Kidney Failure

Kidney Failure

KIDNEY FAILURE,
DIALYSIS, AND TRANSPLANTATION

by Ed
Bryant

I have a special interest in renal failure,
as I have had a kidney transplant for more than 13 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.
Many long-term diabetics face the prospect
of kidney failure, End Stage Renal Disease (ESRD). For them, there are three
options for treatment. 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, there are more than 189,954 kidney patients undergoing dialysis
in the United States today. In 1992, the last year for which Centers for Disease
Control (CDC) figures are available, there were 19,790 new cases among persons
with diabetes, and 56,059 diabetics were undergoing dialysis or transplantation
treatment that year. U.S. Health Care Financing Administration statistics show
that about 30% of all individuals facing dialysis are there because of diabetes
complications, 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 dialysed; they simply sickened and died. Those
who did dialyses 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.
How is kidney failure 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 reaches 6 or above.
However, some diabetics will experience kidney failure before that point. There
is much variation between individuals, and the actual range is 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 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. This test measures how much creatinine comes out in a 24 hour
period.
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. Captopril (trade name
Capoten), a common blood pressure medication, in carefully monitored tests,
significantly reduced further kidney degeneration. The FDA has recommended use
of Captopril for 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. Note: Use of "ACE inhibitors" such as Captopril, for keeping
blood pressure down in the normal range, carries many benefits, such as reduced
rate of kidney failure, and less strain on eyes and cardiovascular system.
Aminoguanidine is the second 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).
Another possible option (currently under
lab investigation) is use of PKC-beta II inhibitors, chemical "blockers"
that resist the complication-causing effects of high blood glucose. It will
be years before we know if this approach has merit. Other options are certain
to materialize, both for those with impaired kidney function and for those whose
kidneys have failed.
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 damage the kidney's filters, leading
to scarring, blockage, and diminished renal function. Diabetes is the leading
cause of kidney disease, and each year over 15,000 diabetics will either need
a kidney transplant, or to start some form of dialysis.
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, 30% more time in
the hospital than does the non-diabetic dialysis patient, according to USRDS
figures.
Some patients choose CAPD (continuous
ambulatory peritoneal dialysis) mr its variant, CCPD (continuous cycling peritoneal
dialysis), both of which can be carried out at home, without an assistant. CAPD
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. CCPD 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.
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. Daniel M. Canafax, PharmD,
FCCP, Professor, College of Pharmacy, University of Minnesota, reports that
Prograft (FK 506, tacrolimus), from Fujisawa, and Cellcept (RS 61443, mycophenolate
mofetil) by Roche/Syntex, have been approved by the FDA, and Deoxyspergualin
(DSG), by Bristol-Myers-Squibb, and Rapamycin (sacrolimus, Rapamune), by Wyeth/Ayerst,
are currently being tested. The risk of 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 no consequence if my surgeon
has only done fifteen 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 $90 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? Do you correspond with this physician?
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?
Here's what some folks have said:
Eivind Frost, from Montana, received
a cadaver kidney on April 24, 1973, at University of Minnesota Hospital in Minneapolis,
and is doing fine. He tells us, "I've been feeling great for 23 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 21 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."
Eric Knoeppel, from Missouri, received
his kidney at Clarkson Memorial Hospital, in Omaha, Nebraska, on July 5, 1981.
He says, "After my transplant, it was nice to be able to go back to work!
Before, I was dependent on government assistance."
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."
These folks know what they're talking
about. Collectively, they have more than 113 years experience living with kidney
transplants! All of them would choose a transplant again. Although kidney transplantation
is not for everyone, it should be given strong consideration.
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.
What percentage of type I diabetics
will face ESRD? Current statistics suggest 20%.
Must the ESRD patient be on dialysis
before being considered for a transplant? NO! Although some behind-the-times
nephrologists still believe so, University of Minnesota 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. And, the success rate for
diabetics needing kidney transplantation is approximately the same as for non-diabetic
transplant recipients. People with diabetes tend to take better care of themselves
than does the general public.
Your nephrologist (kidney specialist)
should be able to tell you more about your options. For information about kidney
transplantation, contact a reputable transplant center (there are more than
239 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. For information
or assistance with interpreting transplant center data, contact: Health Resources
and Services Administration, Bureau of Health Resources Development, Division
of Organ Transplantation, 5600 Fishers Lane, Room 11A22, Rockville, MD 20857;
telephone: (301) 443-7577.
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. I've had
my transplant 13 years, and I'm planning on being here a long time more.
More Resources:
American Association of Kidney Patients,
100 South Ashley Drive, Suite 280, Tampa, FL 33602; telephone: 1- 800-749-2257.
Publishes the quarterly magazine Renalife, with articles about dialysis and
transplantation.
American Kidney Fund, 6110 Executive
Boulevard, Suite 110, Rockville, MD 20852; telephone: 1-800-638-8299. Offers
financial aid ($200 limit), provides written and phone information on kidney
diseases.
National Diabetes Information Clearinghouse,
1 Information Way, Bethesda, MD 20892-3560. Provides free and low-cost publications
on aspects of diabetes.
National Kidney Foundation, Inc., 30
East 33rd Street, New York, NY 10016; telephone: 1-800-622-9010. 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 20892-3580. Provides
free and low cost publications about kidney and bladder diseases. Their booklet
KU-50 is "End Stage Renal Disease, Choosing a Treatment That's Right for
You."
National Organization for State Kidney
Programs; telephone: 1-800-733-7345. Provides information on different state
programs that would help people pay for kidney failure costs.
National Transplant Assistance Fund;
telephone: 1-800- 642-8399; World Wide Web URL: http://www.LibertyNet.org/~txFund/.
Helps patients set up fundraising programs to cover transplantation costs on
any organ; also offers small emergency grants.
Organ Transplant Fund, 1102 Brookfield,
Suite 202, Memphis, TN 38119; telephone: 1-800-489-3863. Advice and instruction
on fund-raising to cover transplant costs on any organ.
PhRMA, Pharmaceutical Research and Manufacturers
of America, Publications Department, 1100 15th Street NW, Washington, DC 20005;
telephone: (202) 835-3400. A catalog of member companies offering free or low-cost
drugs/medications for the indigent.
Renal Failure--Dialysis and Transplantation
Support Committee, Diabetes Action Network, National Federation of the Blind,
811 Cherry Street, Suite 309, Columbia, MO 65201; telephone: (573) 875-8911.
Offers information, encouragement, and support on a person-to-person basis for
diabetics.
Stadtlanders Pharmacy, 600 Penn Center
Boulevard, Pittsburgh, PA 15235-5810; telephone: 1-800-238-7828. Medication,
delivery, and insurance billing; organ transplant recipients receive free express
delivery of medication, anywhere in the U.S.A.