A brief look into some of the challenges that patients and their health professionals face when managing kidney dialysis (by Sheena Gow)
Removal of uraemic waste products such as urea is the main goal achieved by performing kidney dialysis. There is a general acceptance among nephrologists to utilise the formula “Kt/V” (the measure of urea removal) to illustrate effective toxin clearance. However, there are several other parameters to consider in determining if dialysis is occurring at an optimal rate for a given patient. Dialysis adequacy is defined as the ability for a treatment regime to meet the needs and demands of the body at eliminating toxins in a steady state (Watnick, 2011). It is dependent on an individual’s weight, diet, lifestyle, other co-morbidities such as heart disease and diabetes, as well as compliance to the treatment as instructed by their health physician. Another biological challenge of dialysis is the optimal removal of fluid, via a process called ultrafiltration. Overloading of fluid in the body can cause serious cardiac and neuromuscular complications.
While Kt/V gives an insight into the effectiveness of dialysis, toxin clearance involves more than just clearing urea. It is also important to look at other biomarkers and treatment aspects like electrolyte balances, fluid status, anaemia and treatment of other co-morbidities (Heimburger, 2009). Dialysis adequacy is more than just numbers – it is a multidimensional concept and a balancing act. Therefore, apart from the ‘gold standard’ of clearance parameters, dialysis adequacy should also depend is how the person is feeling, both physically and mentally!
Be it peritoneal or haemodialysis, it will only work when the individual is willing to undergo the process of treatment and stay compliant to their regime, sometimes for the rest of their life which could be decades long. A literature review conducted by Victoria (2017) illustrated the negative and positive stimuli that can influence a person’s ability to adapt and cope with a chronic condition. Perception of the illness, how one sees themselves in terms of body image, ability to maintain independence as well as experiences with the medical providers and services will play a crucial role in a person’s compliance and resilience to manage their health. Clinical outcomes are also very much influenced by the environment that the person having dialysis is in – having social and family support, the ability to stay financially independently and the degree of continuing with their lifestyle as before (Pereira et al., 2016). All these factors, and many more, are to be considered as part of the holistic care plan of a patient undergoing dialysis.
Another major challenge in dialysis treatment is the financial aspect of care, concerning both the patient and the provider. The increase in diabetes incidences and the aging population has led to an increase in the number of people requiring dialysis. In Singapore, cost of dialysis can be fully funded by the patient or subsidised through governmental and private organisations. It is estimated that it costs anything between $2500-$4000 per month, with the cheaper option being peritoneal dialysis. While dialysis plays an essential role in sustaining life, there are other costs involved with taking multiple medications and having regular doctor consultations when a person has to live with a chronic condition like End stage Renal disease (ESRD). Disruptions in daily living to have dialysis sessions at a dialysis centre can result in a financial setback to earning a stable income. Whether the costs are borne by the user or the healthcare systems, accessibility, in terms of geography and limitations of health services is a challenge. It is challenging for the governments around the world to provide adequate access to people in need of dialysis, especially with the ever-increasing number of ESRD patients worldwide. To address this challenge, for example in Singapore, the National Kidney Foundation (NKF) has started offering overnight haemodialysis services to improve service accessibility and to make dialysis less disruptive to patient’s lifestyle (Straits Times, July 23, 2017).
In summary, an effective dialysis treatment is not just adherence to a fixed regime and meeting standard clearance targets. Effective communication between the patient and the health provider can help to facilitate a regime that would work for the individual, that is not just defined by a set of numbers but also by the individual’s perception of well-being and quality living.
DaVita Inc. n.d. The challenges of being on a dialysis diet. Retrieved from https://www.davita.com/kidney-disease/diet-and-nutrition/lifestyle/the-challenges-of-being-on-a-dialysis-diet/e/5345
Heimburger, O. (2009). How should we measure peritoneal dialysis adequacy in the clinic. Contributions to Nephrology 163, pp140-146. doi 10.1159/000223792
Pereira, E., Chemin, J., Menegatti, C. L., Riella, M. C. (2016). Choice of dialysis modality- Clinical and psychological variables related to treatment. Brazilian Journal of Nephrology, 38 (2). doi: 10.5935/0101-2800.20160031
The Straits Times. (July 23, 2017). Staying overnight for dialysis and better for it. Retrieved from https://www.straitstimes.com/singapore/health/staying-overnight-for-dialysis-and-better-for-it
Victoria, B. J. (2017). The grapple with dialysis: A qualitative literature study on the experiences with adult dialysis patients. University of Applied Sciences, Vaasa, Finland. Retrieved from https://www.theseus.fi/bitstream/handle/10024/139914/DelaVictoria_BettyJane.pdf?sequence=1
Watnick, S., (2011). Peritoneal dialysis adequacy. Retrieved from https://ispd.org/NAC/wp-content/uploads/2010/11/Peritoneal-Dialysis-Adequacy-Watnick-April-2011-Notes.pdf
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