When Should Dialysis Be Started?

What is Dialysis?

Dialysis is a treatment doctors may use when a patient's kidneys fail due to sudden or chronic illness.

Dialysis helps to:

  • Remove waste products, salts, and excess fluids that, if allowed to accumulate, seriously endanger the patient's life;
  • Help the body regulate blood pressure;
  • Control circulating levels of certain fundamental chemical substances such as potassium, bicarbonates, and phosphorus;

However, other functions, including hormone release, are only restored by a kidney transplant, which is therefore the ideal replacement therapy.

 

How to Determine if Dialysis is Necessary?

To be effective, renal replacement therapy (such as hemodialysis or peritoneal dialysis) should be initiated as soon as kidney disease reaches the terminal stage, where the glomerular filtrate, measured by creatinine clearance, is less than 15 ml/min.

Dialysis is a life-saving measure, treating advanced kidney failure that, if left untreated, can lead to death.

However, for some patients, it may prove particularly difficult without necessarily having a positive impact on extending their life expectancy or improving their quality of life.

 

When Not to Opt for Dialysis?

Situations in which dialysis should not be initiated

It is imperative to ensure that patients in good health, who have been fully informed of the benefits, risks, and implications of dialysis, exercise their free will in deciding not to undergo this treatment.

The patient has the right to refuse the proposed treatment, and the doctor must respect this choice.

Situations in which dialysis may not be started

Although dialysis is a common treatment for kidney disease, it may not be viable in cases where patients suffer from a non-renal illness in the final stages of their life. For example, in situations such as serious neoplastic, cardiovascular, hepatic, or metabolic diseases, dialysis may not be a viable option. However, in some circumstances, even a few extra weeks of life can be crucial for the patient to attend family events or settle important personal and financial matters.

 

Over the past ten years, there has been a considerable increase in the number of seniors over 65 years of age starting dialysis treatment. Among them, patients over 75 years of age constitute the largest group. Furthermore, these patients may be subject to significant cognitive impairment and require hospitalization once dialysis is started.

It is recommended to discuss with the patient and their family the prospects, advantages, and disadvantages of using dialysis in this specific patient group. It is important to note that this form of treatment may negatively impact quality of life and survival, raising the question of whether to consider alternative options such as conservative management of advanced chronic kidney failure.

It is important to note that age alone, without considering other factors such as the presence of other serious illnesses or the inability to live independently, should not be used as an ethical criterion for deciding to delay the start of dialysis.

 

Special Cases: Patients with Cognitive Impairment

Dialysis treatment requires the patient's cooperation, or at least their non-opposition to the treatment. There are situations where this may not occur, making dialysis treatment problematic. The patient's mental state is therefore a condition that influences the decision to start dialysis treatment or not. Non-admission to treatment of patients with serious brain lesions or a severe form of dementia poses several problems.

 

In these patients, non-initiation of dialysis treatment should be an option motivated by respect for the patient's dignity, to avoid unnecessary suffering, and not simply a refusal due to the state of cognitive impairment.

To ensure a judicious decision, the selection of dialysis treatment should be a structured process involving the patient, their nephrologist, and all nephrology staff. This important decision must be considered by the patient after appropriate education and information, taking into account relevant clinical, social, and logistical factors. Thus, the choice of treatment will be informed and rational.

 

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How Does One Feel During Dialysis?

Dialysis is not painful in itself. However, it is possible to feel particularly tired during or immediately after dialysis treatment.

To ensure a smooth and engaging reading experience, it is important to note that some side effects may occur during dialysis, such as low blood pressure, nausea, vomiting, muscle cramps, or dry, dehydrated skin. If you experience pain during the procedure, this may be a sign that something is wrong and you should immediately inform your medical team.

 

How Should the Patient Behave Between Dialysis Sessions?

The effectiveness of dialysis treatment is strongly influenced by the patient's behavior during the period between different sessions. It is therefore important to:

  • Follow dietary guidelines, avoiding foods high in salt, potassium, and phosphorus;
  • Control the amount of fluids taken each day;
  • Follow the prescribed pharmacological treatment, keeping blood pressure and blood sugar under control;
  • Maintain emotional control: maintaining a daily routine can seem impossible, especially at the beginning of treatment;

Talking to your doctor and accepting help from your family and friends can be the first step in adapting to a new life.

 

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