Dialysis and Transplant Decisions

Loretta Swift

Welcome back, y’all, to another episode of NSG4052 Renal! I’m Loretta, your friendly neighborhood RN—and as always, I’ve got James A. Bond here with me. Today, we’re tackling one of the biggest crossroads our patients face when CKD progresses: choosing a treatment pathway. And James, there’s really no ‘one size fits all’, right?

James A. Bond

Absolutely, Loretta. Good to be here with you—and our listeners—again. Just as we detailed in previous episodes, each renal patient’s journey is unique, especially as chronic kidney disease advances. Our main management options are hemodialysis, peritoneal dialysis, kidney transplant, and, for some, conservative or palliative care when interventions don’t align with the patient’s wishes or candidacy.

Loretta Swift

Exactly. And, look, it’s never just about the labs or the guidelines. It comes down to what the patient wants and what’s appropriate, medically speaking. Some folks simply aren’t candidates for transplant because of things like advanced cancer or untreated heart disease. And let’s not forget—for a lot of older adults, the process to even get started can be, well, pretty long and overwhelming.

James A. Bond

That’s right, and as clinicians, we have to be honest and gentle when helping families sift through these decisions. I might add, Loretta, your knack for guiding families through those tough choices—it really exemplifies patient-centered care. Do you have a story you can share?

Loretta Swift

Oh, sure—I remember sitting down with a daughter and her elderly mom, newly diagnosed with end-stage kidney disease. They felt lost. We walked through each option, the realities of dialysis, and what would it look like to focus simply on comfort and symptom management. The daughter told me later what helped was just hearing the truth, kindly, without sugarcoating or guilt-tripping. Sometimes just being present and honest is the best nursing intervention.

James A. Bond

Beautifully said. And as we’ve talked about before—the goal is making sure every patient’s care aligns with their own values and realities. Now, once the decision is made, many begin with hemodialysis, so perhaps let’s break down how that works.

James A. Bond

So, hemodialysis in a nutshell: we shunt blood from the body through a dialyzer—a type of artificial kidney that cleans the blood—and return it back. It corrects fluid and electrolyte imbalances, clears uremic toxins, and, well, basically does what native kidneys can’t anymore.

Loretta Swift

And all that depends on good vascular access. The gold standard is an AV fistula, usually in the forearm. That’s when a surgeon joins an artery and a vein, letting the vein grow thick and tough enough to handle those fast, powerful blood flows. But there’s also AV grafts—those are made with synthetic tubes if the person’s own vessels aren’t up to snuff. And if it’s urgent, we turn to temporary central lines, like in the internal jugular or femoral vein.

James A. Bond

You know, that reminds me of a patient I looked after back in Manchester—a lovely old man with diabetes and pretty poor vessels. When that fistula finally matured, he called it his ‘lifeline’—literally. We spent just as much time caring for his fistula as we did supporting him through his dialysis sessions. Patency checks, listening for a good strong bruit, feeling for that thrill—that access maintenance was everything.

Loretta Swift

Absolutely—especially for elderly folks with vascular disease or a history of, uh, IV drug use, getting and keeping a good access is, honestly, such a hurdle. Sometimes, even if you do everything right, things don’t quite behave.

James A. Bond

And, well, if you don’t have a reliable access, nothing else works. But let’s keep going—because managing the technical side is just the beginning; complications come fast and heavy if you’re not careful.

Loretta Swift

So first up, hypotension. I think every nurse has seen this after a session. It’s usually from too much fluid being pulled out, or just the heparin and blood loss, plus those older adults don’t bounce back like they used to. Replacing with saline helps, but, honestly, you gotta be careful. I always tell students: hold off on any procedures a few hours after HD—they’re still rebalancing!

James A. Bond

Muscle cramps are another classic. Dialysis rates, fluid shifts, electrolyte imbalances—all contribute. And then there’s stuff like steal syndrome, when blood is diverted away from a limb—patients will complain of pain, tingling, even numb fingers. Look for cool skin or poor capillary refill. Access site aneurysms, too—frankly, any bulge at the access has me on high alert.

Loretta Swift

Yeah, and then there’s disequilibrium syndrome—especially risky for older patients. I had a woman just last year, came in for her first session, and after a while started acting confused, agitated—then dizzy. Turned out, we’d dropped her BUN way too quickly. We got neuro involved, slowed or paused the treatment, and she recovered, but it could’ve gotten scary fast. Early warning signs are crucial—headache, agitation, nausea. You never want to see it progress to a seizure.

James A. Bond

And not to forget, infection—especially hepatitis B and C, if infection control slips. The risk of Hep B is much lower these days thanks to vaccines, but Hep C is still a worry. It’s always about scrupulous technique and good site care.

Loretta Swift

So our job—like we always say—is vigilantly assessing access sites, checking labs, never ignoring even “small” symptoms. Patients and families have to know what’s serious and what’s not. It takes the whole team, and lots of communication.

James A. Bond

James A. Bond

Peritoneal dialysis—PD—works on a different principle. Instead of shunting blood through a machine, we’re using a catheter that sits in the abdominal wall. The peritoneal membrane acts like a natural filter, and we fill the cavity with dialysis solution—that's the dialysate.

Loretta Swift

So, the process is pretty neat. There’s the inflow phase, where you infuse the solution—usually over about 10 minutes—then the dwell, where it sits and the exchange happens, and finally the drain, where you remove the now waste-filled fluid. Some folks do this manually several times a day, others have an automated machine work overnight. Either way, it gives a lot of flexibility, especially for patients who value independence. But it requires commitment—and a clean technique.

James A. Bond

Speaking of commitment, I’ll never forget working in Nairobi—training a gentleman to do his own PD exchanges at home. There was a real sense of pride in mastering all the steps: cleaning, connecting, monitoring the solution. It’s teamwork between the patient, family, and us clinicians. It only takes one slip with hygiene to run into trouble.

Loretta Swift

Absolutely. And for many older adults, starting PD means learning new motor skills and routines. We have to assess their home environment and support system, because success really is a group effort.

James A. Bond

And outcomes for PD versus HD are pretty similar in the early years, but, uh, after two years, the risks do seem to climb, especially with age and comorbidities. But let’s dive into the complications to really see what can go wrong, and how we step in early.

James A. Bond

The big one is infection—either at the site or, more seriously, peritonitis. It nearly always traces back to breaks in aseptic technique. You want to get in front of any signs: redness or pain at the catheter, and for peritonitis, that classic cloudy outflow—the effluent—plus abdominal pain and fever.

Loretta Swift

Yes—WBC counts can spike, and GI symptoms like nausea, vomiting, distension, even rebound tenderness may pop up. Repeated infections are a recipe for adhesions or scarring. I once worked with a client who kept getting peritonitis, and after each instance, we had to revisit training—over and over. Sometimes you feel like a broken record but, honestly, the reminders are life-saving.

James A. Bond

Other complications: protein loss through the exchange process—sometimes leading to malnutrition if we’re not vigilant. Hernias can develop from increased intra-abdominal pressure, and the elderly are at even higher risk. I see people surprised that lower back pain or even a cough could be related to PD!

Loretta Swift

Don’t forget the risk of atelectasis and pneumonia from that upward pressure on the diaphragm. We teach deep breathing and repositioning, but it’s a constant worry, especially with frail clients.

James A. Bond

So again—early assessment, watching for subtle changes, and ongoing, relentless education are musts. Now, in acute scenarios—where instability reigns supreme—there’s another option: continuous renal replacement therapy.

James A. Bond

CRRT is kind of the gentle giant of renal replacement therapies, used mostly in ICU settings. It’s lifesaving for folks with acute kidney injury who are too unstable for traditional dialysis. Instead of rapid fluid shifts, CRRT works slowly, shifting fluids and toxins over 24 hours or more through a special catheter—usually in the jugular vein.

Loretta Swift

I think some students mix it up and think CRRT is just ‘slower HD’—but it’s really its own beast, isn’t it, James? With frail or unstable patients, especially those with sepsis or multi-organ issues, this slow and steady approach keeps hemodynamics much steadier.

James A. Bond

You’re spot on. I remember during my Sydney critical care rotation, we had several patients on CRRT for days at a time—sometimes even weeks. It’s a bridge for those whose AKI is expected to recover, and once kidney function returns, therapy stops. But it’s too gradual for a truly emergent uremic crisis—standard HD is still king there.

Loretta Swift

But, when it’s called for, CRRT is a vital tool in the arsenal, especially in the hands of a good interprofessional ICU team.

James A. Bond

Which leads us to, perhaps, the most hopeful—and often the most daunting—intervention for kidney disease: transplantation.

James A. Bond

Transplant is, according to all the data we have, hands-down the best long-term solution for end-stage renal disease. Compared to dialysis, it eliminates most of the renal complications and, over time, is less expensive. Trouble is, less than 4% of patients ever get a kidney—mostly due to the tight screening process and, well, the shortage of donors.

Loretta Swift

And that screening’s no joke. Patients get ruled out for advanced cancers, untreated heart disease, chronic infections, or simply not being able to follow tough medication and lifestyle routines. But these days, things like HIV or even having Hep B or C aren’t necessarily showstoppers for candidacy, which, honestly, is a big shift from what I learned 20 years ago.

James A. Bond

It’s been a long road. But even when a transplant goes well, management doesn’t end at surgery. There’s the big risk of infection because of heavy immunosuppression, and then the heightened rate of certain cancers, cardiovascular disease, and, of course, various rejection syndromes—hyperacute, acute, or chronic. Ongoing monitoring, lifelong meds, and major lifestyle tweaks are all part of it.

Loretta Swift

You know, some moments stick with you—I’ll never forget a family reunion we put together at the hospital for a young grandma who got her new kidney. The look on her face, seeing her grandkids, knowing she’d have more time with them—it made all the effort worth it. That’s the power of organ donation; it changes not just lives, but whole families.

James A. Bond

And it reminds us, Loretta, why all these complicated decisions—the pathway chosen, the hurdles faced—are so deeply personal. Our job is to walk the road with them, every step of the way.

Loretta Swift