DIALYSIS AND TRANSPLANTATION

The first visit to a dialysis unit may be daunting but the earlier dialysis education begins the better informed the patient and family are to chose the most appropriate dialysis modality and to consider transplantation. Some patients feel that "life supporting" dialysis therapy will not improve quality of life and elect not to start dialysis.
The main aims in providing effective dialysis therapy are to maintain residual renal function and provide adequate therapy to improve the patients quality of life and life expectancy.
The two common forms of dialysis are haemodialysis and peritoneal dialysis. Both can provide effective dialysis but the benefits and complications differ between the two modalities.

Peritoneal dialysis

A plastic tube the size of a drinking straw is inserted into the abdomen and a 2000ml bag of warm sugar-water is run in for 4-6 hours, drained, then repeated with fresh solution. Each exchange takes between 30-45 minutes and can be performed independently in the home. A clean room to perform exchanges and a microwave oven to heat bags are required. Diabetic patients may choose to add insulin into the bags and avoid repeated injections PD may provide greater patient independence and allow more dietary flexibility as the dialysis therapy is continuous.
PD has also be associated with preservation of residual renal function which is linked to increased patient survival.
The main complication is infection of the fluid (peritonitis) which may damage the abdominal tissue significantly reducing dialysis efficiency.

Haemodialysis

A vein is surgically connected to an artery in the forearm or arm to form an arteriovenous (AV) fistula. Dialysis needles are inserted into the fistula and blood is pumped through a filter system then returned to the patient. Some patients may choose to perform dialysis at home and undergo home dialysis training. Others dialyse within a hospital or satellite unit. Dialysis is most often performed for 4-5 hours 3 times a week. The dietary restrictions tend to be greater than those associated with PD therapy as all the dialysis must be performed during the short treatment time. The most common problems relate to the maintenance of the fistula with blockages and infections.

Transplantation

Transplantation is the treatment of choice for most patients with end stage renal disease. Successful transplantation has been associated with an improvement in quality of life enabling many patients to return to work or study. In the long run transplantation is cheaper than either CAPD or haemodialysis despite the high costs of immunosuppressive agents. For these reasons most Australian renal units are committed to transplanting all suitable patients.
With the decline in the availability of cadaveric organs, living related and unrelated kidneys constitute half of all the transplants performed in this hospital. Insulin dependent diabetics may be referred to a kidney pancreas transplant program to discuss combined kidney and pancreas transplantation.

The selection criteria for suitability vary between transplanting hospitals and should be discussed in detail with your doctor. There are contraindications and relative contraindications to transplantation and these are listed briefly below.
Contraindications include active infection such as TB, osteomyelitis or hepatitis B. Other illness include strokes, gangrene of feet/toes and cancer.

Relative contraindications: Age >65 which is more frequently associated with heart or vascular disease. Others include peptic ulcer disease, ischaemic heart disease, chronic hepatitis B or C. Psychiatric/psychological problems such as non-compliance and substance abuse including alcoholism and smoking will be taken into consideration.

Transplant list After considering the absolute and relative contraindications, blood will be sampled from suitable patients and sent to a tissue typing laboratory for tissue typing and panel reactive antibodies (PRA). Alternate monthly blood samples are required to update the tissue typing laboratory serum stores and determine the PRA.

Patients available for transplantation are in Category I. Patients accepted onto the waiting list but not available for transplantation due to medical reasons such as severe obesity are placed in Category II. Patients in category II do not accrue waiting time.
When a cadaveric kidney becomes available the donor is blood grouped, tissue typed and then a lymphocyte cross match is performed with the donors lymphocytes and the potential recipients serum. A score is allocated to each recipient incorporating blood group, tissue type, and waiting time on dialysis. We aim to achieve the best-matched kidney for each recipient and organs will be transported interstate if required.

Living kidney donation

With the current shortage of organs available for transplantation live donors who are related or unrelated (spouse, friend) may be suitable. Kidneys from live donors tend to function earlier after transplantation and may last longer. Hence, patients are encouraged to discuss transplantation with their families and family members who express the wish to donate can be screened.