According to the National Kidney Foundation (NKF), 5.5 new patients get diagnosed with kidney failure daily in Singapore. The country is ranked fourth in the world for prevalence of kidney failures, and first for diabetes-induced kidney failures, both of which are worrying ‘records’. The incidents are significantly more common among older adults. Among newly diagnosed kidney failure cases, 80% of cases are aged 50 and above, according to a study published by NUH.
Kidney failure sounds like a serious condition and it definitely is. But it does not necessarily mean fatality. A lot of kidney failure patients live long fulfilling lives with proper treatment and care. In this article, we will discuss treatment and care for kidney failure, with a focus on palliative care for kidney failure – an important part in the therapeutic approach to help kidney failure patients maintain their quality of life.
1. What is Kidney Failure?
Kidney Failure refers to the most advanced stage in the 5 stages of Chronic Kidney Disease (CKD) which in turn can be caused by various diseases such as diabetes, high blood pressure, glomerulonephritis (inflammation of kidney tissues), polycystic kidney disease. In a kidney failure case, the kidneys only function at 15% of their capacity or less. Kidney is medically referred to as ‘renal’. Kidney failure is therefore also called end-stage renal disease (ESRD).
The two main treatments for ESRD include dialysis (more details below) and kidney transplantation. Kidney transplantation is a surgical procedure that involves the graft of a new kidney from a healthy individual who can be a family member (genetically related kidney transplantation) or non-related person (genetically non-related kidney transplantation). Other care plans for kidney failure are mainly palliative, to relieve symptoms and prevent complications.
To learn more about causes of kidney failure and how to prevent them, read our in-depth article about kidney failure and other diseases here.
2. Dialysis Treatment for Kidney Failure
Dialysis is one of the main treatments for kidney failure. It is the process of using an ‘alternative kidney’ to perform the part of kidney functions that the failing kidneys are unable to do, including removing waste and toxins from blood, regulating electrolytes and blood pressure, and maintaining homeostasis. There are two main types of dialysis – hemodialysis and peritoneal dialysis.
In hemodialysis, the ‘alternative kidney’ is an external artificial kidney machine. Patients usually have to go to a dialysis centre at a clinic or hospital to use the machine 3 to 4 times a week. Each session lasts about 4 hours. Blood from the body is passed through the machine, filtered and then transferred back to the body.
Kidney failure patients under hemodialysis have to follow a strict diet regime. Fluid intake is usually restricted to 1 to 1.5 litres per day, instead of the usual recommended 2 litres per day. Minerals intake such as salt, potassium and calcium also need to be watched carefully. These restrictions help to avoid the build-up of fluid and minerals in the body between dialysis sessions, which can have severe consequences such as heart and lung damages or bone disorders.
Hemodialysis is the main form of dialysis that kidney failure patients receive. Apart from regular trips to dialysis centres and dietary requirements, patients on hemodialysis can live their life ‘freely’ the rest of the time.
2.2. Peritoneal dialysis
In peritoneal dialysis, the filter of the ‘alternative kidney’ is another part of the body called the peritoneum, which is the membrane lining the walls of the abdomen. A catheter is permanently inserted in the abdomen region, allowing for the injection of an external fluid called dialysate, or dialysis fluid, into the peritoneal cavity. The peritoneum and dialysate fluid filter and draw out waste, toxins and excess fluid from the blood.
Different from hemodialysis, the filtering process happens inside the body and blood is not transferred out of the body. After a few hours when dialysis fluid is filled up with waste products, it is transferred to a drainage bag located outside the body. The process then needs to be repeated again, with new dialysate (dialysis fluid) being injected.
A patient on peritoneal dialysis typically needs to repeat the above process 4 times a day. At night, peritoneal dialysis can be automated with the help of a machine, allowing patients to sleep through the night. Compared to hemodialysis, patients on peritoneal dialysis usually have less diet restrictions, due to more frequent blood filtering. They also do not need to visit a clinic or hospital for the procedure. It can be safely carried out at home, and less costly.
However, the number of times peritoneal dialysis procedure needs to be performed a day means that patients cannot be away from the dialysis equipment for long. Some patients may also be sensitive to a catheter or find it inconvenient, making peritoneal dialysis unsuitable for them.
3. Palliative Care for Kidney Failure
3.1. Why is Palliative Care Necessary for Kidney Failure Patients
When kidney failure or ESRD occurs, most of the kidney’s function is lost. Dialysis helps replace kidney functions to a large extent. However, symptoms and complications can manifest between treatment sessions or over time if the condition is progressive. In some cases, patients may not opt for dialysis, for various personal or medical reasons, and may experience a wide range of physical symptoms and impaired quality of life.
A comparison study revealed that symptom burden of kidney failure in fact is similar to those with advanced cancer. About half of kidney failure patients or more experience fatigue, itchiness, breathlessness, constipation, loss of appetite and pain, according to statistics. Other medical complications from kidney failure include blood hypertension, hyperkalemia (accumulation of potassium in the blood), edema (fluid retention), hypocalcemia (reduced blood calcium levels), metabolic acidosis (acidic blood PH), anemia (underproduction of red blood cells), and decreased libido.
Well-being and psychological symptoms ranging from poor quality of sleep to anxiety and depression are also widely reported. Faced with the prospect of a lifetime dependency on dialysis, financial burden and changing role in family and at work, many patients as well as patients’ families find it hard to cope without social, psychological and spiritual support. In short, the need for symptom control among kidney failure patients is large and diverse, and often cannot be addressed adequately by curative treatment. Palliative treatment is designed to fill in the gap.
Palliative care is the specialised care with the aim of improving the quality of life for both patients and their family. A palliative care team for kidney failure often consists of a palliative doctor or palliative specialist, kidney doctor, nurse, counsellor, even social workers or volunteers. They work together to help kidney failure patients and their families navigate the unfamiliar journey of treating and caring for kidney failure, help them make critical decisions in line with their care goals, manage physical and psychological pain and other symptoms, and in general improve their quality of life.
To learn more about palliative care in Singapore, read our article on how and where to get palliative care in Singapore here .
3.2. Aspects of Palliative Care in Kidney Failure Cases
3.2.1 Manage pain and other symptoms
Since palliative care focuses on reducing the patient’s suffering, management of pain is a cornerstone of this practice. Over 70% of kidney failure patients are reported to experience pain, often related to bone deterioration as a result of an imbalance in the levels of calcium and other minerals. With a palliative care plan, pain will be addressed with appropriate medication and therapy.
Aside from pain, the palliative care team will address other related conditions, including heart disease, high blood pressure, irregular blood sugar, low urine output, urinary tract infections, and more.
3.2.2 Help you make critical decisions while communicating with your doctors
Your palliative care team will be part of critical decisions related to treatment options. For instance, when your kidney doctor recommends hemodialysis, or peritoneal dialysis, or a kidney transplant, the palliative care team will help you understand the goals, benefits, and side effects of each treatment, which will make the decision much easier for you.
As another example, a kidney patient may not be fit for dialysis due to comorbidity. Health conditions are likely to worsen without the supporting ‘artificial kidney’. In this scenario, the palliative care team will be able to help the patient manage the disease and its complications without the curative dialysis treatment.
Regardless of the patient’s decision, once it is made, the palliative care team will be there to support the patient before, during, and after the procedure. For instance, if you decide to get a kidney transplant, you will likely require extensive care after the procedure. Going through this by yourself can be daunting for you and your family, which is where palliative care experts come in handy.
3.2.3 Explain the disease process and manage expectations
When you meet with your palliative team, they will explain to you the disease process, how it develops over time, and the steps you can take to improve your prognosis (i.e., treatment outcome). They will also help you and your family understand the expectations behind the treatments you are taking and the timeline of symptom improvement.
This is vital since setting the bar too high is often the reason patients get depressed and anxious. Your team will explain their role in this process and how they can help, all without overestimating the expected results.
3.2.4. Help you cope with mental disorders (e.g., depression, anxiety, stress)
While most people only associate physical symptoms when they think about kidney failure, the mental burden of these conditions is just as heavy. According to one study, patients with chronic, incurable illnesses are significantly more likely to develop psychiatric disorders, such as major depression and generalized anxiety.
Fortunately, this is one aspect of care your palliative team will take into account when providing care. You will receive emotional support and spiritual guidance to help you get through these difficult times, from the palliative core team as well as the extended team, consisting of counsellors, therapists, social workers, etc. Some of the therapies that may help with this process include massages, relaxation techniques, and talk therapy.
3.2.5. Help you do advance care planning (ACP)
Advance care planning (or ACP) is the process of planning for care requirements down the road when the person is still healthy and mentally sound. Kidney failure, though treatable, may have serious and sudden complications. Having an advanced care plan handy, the care team and family will be able to react quickly according to the patient’s care wishes and preferences communicated earlier during the ACP process.
The role of the palliative care team is to help kidney failure patients and their families navigate possible care scenarios and make decisions in advance, including end-of-life care options. The ultimate purpose is not to plan for the worst, but to ensure the patient receives the best treatment and care according to their needs, wants and goals. To find out more ACP, its benefits and steps to get started, read our earlier article here.
Kidney failure, or end stage renal kidney disease, is the last stage of chronic kidney disease, signifying a major loss of kidney function. Treatment options include dialysis and kidney transplant. Though treatable, kidney failure patients often experience physical symptoms such as pain, fatigue, breathlessness as well as psychological symptoms, leading to a compromised quality of life. Thankfully, palliative care offers the benefits of relieving pain and easing up other challenges for the patients and improving their quality of life, as well as that of their families.
We hope that this article explains the role of curative treatment and particularly, palliative treatment for kidney failure patients. To learn more about other conditions where palliative care is indispensable, check out our palliative care series here . If you want to find out about palliative care for the specific circumstance of yourself or your loved one, check out our Ninkatec palliative care plans here, or call/chat with our care team for a personal consultation. With Ninkatec’s 24/7 monitoring technology and palliative care service provided in the comfort of your home, kidney failure patients and families can be assured that Ninkatec is always there for you.