.

He is a world renowned nephrologist who has spent decades conducting research on the cause and the treatment of kidney disease.

Dr. Nangaku, thank you for joining us yet again.

I'm happy to be back.

Doctor, when chronic kidney disease advances to end-stage kidney disease, why does it become necessary to get treatment such as dialysis?

When the kidneys lose their function, waste accumulates in the body.

This causes uremia, a painful condition that results in nausea, breathing difficulties, and other symptoms.

In order to control these symptoms, patients need to undergo kidney replacement therapy which replaces the function of the kidneys.

Without such treatment, the condition will be life-threatening for the patient.

So it is a very important therapy.

Can you say that one is better than the other?

Well, a kidney transplant is the only way to restore all the functions of the kidney.

However, a kidney transplant is performed on the condition that an organ donation is available.

In addition, the recipient must be in good physical and mental condition with the exception of the kidneys.

This is why in some cases, older adults and obese patients may not qualify.

Next, let's find out about hemodialysis, the most common type of treatment for end-stage kidney disease.

Hemodialysis is performed by inserting a needle into a blood vessel, while the patient is lying in bed.

Blood is transferred into a machine called a dialyzer.

Waste products, excess water and excess salt in the blood are drained into a cleansing liquid that flows inside the dialyzer.

This is how the blood is filtered.

Each treatment lasts four to five hours and is performed three times a week.

This is basically continued throughout your life.

Hemodialysis is very time consuming.

Yes. It is also known that sarcopenia, a condition of significant muscle loss, is common in patients who get hemodialysis.

For example, the prevalence of sarcopenia in Asian hemodialysis patients is reported to be as high as 50-60% in men and 52-68% in women.

Those are very high numbers.

So, more than half of the patients getting hemodialysis have sarcopenia.

Why is it so common?

Dialysis patients will be allowed to ease their protein intake restrictions and will be instructed to consume enough protein.

However, it is thought that a combination of different factors can lead to sarcopenia.

For example, the aging of dialysis patients.

Muscles damaged by urine toxins that accumulate due to poor excretory function.

Many years of protein restriction.

Lack of exercise due to time-consuming hemodialysis.

And muscles damaged due to chronic inflammation seen in patients with kidney failure and hemodialysis patients.

So patients who are receiving hemodialysis...

what are they supposed to do?

Well, that has become a major issue worldwide.

In Japan, attempts are being made to address this issue.

The concept of "Renal Rehabilitation" is being adopted throughout Japan in which CKD patients are being instructed to perform exercise that's right for them.

For hemodialysis patients, some facilities are offering "low-intensity strength training" to be performed during dialysis.

For instance, patients use resistance bands to bend and stretch their arms and legs.

Another exercise is to pedal using their legs and feet.

These exercises help to prevent sarcopenia.

It doesn't sound so strenuous, but is it safe to exercise during dialysis?

Medical staff trained in Renal Rehabilitation watch over the patients, so the exercise can be performed safely.

It is also a great benefit as it allows patients to make effective use of their dialysis time.

In recent years, more and more patients are choosing to put off dialysis.

Particularly in some countries in Europe and Oceania and in the United States, it is thought that an increasing number of elderly patients are choosing not to undergo dialysis.

A recent report in Japan shows this situation.

In the year 2019, there were 917 cases in which patients chose not to start dialysis.

There were also 492 cases where patients ended their dialysis treatment.

Some patients choose to stop or not start dialysis treatment.

What are the reasons, Doctor?

Patients requiring dialysis are often elderly and many of them have serious complications.

Among them, some patients may not wish to get dialysis.

In other cases, the physicians may decide that the risk of getting dialysis are too high and that the patients may not be able to tolerate dialysis.

But won't the patients suffer from various symptoms without dialysis?

That's why we have conservative kidney management which is a treatment that focuses on reducing the symptoms

such as uremia for those who choose not to undergo dialysis.

In western countries, it is becoming recognized as a fourth treatment option.

Countries such as Canada and Australia have published guidelines on their homepage.

It's a guide that describes the necessary procedures and treatment patients should receive when deciding not to get dialysis.

Based on this, "The Guide for Conservative Kidney Management for Elderly CKD Patients" was published in Japan in May 2022.

It must be very tough for both patients and doctors to decide not to go with dialysis treatment.

How do they decide?

An important step in this process is "shared-decision making" where the patient and the doctor think and discuss together to decide on a treatment plan.

In this process, it is crucial for the doctor to understand the values that are important to the patient, and for the patient to fully understand the treatment options.

Based on the patient's condition and values, they decide on what the best choice for the patient would be, including dialysis and conservative kidney management.

I hope that, more than ever, we'll be able to provide medical care to accommodate the wishes of patients with end-stage kidney disease.

Dr. Nangaku, thank you so much for your insight today and thank you for your being on our show once again.

Thank you for having me.