Hemodialysis in the Philippines: To re-use the Dialyzer or not?

Hemodialaysis centers in the Philippines especially in Manila are plentiful.

Prices per 4 hour session varies from P2,800 to 5,000 depending on the hospital / center and depending whether they re-use the dialyzer or not.

The dialyzer is the filter through which the toxins are passed in the machine. It is actually the "artificial kidney" By re-using, it means that the dialyzer is cleaned and sterilized and re-used for about 2-4 times.

Our family opted for a center that did not re-use (Fresenius in Pasong Tamo extension in Makati) but we also tried other centers which re-used. My father especially liked Fresenius because of its very nice facilities, superb cleanliness and very nice and friendly staff. With Senior Citizen discount, the treatment cost us P3200 back in 2008 (I think it was in promo then). 

Hemodialysis Needs Arterio-Venous FISTULA

Patients with kidney failure are treated with hemodialysis.

In dialysis, blood is withdrawn from an artery or vein, purified, and returned to a vein. The volume of blood is too great for veins to handle, so a vein must be enlarged. An artery and vein, usually in the arm above or below the elbow, are sewn together, to create a fistula, and arterial pressure eventually enlarges the vein. The enlarged vein can accommodate a cannula or large needle.

In the Philippines, more doctors opt for Hemodialysis so they require a fistula done on the patient as early as possible (around stage 3 or 4)  especially if the patient chooses not to go through kidney transplant.

My father had his done at the UST hospital (University of Sto. Tomas) in Manila last 2006 and it cost around P12-15,000.

You know it's a good fistula when the artery and vein actually bulge and touching it, you feel the full forceful pressure of the flow.

If there is a sudden need for dialysis and the AV Fistula was not done, I have seen the doctors gain access on the neck or on the abdominal area which is so inconvenient.

Best to do this earliest possible. All patients with kidney disease will eventually go to dialysis at one point anyway, even while waiting for a donor (if he does opt for a transplant in the future). 

Treatments for Kidney failure: Dialysis

There are 2 kinds of Dialysis treatments. Both basically rely on a particular method (hemodialysis or peritoneal dialysis) where wastes of the body which cannot be removed by the kidneys, are removed by body fluids being cleansed by a machine or  pumped out.

HEMODIALYSIS

When a patient is diagnosed to have failing kidney progressively, he is usually advised to have an Arterio-Venous (AV) fistula (discussed on next blog) on his arm as access point where the machine will be connected to his arm.

Hemodialysis is done 2-3 times a week with each session lasting 4-5 hours.

PERITONEAL DIALYSIS

 The process uses the patient's peritoneum in the abdomen as a membrane across which fluids and dissolved substances (electrolytes, urea, glucose, albumin and other small molecules) are exchanged from the blood. Fluid is introduced through a permanent tube in the abdomen and flushed out either every night while the patient sleeps (automatic peritoneal dialysis) or via regular exchanges throughout the day (continuous ambulatory peritoneal dialysis). PD is used as an alternative to hemodialysis though it is far less common. It has comparable risks and expenses, with the primary advantage being the ability to undertake treatment without visiting a medical facility. The primary complication with PD is a risk of infection due to the presence of a permanent tube in the abdomen.

Peritoneal dialysis is done everyday at home.Here is a comparison of the 2 in a diagram:

Treatments for Kidney failure: For Acute and Chronic Renal Failure

Specific treatment for renal failure will be determined by your physician based on:

1. your age, overall health, and medical history
2. extent of the disease
3. type of disease (acute or chronic)
4. underlying cause of the disease
5. your tolerance for specific medications, procedures, or therapies
6. expectations for the course of the disease
7. your opinion or preference

Treatment may include:
•hospitalization
•administration of intravenous (IV) fluids in large volumes (to replace depleted blood volume)
•diuretic therapy or medications (to increase urine output)
•close monitoring of important electrolytes such as potassium, sodium, and calcium
•medications (to control blood pressure)
•specific diet requirements

In some cases, patients may develop severe electrolyte disturbances and toxic levels of certain waste products normally eliminated by the kidneys. Patients may also develop fluid overload. Dialysis may be indicated in these cases.

Treatment of chronic renal failure depends on the degree of kidney function that remains. Treatment may include:
•medications (to help with growth, prevent bone density loss, and/or to treat anemia)
•diuretic therapy or medications (to increase urine output)
•specific diet restrictions
•dialysis
•kidney transplantation


reference

How is Kidney Failure diagnosed?

In addition to a physical examination and complete medical history, diagnostic procedures for renal failure may include the following:



•blood tests (to determine blood cell counts, electrolyte levels, and kidney function)

•urine tests

•chest x-ray - a diagnostic test that uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film.

•bone scan - a nuclear imaging method to evaluate any degenerative and/or arthritic changes in the joints; to detect bone diseases and tumors; to determine the cause of bone pain or inflammation.

•renal ultrasound (Also called sonography.) - a non-invasive test in which a transducer is passed over the kidney producing sound waves which bounce off the kidney, transmitting a picture of the organ on a video screen. The test is use to determine the size and shape of the kidney, and to detect a mass, kidney stone, cyst, or other obstruction or abnormalities.

•electrocardiogram (ECG or EKG) - a test that records the electrical activity of the heart, shows abnormal rhythms (arrhythmias or dysrhythmias), and detects heart muscle damage.

•kidney biopsy - a procedure in which tissue samples are removed (with a needle or during surgery) from the body for examination under a microscope; to determine if cancer or other abnormal cells are present.
 
reference

What does a CKD STAGE 5 or ESRD patient feel?

Stage 5 CKD is also called
1. established chronic kidney disease
2. end-stage renal disease (ESRD)
3. chronic kidney failure (CKF)
4. chronic renal failure (CRF)


What is renal failure?

Renal failure refers to temporary or permanent damage to the kidneys that results in loss of normal kidney function. There are two different types of renal failure - acute and chronic. Acute renal failure has an abrupt onset and is potentially reversible. Chronic failure progresses slowly over at least three months and can lead to permanent renal failure. The causes, symptoms, treatments, and outcomes of acute and chronic are different.

What is end-stage renal disease (ESRD)?
End-stage renal disease is when the kidneys permanently fail to work.

What are the symptoms of renal failure?
The symptoms for acute and chronic renal failure may be different. The following are the most common symptoms of acute and chronic renal failure. However, each individual may experience symptoms differently. Symptoms may include:

Acute: (Symptoms of acute renal failure depend largely on the underlying cause.)
•hemorrhage
•fever
•weakness
•fatigue
•rash
•diarrhea or bloody diarrhea
•poor appetite
•severe vomiting
•abdominal pain
•back pain
•muscle cramps
•no urine output or high urine output
•history of recent infection (a risk factor for acute renal failure)
•pale skin
•nosebleeds
•history of taking certain medications (a risk factor for acute renal failure)
•history of trauma (a risk factor for acute renal failure)
•swelling of the tissues
•inflammation of the eye
•detectable abdominal mass
•exposure to heavy metals or toxic solvents (a risk factor for acute renal failure)

Chronic:
•poor appetite
•vomiting
•bone pain
•headache
•insomnia
•itching
•dry skin
•malaise
•fatigue with light activity
•muscle cramps
•high urine output or no urine output
•recurrent urinary tract infections
•urinary incontinence
•pale skin
•bad breath
•hearing deficit
•detectable abdominal mass
•tissue swelling
•irritability
•poor muscle tone
•change in mental alertness
•metallic taste in mouth

The symptoms of acute and chronic renal failure may resemble other conditions or medical problems. Always consult your physician for a diagnosis.

Why may I need a kidney transplant?

Why may I need a kidney transplant?


When a patient has kidney failure, it causes him or her to feel ill. Over time, waste products and fluid build up in the body. This may result in death if untreated. There are three treatment methods for patients with End Stage Renal Disease (ESRD). The first is hemodialysis, where blood is passed through a dialysis machine and filtered in the same way as done by functioning kidneys. Another technique is peritoneal dialysis, which works by passing special fluid into the abdomen. Some of the toxic chemicals in the blood pass into the fluid. After a couple of hours the fluid is drained along with the toxins. A kidney transplant is the final means of replacing a failed kidney.

End Stage Renal  disease (ESRD) is also known as Chronic Kidney disease (CKD) in the 5th stage. The kidney's function of filtering removing toxins from the body is diminished. This function is called the Glomerular filtration rate. All individuals with a Glomerular filtration rate (GFR) <60 mL/min/1.73 m2 for 3 months are classified as having chronic kidney disease, irrespective of the presence or absence of kidney damage. The rationale for including these individuals is that reduction in kidney function to this level or lower represents loss of half or more of the adult level of normal kidney function, which may be associated with a number of complications.


All individuals with kidney damage are classified as having chronic kidney disease, irrespective of the level of GFR. The rationale for including individuals with GFR 60 mL/min/1.73 m2 is that GFR may be sustained at normal or increased levels despite substantial kidney damage and that patients with kidney damage are at increased risk of the two major outcomes of chronic kidney disease: loss of kidney function and development of cardiovascular disease.

Stage 1 CKD

Slightly diminished function; Kidney damage with normal or relatively high GFR (>90 mL/min/1.73 m2). Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine test or imaging studies.
Stage 2 CKD
Mild reduction in GFR (60-89 mL/min/1.73 m2) with kidney damage. Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine test or imaging studies.

Stage 3 CKD
Moderate reduction in GFR (30-59 mL/min/1.73 m2). British guidelines distinguish between stage 3A (GFR 45-59) and stage 3B (GFR 30-44) for purposes of screening and referral.

Stage 4 CKD
Severe reduction in GFR (15-29 mL/min/1.73 m2) Preparation for renal replacement therapy

Stage 5 CKD
Established kidney failure (GFR <15 mL/min/1.73 m2, or permanent renal replacement therapy (RRT), or Kidney transplant patient

reference




 

The Decision to Go for Kidney Transplant

My dad Rene Aquino

 on his 70th birthday

June 26, 2006

Gale Julian Cera, born November 25, 2008.
 The youngest of 8 grandchildren of Rene and Thelma Aquino.

The first born of Gale and Melanie Cera

The happy bride with her parents on her most special day, February 20, 2008

Gale and Melanie Cera

I was truly happy on my wedding. My father had brought me to tha altar. I was to stay home again, with a family of my own.

My father's health check ups monthly bacame a dreaded thing for me. It would sentence my dad to a nearing meet with the dialysis machine.

Another family meeting where I present the pros and cons of kidney transplant. My boss said we had to meet the right doctors, those who are open to kidney tranplants...only then did I realize that there were 'conservative' and 'aggressive' nephrologists. My boss said we had to meet with the right doctors, of which ours was of the first kind. Upon talking to our doctor, he felt that at dad's age there would be more harm than good in a kidney transplant. We then decided to seek for a second opinion for the sake of hearing the other side, or the other option.

Our next nephrologist was to be a lady. Very vibrant and alive. She would tell us that there would have to be tests for dad's suitability to receive and if he is suitable then we proceed to finding the donor.

By June to August 2008, our family decides to see if dad is suitable by going thru the tests for the heart, and other organs of the body. Dad passes the tests.

By September, we had enrolled him already at HOPE (Human Organ Preservation Effort) which is the hospital arm of the Philippine Kidney Foundation, tasked to coordinate and source cadaveric kidney donors nationwide. We also registered him for a non - related living donor at the Philippine Kidney Foundation.

Then we had to wait. Wait. And wait some more.

Pray. Pray. And Pray some more.

Several calls came from the HOPE foundation saying dad would be up for consideration of 5 possible receivers depending on suitability and cross matching. We would be hopeful but then, the 2nd call would not come.

In the meantime, the tests had only a 6 month validity and a repeat would be imminent if we were still to consider transplant. With our fund and spirits low, we only had to believe and have faith...more faith. With time ticking, dad's kidneys were also starting to fall to 10% function.

2008 Christmas was joyous with the birth of my son, Gale Julian. We were the happiest parents. Our son would live to see and be with his grandparents.

Come March of 2009, we had to face the realization that daddy needed dialysis. Though he was not showing symptoms of UREMIA, vomitting, nausea, urinating problems - we found it best not to wait and have his blood cleaned regularly.

Dr  Alvin Wee, a very god friend of my cousin, a Filipino renal transplant surgeon from St. Vincent Indianapolis Hospital was in town. My very thoughtful cousin Dr. John Silva, asked us to meet up with him to discuss all we needed to know of Dad's case. We were impressed! A Filipino who's made us proud by being very good at his craft in a foreign land! Apart from the very thoughtful and truthful insights and facts he said, the most important questions we had to ask was:

1. Do you think my dad would survive a surgery as big as this?
2. Do you think you can help us find a donor...fast?

To both, he was very positive. Eyeballing at my dad, he said he was strong enough to survive it, as for the donor, surely there is, another doctor was referred to us.

Then the next big question from the good doctor was: What does your father like? At first I say to myself, what a weird thing to ask...of course my father would like to have that transplant! From his experience in the States where dialysis is covered by health insurance and donors are far and few, many choose to live on dialysis for "socializing" purposes....old folks get to have friends in the sessions, etc.

But dad was quick to answer, "After undergoing only 6 dialysis sessions, I would rather die in the operating table than live on dialysis".

Fresenius Dialysis Center

April 7, 2009

So the decision was finally made, we have passed all the tests, we now wait for the donor.

In the meantime, we schedule ourselves to see the new doctor who might be able to facilitate finding a donor faster.

I realize my dad is sick

If you have read my blog (http://favoritequeendom.blogspot.com/), my stay there ended because I decided to stay back home for my dad.

Daddy had a failing kidney and I just felt I needed to be home for him.

My dad and mom on Decmber 9, 2007

46th Wedding Anniversary

@ Serendra, Fort Bonifacio, Makati

He was diagnosed with about 50% kidney function way back in 2004 and during that time, he was assymptomatic, he was strong and going about his normal ways. My dad was strong at 69 years old. Considering he was a chain smoker, has had a heart problem since he was 27 years old, my daddy was strong. That even made me decide to leave for the kingdom the following year. But on diagnosis, he was told that his condition had to be monitored and his kidney function analyzed regularly for its function.

Why was his kidney failing him? Back then it was called Chronic kidney disease - assymptomatic but guarded kidney failure/failing, if I may put a definition to it. It was explained to us that a lifetime of hypertension took a toll on his kidneys so while he is hypertensive and taking his meds for his heart, his kidneys are being hurt by it. The doctor put it this way, a man can live without a kidney but he can't live without his heart. So we must do all to save the heart at the cost of his kidneys .

What can be done for him to stop the kidney from failing? His heart has to be diagnosed, his blood vessels evaluated for any blockages or heart structure problems by injecting a radioactive dye that would be bad for his kidneys as well....further "kill" the kidney for lack of better word to use. Such a double edged problem.

We go for the conservative way of looking at the heart and its functions .... no dye. Tests show that the heart is strong, but daddy has peripheral vascular disease, blockages on his arms and legs blood vessels, including his kidney blood vessels.

The solution to this was either to wait for his kidneys to eventually fail and then need dialysis or have a kidney transplant.

Our family was put in a very delicate situation of deciding the fate of our dear father.

Very clear to all of us was we did not want to lose dad, so any procedure that would threaten his life at present we would avoid. So no radioactive dye which would hasten the kidney's failure, no kidney transplant because as it is, his kidney was still functional. The likelihood if it failing would be years provided he takes the right medicines, follows the right diet and lifestyle...and of course, the power of prayers and miracles we deeply believed in....daddy would get well and we claimed that. This was in 2004.

Fast track to 2007, 3 years after, my father starts losing weight, kidney function is down to perhaps 30% and he feels weakening. Daddy begins to miss his eldest son in the States, Kuya and Joyce and all his 5 grand kids - 2 of which he has never ever laid his hands on. Him and mom plans for a trip to the US.

I on ther other hand, finally home preparing for my wedding in Feb 2008, gets an aggressive advice from my former boss (a kidney transplant surgeon) to consider a kidney transplant for my father. More than the age as a consideration, dad's suitability and his health condition as a receiver as well as the donor is of utmost priority.

Again, the family is faced with the decision, to go or not to go for this. kidney transplant was expensive, where would we find the donor, would daddy be fit to go through it and live at 73? Dialysis is imminent and we were already told to prepare for it emotionally and financially.

My advisor, and my boss, said life in dialysis was not only hard but it did not offer any hope for the patient. Dialysis was a procedure to extend life by putting yourself in a machine that acted like an artificial kidney but for how long would you endure it, 4 hours every other day....taxing, expensive, and for a 73 year old, no way to spend the remaining years of his life. Whereas with kidney transplant, dad would get better, it was a solution. It was not to say there would be no risks but atleast, the chance of a better quality of life was there. Would we take the risk?

For now, dad is getting sicker by the day and we had to do something.....decide on what to do...fast.