Stage 5 kidney disease also known as End-Stage Renal Failure (ESRF), is the final stage of chronic kidney disease, where kidney function has markedly declined, leading to a build-up of toxins and waste products in the body. In Malaysia, ESRF is a leading cause of death for patients with kidney disease. The Malaysian Dialysis and Transplant Registry 2020 reports that there is a steep increase of ESRF patients from 4,606 ESRF patients in 2008 to 8,431 patients in 2018.
In conjunction with International Kidney Month, Dr Nur Hidayati Mohd Sharif, Consultant Physician & Nephrologist at KPJ Selangor Specialist Hospital explains the dangers of having end stage renal failure and the consequences of delaying dialysis.
“The term ‘failure’ can be misleading. It does not mean the kidneys are not functioning at all, but rather that the kidneys have become less efficient at doing their job. When kidneys cannot do its job well, this is when patients can become unwell due to build up of toxins thus need urgent treatment ”, she adds.
How is end-stage renal failure treated?
The treatment of ESRF involves replacing the function of the kidneys either using hemodialysis or peritoneal dialysis. As commonly known, the Haemodialysis is a process where blood is filtered through a machine that removes waste and extra fluids from the body. Peritoneal dialysis on the other hand, can be done at home by the patient themselves using a special liquid called dialysate.
The best treatment option for an ESRF patient with a failing kidney would actually be a kidney transplant. By replacing the damaged kidneys with a healthy kidney from a donor, ESRF patients would not need to depend on dialysis treatments to live. However, a kidney transplant may not be an option for everyone due to factors such as old age, medical history and the non-availability of a suitable kidney donor.
Why do patients stop or delay dialysis?
There are many reasons why someone with ESRF may not want to continue or start dialysis. Some people feel they’ve lived a full life and don’t want to bother with additional treatments.
“Dialysis is an amazing technology that has extended the lives of many people,” says Dr Nur Hidayati. “But the benefits are less certain in older, frailer patients.”
Studies have shown that people most likely to withdraw from dialysis are older, bed bound or with chronic disability. They often have other health problems in addition to kidney disease, and suffer more severe pain. They usually have physical limitations that restrict normal daily activities.
Patients choose to delay dialysis because they feel that the procedure is painful, time-consuming, and an uncomfortable process. Some patients are afraid of the procedure because they knew someone with a negative experience with dialysis in the past, which can lead them to delay or refuse dialysis treatment.
But apart from that, there are financial constraints for patients to get dialysis treatments. Dialysis can be expensive, and patients may not be able to afford the required dialysis treatments. Lack of knowledge of the severity of their condition is another reason why patients avoid dialysis. Some patients may not fully understand the consequences of delaying treatment and may not even recognize the severity of their condition.
What happens if ERSF patients delay dialysis?
They are prone to develop accumulation of toxins and waste products in their body. As their kidneys no longer work, toxins can build up in the blood, leading to a condition known as uraemia. Uraemia can cause a range of symptoms, including fatigue, nausea, vomiting, and confusion. If left untreated, uraemia can lead to seizures, coma, and even death.
Apart from that, delaying dialysis can also lead to fluid overload. The kidneys manage the fluid balance in the body by excreting excess fluid in the body in the urine. When kidneys fail, this excess fluid can build up in the body, leading to swelling, particularly in the legs. This also causes accumulation of fluids in the lungs causing difficulty breathing.
Not just that, delaying dialysis also can lead to other health complications, including high blood pressure, anaemia and heart disease. High blood pressure or hypertension is a common complication of ESRF. ESRF patients can have severe hypertension that can lead to hemorrhagic stroke and chronic heart failure. Anaemia is another complication of ESRF that can lead to patients feeling weak, easily fatigued, and having shortness of breath.
“I have seen a young patient diagnosed with ERSF who chose not to continue dialysis treatment. This patient ended up with severe complications of hemorrhagic stroke and heart failure. It is very sad when a man’s life is cut short by a treatable disease this way ”, shares Dr Nur Hidayati.
What is the long-term outlook?
Medical advancements have allowed people with ESRF to live longer than ever before. Living with dialysis although can be difficult and burdensome but it helps ESRF patients remain symptoms-free and able to live for many years afterward.
Without undergoing dialysis treatment, patients are prone to get frequent hospitalizations with ESRF complications like uremia and fluid overload. In fact, some patients may only be able to survive only for a few months before succumbing to the disease. In the Dialysis Outcomes and Practice Patterns Study (DOPPS) study, it found ESRF patients who delayed the start of dialysis had a higher risk of death, hospitalization, and cardiovascular events compared to those who started dialysis earlier. Other studies also have shown that patients who delay dialysis have a higher mortality rate than those who start treatment promptly.
Dialysis can certainly help ESRF patients manage with symptoms of ESRF. Being on dialysis can improve patients’ quality of life as well as prolonging their life expectancy. If you are an ESRF patient who is still unsure regarding dialysis treatments, please consult with a nephrologist who can provide further information and support before deciding whether or not to start or continue with dialysis.