Kidney Failure: Prevention, Dialysis, or Transplantation
Kidney Failure: Prevention, Dialysis, or Transplantation
KIDNEY FAILURE: PREVENTION,
DIALYSIS, OR TRANSPLANTATION
by Ed Bryant
Photo: portrait. Caption: Ed Bryant
I have a special interest in renal failure, as I
have had a kidney transplant for over 16 years, and I feel great. I know folks who've had
transplants far longer than I have, and they're doing fine, too. I hope the following
answers some questions.
Prevention Comes First
"I'm sorry, but your kidneys are beginning
to fail..." If you hear those words, what do you do next? Knowing that nephropathy,
kidney failure, is a frequent complication of diabetes, do you sit and wait to get worse,
or do you act? What can YOU do to prevent, minimize, or slow kidney failure?
The Diabetes Control and Complications Trial
(DCCT), a large, long–term, federally–funded study of the relationship between
diabetes control and the onset of complications, in type 1 diabetics, found that there was
a tight statistical link between quality of diabetes control and ramifications such as
heart and blood vessel disease, diabetic eye disease, and diabetogenic kidney failure. The
British UKPDS (United Kingdom Prospective Diabetes Study), a similar long-term look at
type 2 diabetes, found the same pattern of results. We now know the tighter your control,
the less chance you will experience complications. (Note the linkage is not absolute; you
can do your best and still face these ramifications, though the statistical risk-reduction
is clear.)
The DCCT's findings are not mysterious. High
blood sugar causes diabetes complications; and the better job you do of keeping your blood
glucose numbers down where they should be, the less your chance of developing conditions
such as nephropathy. The importance of this cannot be overstated: Good
self–management is the BEST way to cut the risk of experiencing diabetes
complications.
There are other things you can do to cut the
risk. Some of them come under the heading of "healthy lifestyle." First, don't
smoke. Nicotine, the narcotic active ingredient in tobacco, is a vasoconstrictor, raising
blood pressure, stiffening capillaries, and making it harder for the kidneys to filter
wastes.
Urinary tract infections need prompt treatment,
to limit the damage they can do to already strained kidneys. Tell your doctor promptly, if
you think you have such an infection.
Excessive obesity both raises blood pressure and
increases insulin resistance. Keeping your weight at or below your recommended level helps
in general, and the resultant blood pressure drop is good for your kidneys.
You need to control your cholesterol, as too much
of this fatty substance in your blood overworks (and can even clog up) your kidneys. Diet,
exercise, and appropriate medications can lower your cholesterol levels.
Heart specialists have known for years that high
levels of stress can be damaging. Excessive stress, driving up blood pressure, can harm
the kidneys by raising fluid pressure, further straining already weakened filter networks.
Stress reduction is part of a healthy lifestyle.
There is a lot of disagreement among doctors over
the specifics of what will prevent kidney failure. So much is genetics; more may be
environment, or other factors we are not yet aware of. Other than "keep your diabetes
under the best possible control, and live a healthy lifestyle," we can offer little
advice about prevention. The manual, "The Prevention and Treatment of Complications
of Diabetes Mellitus," published 1991 by the Centers for Disease Control (and now
available on the World Wide Web, at: http://www.cdc.gov/diabetes/pubs/pubs.htm), states:
"At present, strategies for preventing diabetic nephropathy must be viewed as limited
in their effectiveness, since the exact pathogenic factors responsible for this condition
are unknown."
Once kidney disease is diagnosed, however, a
great deal can be done to retard its progression, and sometimes interventions such as
described above are sufficient to keep the need for dialysis or transplantation well at
bay. Current statistics suggest up to four out of every ten diabetics may experience
measurable kidney disease, though with considerations such as described in this article,
many of these individuals should be able to avoid outright kidney failure, End Stage Renal
Disease (ESRD).
If you do your best and still experience kidney
failure, it is not time to despair. Whether you choose transplantation, or one of the
forms of dialysis, the outlook is good and getting better all the time.
Testing Your Kidney
How is the severity of kidney disease measured?
Several tests measure creatinine, a waste product from muscle mass. Although everyone
produces creatinine, people whose kidneys are failing cannot properly excrete it. One test
measures the amount of creatinine in the blood, and the other is "creatinine
clearance," a 24–hour urine test. Normal "blood creatinine," for
someone with healthy kidneys, is about 0.7 to 1.3. Government guidelines (April 1995)
recommend dialysis when the blood creatinine rises to 6 or above (the number rises as you
get worse). However, some diabetics will experience kidney failure before that point.
There is much variation between individuals who have ESRD, and the actual range for
"kidney failure" runs from 3 through 8--but at or above 6, Medicare will pay for
dialysis.
"Creatinine clearance" is considered a
more reliable test. In this 24-hour urine test, the numbers produced approximately
indicate the percent of normal kidney function remaining to the individual (the number
goes down as you get worse). The 1995 government guidelines (which relate to Medicare part
B eligibility) state they will fund dialysis when the test produces a reading of 15 or
less.
Two other tests measure protein spillage into the
urine. These are the microalbumin test and the test for proteinurea. The protein albumin
is not normally excreted into the urine, and its presence in the urine, in small amounts
(microalbuminuria) or larger concentrations (proteinurea) can indicate kidney disease.
While not considered absolute diagnostic evidence, a positive finding in either should be
immediately followed by further testing, as these tests are very sensitive, and the
microalbumin test can detect kidney disease long before the other tests–-allowing
earlier medical intervention.
Options
Individuals experiencing impaired kidney
function, but whose test results indicate that they do not yet need dialysis or
transplantation, might benefit from two new therapies. The first is regular use of ACE
(Angiotensin-Converting-Enzyme) Inhibitors, commonly used to control hypertension, high
blood pressure. Now widely accepted, these ACE Inhibitors have been shown to significantly
reduce further kidney degeneration. In FDA Clinicals, the ACE Inhibitor Captopril (trade
name Capoten) was given to patients showing early signs of kidney damage. It reduced fluid
pressure in the kidneys, and cut in half the rate of kidney failure in its test
population. Doctors have since prescribed other ACE Inhibitors, with similar results.
Note: A diabetic experiencing kidney failure, but whose blood pressure is not elevated,
can still use ACE Inhibitors for keeping fluid pressure down in the kidneys. This therapy
has been shown to significantly reduce strain on eyes and cardiovascular system as well.
Talk to your nephrologist about the ACE Inhibitors.
A new class of similar drugs is the Angiotensin
II Receptor Antagonists (or ARBs). Teveten, the first member of this class to gain FDA
approval, "may be of benefit in preserving renal function in patients with
progressive renal disease," researchers state.
Aminoguanidine (Pimagedine) is another
possibility. Tests are still underway, but this drug appears to reduce the damage done to
the kidneys by excess glucose in the blood (and may reduce retinopathy as well). Other
options are certain to materialize, both for those with impaired kidney function and for
those whose kidneys have failed.
End Stage Renal Disease
The damaged kidney may worsen to the point (as
described in "Testing Your Kidney," above) where it can no longer carry out its
blood-purifying function. Now dialysis or transplantation are necessary in order to
preserve life. This is ESRD, end stage renal disease. What are your options then?
There are three. In hemodialysis, the patient's
circulatory system is temporarily linked with a machine that performs the
blood–cleansing functions of the human kidney. In peritoneal dialysis (CAPD or CCPD)
a tube is inserted into the patient's peritoneal cavity, allowing urine and unneeded
fluids to periodically drain from the body. The third option is kidney transplantation, in
which a donated kidney is surgically implanted into the patient's body.
According to U.S. Renal Data System (USRDS)
figures, more than 304,083 Americans have ESRD, and 221,596 of these kidney patients are
undergoing dialysis at this time. In 1995, the last year for which Centers for Disease
Control (CDC) figures are available, there were 27,851 new cases of ESRD among persons
with diabetes, and 98,872 diabetics were undergoing dialysis or transplantation treatment
that year. National Institutes of Health statistics show that 35.9% of all individuals
facing dialysis are there because of diabetes, and about 40% of those commencing dialysis
or seeking a transplant at this time are diabetic. Some remain on dialysis long–term;
others make use of the process while awaiting a kidney transplant. As an aside, before
1970, few diabetic ESRD patients were dialyzed; they simply sickened and died. Those who
did dialyze faced a high mortality rate. Medicine has come a long way since then, and the
odds have improved with the options. Dialysis techniques have improved substantially since
my personal experience with them.
Dialysis
Dialysis is not an "artificial kidney."
A person undergoing hemodialysis must be hooked up to a machine three times a week, three
to four hours per session. A normal vein cannot tolerate the 16–gauge needles that
must be inserted into the arm during hemodialysis, so the doctor must surgically connect a
vein in the wrist with an artery, forming a bulging fistula that will better accommodate
the large needles needed for treatment.
Like the kidney, a hemodialysis machine is a
filter. Where it uses tubes and chemicals, the kidney uses millions of microscopic blood
vessels, fine enough to pass urine while retaining suspended proteins. Long–term high
blood glucose can significantly damage the kidney's filters, leading to scarring,
blockage, and diminished renal function. Diabetes is the leading cause of kidney disease.
Long–term diabetics often have cardiovascular and blood pressure problems, and the
added strain of hemodialysis, with its rise in blood pressure straining eyes and heart
function, can be too much for some. The diabetic dialysis patient spends, on the average,
33% more time in the hospital than does the non–diabetic dialysis patient, according
to 1999 USRDS figures.
Some patients choose CAPD (continuous ambulatory
peritoneal dialysis) or its variant, CCPD (continuous cycling peritoneal dialysis), both
of which can be carried out at home, without an assistant. Unlike hemodialysis, which uses
a big machine to remove toxic impurities from the blood, peritoneal dialysis works inside
the body, making use of the peritoneal membrane to retain a reservoir of dialysis
solution, which is exchanged for fresh solution, via catheter, every four to eight hours.
CAPD is carried out by the patient, who simply exchanges spent for fresh solution, every
four to eight hours, at home, at work, or while travelling. CCPD, its variant, makes use
of an automated cycler, which performs the exchanges while the patient is asleep. Although
more complicated and machine–dependent, it does allow daytime freedom from exchanges,
and may be the appropriate choice for some. Though the risk of infections is heightened
(as it is with any permanent catheterization), these two processes have advantages, one
being that insulin can be added to the dialysis solution, freeing the patient from the
need to inject, and giving good blood sugar control.
Transplantation
Kidney transplantation is a logical alternative
for many. It substantially improves a patient's quality of life. Although the transplant
recipient must be on anti–rejection/ immunosuppressive therapy for life, with the
inherent risk from otherwise nuisance infections, a transplant frees the patient from the
many hours spent on hemodialysis procedures each week, or from the periodic
"exchanges" and open catheter of CAPD, allowing a nearly normal lifestyle. For
those ESRD patients who can handle the stresses of transplant surgery, the resulting gains
in physical well–being add up to real improvement in quality of life and overall
longevity.
"Fifty percent of all kidney
transplantations taking place today are into diabetics," states Giacomo Basadonna,
MD, PhD, a transplant surgeon at Yale University School of Medicine, in New Haven,
Connecticut. He reports that success rates are identical with kidney transplants performed
on non–diabetic ESRD patients. "Today," he advises, "average kidney
survival, from a living donor, is greater than 15 years."
One of the areas where we are seeing rapid
improvement is immunosuppressive medication. The traditional mix of immunosuppressants:
cyclosporine, prednisone, imuran, is giving way to more targeted medications that may have
fewer side effects. Cellcept, by Roche/Syntex, and Rapamycin (Rapamune), by Wyeth/Ayerst,
have been approved by the FDA, and others are being tested. The risk of organ rejection is
always present, but each new development increases the chances of success.
I and others knowledgeable in kidney
transplantation advise you to pick the best transplant center possible. Once you have read
their statistics, ask your prospective center the following questions. If they don't
answer to your satisfaction, you should consider going to another center.
1. Do you have an information packet for
prospective donors and recipients?
2. Can you put me in touch with someone who has
had a transplant at your center?
3. What is your "graft survival"
(success) rate?
4. Who will my transplant surgeon be? If a fellow
or resident, will he/she be supervised by a practicing transplant surgeon?
5. How long have your current surgeons been doing
kidney transplants? How many have they done? That your center has 35 years experience with
kidney transplants is of little consequence if my surgeon has only done ten in his or her
career.
6. What is the average post–operative stay
in your hospital?
7. When I come for my transplant, or come back
for follow–ups, will there be any affordable housing for me and/or my family? (Ronald
McDonald House, or other lodging with discount rates...) or will I get stuck in a luxury
hotel for $125 a night?
8. How often will I need to come back to the
center for follow–ups? Can my nephrologist do the blood tests and send you the
results?
9. Can you recommend a nephrologist in my area?
10. Do you have a toll–free number to call
for after–transplant information?
11. What is your policy on people with
insufficient health insurance? Will you work with an uninsured patient? What will it cost?
12. Are you prepared to satisfy my doubts? Will
you show me the documents that answer my questions? Will you guarantee the price quoted?
Transplant Patients Speak:
The following individuals are the real experts.
Collectively, they have more than 146 years experience living with a transplant! All of
them would choose a transplant again. Although kidney transplantation is not for everyone,
and sometimes it doesn't work, it should be given strong consideration.
Eivind Frost, from Montana, received a cadaver
kidney on April 24, 1973, at University of Minnesota Hospital in Minneapolis (now
Fairview–University Medical Center), and is doing fine. He tells us, "I've been
feeling great for 26 years now."
Ken Carstens, from Minnesota, who received his
kidney transplant at University of Minnesota Hospital in Minneapolis, on September 10,
1975, states, "It's been 24 years now, and I'd make the same choice again."
Karen Mayry, from South Dakota, received her
kidney transplant at University of Minnesota Hospital in Minneapolis, on January 12, 1977.
She declares, "I feel great!"
Betty Walker, from Missouri, received her
transplant on July 13, 1978, at Yale–New Haven Hospital in Connecticut. In her words:
"I was just existing on dialysis; and my transplant gave life back to me."
Lenny Ruygt, from California, received her kidney
at Presbyterian Hospital (now Pacific Medical Center), in San Francisco, on St. Patrick's
Day, March 17, 1980. She says: "On dialysis, I had no energy at all--I would sleep
all but two hours of a day. After my transplant, I felt energized!"
Linda Bingham, from Ohio, who received a dual
transplant (kidney and pancreas) at University Hospital in Cincinnati, Ohio, on December
10, 1981, says, "I feel great. I have been given a whole new life."
Ed Bryant, from Missouri, received his transplant
on August 9, 1983, at University of Minnesota Hospital in Minneapolis. He says:
"There is no comparison between life on dialysis, and how I've felt since my
transplant."
Facts and Statistics
What is the success rate for
kidney–transplant surgery? According to the "United States Renal Data System
1993 Annual Data Report," published by the National Institutes of Health, about 75%
for a cadaver–donated kidney, better than 90% with a kidney donated by a living
relative, with an overall success rate of better than 85%, better than 90% in some
centers. UNOS data indicate the averages (based on graft survival, healthy kidney, five
years after transplant) are improving. The National Institutes of Health reports that
current "graft survival" (donated kidneys successfully functioning in the
transplant recipient) rates are approximately the same, whether the recipient has diabetes
or not.
What percentage of type I diabetics will face
ESRD? Current statistics suggest between 20 and 25%, with many factors (genetic, ethnic,
lifestyle) taken into account.
Must the ESRD patient be on dialysis before being
considered for a transplant? NO! Although some behind–the–times nephrologists
still believe so, Fairview–University Medical Center's Transplant Center, which
pioneered diabetic kidney transplantation, recommends that once your physician has
determined kidney failure is on the way, further delay could be harmful. The more time
spent subjecting your body to the toxic excesses of kidney failure and the strains of
dialysis, the greater the risk of serious complications like retinopathy and
cardiovascular (heart) degeneration.
Your nephrologist should be able to tell you more
about your options. For information about kidney transplantation, contact a reputable
transplant center (there are more than 252 in the U.S. today), or the United Network for
Organ Sharing, 1100 Boulders Park, Suite 500, Richmond, VA 23225; telephone:
1-800-243-6667; website: http://www.unos.org All UNOS information is available on the
World Wide Web, but they will also send you pertinent information, by mail, on any three
transplant centers you request, without charge.
For information or assistance with interpreting
transplant center data, contact: Health Resources and Services Administration, Bureau of
Health Resources Development, Division of Transplantation, Park Lawn Bldg., 5600 Fishers
Lane, Room 7C-22, Rockville, MD 20857; telephone: (301) 443–7577; website:
Renal failure is not a kiss of death. There are
options, and at least one of them will be right for you. Keep your diabetes under good
control, and your blood pressure down, to cut the risks--but if it happens (like it did to
me), remember that with proper care you stand every chance of living just as long as you
would have with healthy kidneys.
More Resources:
American Association of Kidney Patients, 100
South Ashley Drive, Suite 280, Tampa, FL 33602; telephone: 1–800–749–2257;
website: http://www.aakp.org/aakpteam.html. Publishes the quarterly magazine
"Renalife," with articles about dialysis and transplantation.
American Kidney Fund, 6110 Executive Boulevard,
Suite 1010, Rockville, MD 20852; telephone: 1-800-638-8299. Offers financial aid ($200
limit), provides written and phone information on kidney diseases. website:
Diabetes Action Network, National Federation of
the Blind, Renal Failure—Dialysis and Transplantation Support Committee, 811 Cherry
Street, Suite 309, Columbia, MO 65201; telephone: (573) 875-8911. website:
http://www.nfb.org/voice.htm. Offers information, encouragement, and support on a
person–to–person basis for diabetics.
Fairview University Medical Center, Patient
Education Department, 420 Delaware St. SE, Box 603, Minneapolis, MN 55455; telephone:
(612) 273-3354. Offers "The Transplant Handbook," prepared for patients facing
kidney transplantation. Available in standard print or audiocassette, cost: $12 (print) or
$30 (6 tapes).
National Diabetes Information Clearinghouse, 1
Information Way, Bethesda, MD 20892; telephone: (301) 654-3327; website:
http://www.niddk.nih.gov/health/ diabetes/diabetes.htm Provides free and low–cost
publications on aspects of diabetes.
National Foundation for Transplants, 1102
Brookfield, Suite 202, Memphis, TN 38119; telephone: 1–800–489–3863;
website: http://www.transplants.org. Advice and instruction on fund–raising to cover
transplant costs on any organ.
National Kidney Foundation, Inc., 30 E. 33rd
Street, New York, NY 10016; telephone: 1-800-622-9010; website; http://www.kidney.org.
Provides services such as: doctor referrals, patient peer counseling, education,
medication programs, transportation, and financial services.
National Kidney and Urologic Diseases Information
Clearinghouse, 3 Information Way, Bethesda, MD 20892; telephone: (301) 654-4415. Provides
free information booklets such as #KU–50: "End Stage Renal Disease, Choosing a
Treatment That's Right for You," and #KU-134: "Eat Right to Feel Right on
Hemodialysis." Two new publications will be "dictionaries," of urologic
diseases, and of kidney diseases. Contact NKUDIC for availability information. All
publications are downloadable from their website:
http://www.niddk.nih.gov/health/kidney/nkudic.htm
National Transplant Assistance Fund, PO Box 258,
Bryn Mawr, PA 19010; telephone: 1-800-642-8399; website: http://www.transplantfund.org
Helps patients set up fundraising programs to cover transplantation costs on any organ;
also offers small emergency grants.
The Patient Travel Service, Fresenius Medical
Care, Two Ledgemont Place, 95 Hayden Ave., Lexington, MA 02420; telephone: 1-800-634-6254.
Provides referrals and information for dialysis patients wishing to travel anywhere in the
world, who need dialysis facilities. Also offers free brochure, "On the
Road...Again," a how-to guide for arranging dialysis away from home.
PhRMA, Pharmaceutical Research and Manufacturers
of America, Publications Department, 1100 15th Street NW, 9th Floor,
Washington, DC 20005; telephone: (202) 835-3400; website: http://www.phrma.org. An
industry association, PhRMA publishes a catalog of member companies offering free or
low–cost drugs/medications for the indigent, available for download from their
website.
Stadtlanders Pharmacy, 600 Penn Center Boulevard,
Pittsburgh, PA 15235; telephone: 1-800-238-7828; website: http://www.stadtlanders.com
Medication, delivery, and insurance billing; organ transplant recipients receive free
express delivery of medication, anywhere in the U.S.A.
United States Renal Data Survey, USRDS
Coordinating Center, 914 S. 8th Street, Suite D206, Minneapolis, MN 55404; telephone:
(612) 347-7776; website: http://www.usrds.org
Noven Pharmaceuticals, of Miami, Florida, is one
of the companies exploring this technique, the medicated insulin patch. Its president,
Steven Sablotsky, commented, "Research continues... If this proves to be a new way of
delivering insulin, commercialization would still be several years away."
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