1.7.5.

1 Continuous ambulatory peritoneal dialysis (CAPD)

If choice of treatment for CKD is based on the patient’s own circumstances (Morton et al.,

2012), CAPD has distinct positive advantages over haemodialysis. As suggested by the

name continuous ambulatory peritoneal dialysis, the dialysis takes place whilst the patient

carries on with their daily lives and does not necessitate them visiting a hospital on a

regular basis. Even though CAPD can be performed in the home and sometimes in the

workplace, dialysis exchanges have to be carried out four or five times every day, making

travelling and socialising problematic (Mean, 2014). Patients may also find the catheter

very invasive and can be self-conscious of its placement (Prakash et al., 2013).

1.7.5.2 Haemodialysis (HD)/Haemodiafiltration (HDF)

Descriptions of treatments by haemodialysis and haemodiafiltration are provided in earlier

sections of this chapter (Sections 1.6.2.4 and 1.6.2.5). Haemodialysis and

haemodiafiltration are very time-consuming treatments as the patient has to be connected

to a dialysis machine for four hours three times a week. Once the time of travelling to and

from the renal unit is added to the treatment time, patients are away from home the best

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part of three full days per week (Diamant et al., 2010). However, satellite HD units provide

patients with dialysis facilities nearer their homes to reduce travelling times, and recently

there has been a drive to encourage more haemodialysis to be performed at home (Walker

et al., 2014). Patients on haemodialysis can often experience quite alarming events

including hypotensive episodes and painful cramps (Kistler et al., 2014). A strict diet is

also advised for haemodialysis patients which may result in patients having to prepare

different meals from their families from themselves (Untas et al., 2012). As represented in

Figure 1.4 the arrow between treatment and dialysis access is bi-directional due to patients

wanting to or needing to change methods of treatment.

1.7.5.3 Transplantation

Kidney transplantation is also discussed in Chapter 1, Section 1.6.2.2. Transplantation is

also classed as another form of renal replacement therapy. However, compared to other

RRTs, transplantation is seen as the best treatment for CKD (Weir and Lerma, 2014) for
reasons of cost effectiveness (Kerr et al., 2012) and patient outcomes (Tonelli et al., 2011).

When receiving a successful kidney transplant the patient can return to a relatively normal

life (Rambod et al., 2011). Patients receiving a transplant have also reported superior

HRQoL in many studies (Tonelli et al., 2011). However, transplantation is not a panacea

with chronic rejection being a possibility and severe side effects from immunosuppression

drugs e.g. skin cancer (Kuschal et al., 2012), increased risk of infection (Fishman and Issa,

2010) and secondary cardiovascular complications (Pham and Pham, 2011).

1.7.5.4 Conservative management

When CKD patients are making decisions regarding the different treatment options, they

may choose not to dialyse and as an alternative prefer to be treated by diet and medication

alone. More elderly CKD patients elect to follow this pathway as an alternative to spending

the last years or months of their lives on dialysis. In such patients, the prospects of

rehabilitation are remote and also prognosis is poor (Smith et al., 2003, Chandna et al.,

2011), therefore more emphasis is placed on the quality of life and symptom control than

prolonging life (Chandna et al., 2011). Symptom control can be achieved by controlling

fluid balance, maintaining equilibrium of electrolytes and correcting anaemia by

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erythropoietin EPO (Smith et al., 2003). Rather than the patient withdrawing from

treatment, the emphasis in conservative management (CM) is on a complete package that

promotes a good level of quality of life and a planned package for end of life care. Studies

have reported that elderly patients receiving CM who have several comorbidities do not

suffer from a significant survival disadvantage to those who are on dialysis (Smith et al.,

2003, Murtagh et al., 2007).

1.7.6 Complications

Although the diagram in Figure 1.4 tracks the stages of a CKD patient’s pathway through

their illness, it does not include complications that they may experience along the way.

Complications may occur at any time along the trajectory including cardiovascular events,

infection episodes, and problems with fluid overload and dialysis access (Murtagh et al.,

2008). Complications can also arise from co-morbid conditions that patients may have in
conjunction with CKD, such as diabetes. Acute episodes may increase with age and could

alter or accelerate the course of the illness.

1.7.7 Death

Sudden death can happen at any stage of the illness trajectory without any prior diagnosis

or warning (Murtagh et al., 2008). Cardiovascular events are the most common causes of

sudden death in CKD (Shamseddin and Parfrey, 2011). Patients who choose not to dialyse

or withdraw from dialysis have a much shorter decline in the illness trajectory (Murtagh et

al., 2008) but may have planned to die in their home environment surrounded by their

family. As the CKD population increases in age, we need to further understand the final

stages in their illness trajectory so that provision can be made for patients to die with a

comprehensive end of life package in place ensuring a dignified and pain free death

(Douglas et al., 2009).

1.8 Summary

This chapter has described and discussed the condition of CKD, its prevalence and

incidence, aetiology clinical management and illness trajectory.

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CKD is an important health problem which is growing worldwide. There is no cure for

CKD and its treatments at end stage are invasive and time consuming. The burden of

medication is also high and restriction of diet and fluids is also very limiting for patients

who have not been successful in obtaining a donor organ.

As this chapter only addresses the clinical management of CKD, future chapters will

discuss the psychosocial and health-related quality of life (HRQoL) of patients suffering

from this debilitating condition.