This is when a patient’s kidneys are unable to remove wastes and excess fluid from the blood. Kidney failure is divided into two general categories, acute and chronic. Acute kidney failure (acute kidney injury) occurs suddenly and may be the result of injury, infections, loss of large amounts of blood/fluids, drugs or poisons. Kidneys may return to normal function if they are not too badly damaged. Chronic renal failure means kidney function has slowly worsened over a number of years and the kidneys do not get better but stay the same or slowly get worse. When chronic renal failure has progressed to end stage kidney disease (ESKD), it is considered irreversible and unable to be cured. End Stage Kidney Disease (ESKD) End stage kidney disease (ESKD) has many causes but no cure. When almost all kidney function is lost, dialysis or kidney transplantation (in those appropriate for these) must be used to maintain life. Specialist input from a skilled physician (renal/kidney physician, also called nephrologist) is necessary. Regular blood tests and urine tests are necessary to see how fast your kidney problem is progressing. The kidney physician will look at many issues, like your fluid balance, the concentration of waste products in your body and the influence of renal disease on many of your body's functions such as blood pressure, bones and red blood cell production. Together with the physician you will discuss when the moment has come to seriously think about one of the options, as mentioned below. He/she will then refer you to a pre-dialysis nurse specialist. This is a nurse with special skills who will discuss with you the options that there are in dialysis, looking at your specific situation. Additionally, it may be appropriate to consider kidney transplantation. You can discuss the pros and cons of the type of treatment with your healthcare team and choose the best type for you and your medical condition. Dialysis treatment may change over time e.g. you may start on peritoneal dialysis (PD) and then switch to haemodialysis (HD) in the unit or at home.

Home dialysis is recognised around the world as offering people the best quality of life, and quality of treatment, for people on dialysis. New Zealand is proud to be recognised as a world leader in home dialysis, and ‘Home First’ is always our recommendation to new and existing dialysis patients if this is at all possible. There are two kinds of home dialysis, Peritoneal Dialysis and Home Haemodialysis; both are offered at Auckland Hospital from our purpose built home dialysis training and support building at Greenlane Clinical Centre. This unit was built in 2011 and is staffed by a dedicated team of specialist nurses, technicians, dietitians, support staff and doctors. The two types of home dialysis are quite different from each other, and one or the other may suit you best. Prior to starting home dialysis you will meet with members of the home dialysis team who will discuss the pros and cons of each type of home dialysis with you and how it might fit with your family, life and work commitments. They will visit you at home to give you an idea of how home dialysis will fit in with your household and to check that home dialysis is suitable for you. When it is time to start home dialysis you and/or your whanau/family/carers will spend a period of time learning all the skills needed to successfully dialyse at home. Once confident to begin your home dialysis you will be supported by staff from the home dialysis unit with regular medical reviews, home visits, advice and 24/7 access to staff skilled in their choice of home dialysis. More detailed information about Home Haemodialysis can be found here. More detailed information about Peritoneal Dialysis can be found here.

Peritoneal dialysis is a treatment where the peritoneal membrane (lining around the inside of your abdominal wall and the outside of your intestines) is used to filter and cleanse the impurities, waste products and extra fluid from your body. Peritoneal dialysis uses a fluid called dialysate to gently remove fluid and waste products from your abdominal cavity and place them in the dialysate. The dialysate fluid acts like a magnet that attracts waste and excess fluid from the body. Peritoneal dialysis uses a catheter that is surgically or radiologically put into the abdominal cavity but outside the intestines and attached to the bag of dialysate solution for the treatment. After the treatment, the catheter is disconnected from the bag of dialysate and covered to keep it clean. You do not walk around with a bag stuck to your tummy. You or a family member, in the comfort of your own home, perform the treatment. The treatment can be done safely in other locations so that you have the most flexible treatment arrangement. You can do the procedure at work or at school as well. When your physician decides that your catheter is ready to use, training sessions will be arranged to teach you the best and safest way to perform dialysis. Trained dialysis staff will work with you to make your dialysis therapy and transition to independence as easy as possible. You are able to get advice at any time if you are running into difficulties with your dialysis. The types of peritoneal dialysis are: Continuous ambulatory peritoneal dialysis (CAPD): A set amount of fluid is placed into the abdominal cavity through your catheter. This fluid remains in the abdominal cavity for several hours and is then drained. The process is repeated 4 times daily. Each exchange takes about 30-40 minutes. The exchange schedule can be flexible to meet your needs. No machine is used for this type of treatment. YOU are in control. Automated peritoneal dialysis (APD): APD is done at night using a machine called a cycler. The system automatically does the exchanges for you while you are sleeping. Most people must spend 8 to 10 hours every night to complete this process. It usually makes daytime manual exchanges unnecessary. Peritoneal dialysis must be done every day. During your training, you are taught to follow specific procedures that allow you more freedom than on haemodialysis. It is a commitment that can be easy to follow. With encouragement from your family and healthcare team your lifestyle will require only minimal adaptation. One of the major advantages of CAPD/APD is that it closely mimics the way the kidneys work naturally. Whereas haemodialysis removes waste products and water from your body 3 times per week in just a few hours, CAPD/APD does this constantly i.e. much like healthy kidneys do. It is for this reason that CAPD is often the preferred method for patients when more gentle dialysis is required. The Peritoneal Dialysis Unit facility is based at Greenlane Hospital and shared with the Home Haemodialysis Unit and it is called the Home Dialysis Unit. The Peritoneal Dialysis Team consists of 2 kidney doctors (Renal Physicians), 3 nursing staff plus 2 dietitians.

For many people Home Haemodialysis will offer you the best quality of life, and quality of treatment possible with haemodialysis. Like hospital based haemodialysis, home haemodialysis involves using a machine to clean the blood several times a week. The major advantage of home haemodialysis over hospital haemodialysis is that you are able to choose how to fit this in amongst the other important things in your daily life. Many people continue to work full time whilst performing home haemodialysis. Some people choose to do their treatments overnight (and sleep through the treatment), freeing their days for other things. Your motivation is the key factor to successful home haemodialysis. We try to accommodate all people who wish to start home haemodialysis, and our experienced team are experts in overcoming hurdles that might prevent you getting home. Before you enter the program a member of the home haemodialysis team will arrange to meet with you at home to discuss with you the process of home haemodialysis and how it might fit into your life and household. If you and the team are happy to proceed, and it is time for you to start dialysis, you will then train to use the machine and trouble shoot any problems at the Home Dialysis Unit at Greenlane Hospital. Training usually take 2-3 months and occurs during your usual dialysis treatments. During that time, you will become confident with all parts of your treatment. Many people train to do the dialysis themselves, however we also train whanau, family, carers and support people to do the treatment if that would suit you better. When you are ready to go home we will arrange to have your own machine installed in the chosen location and you’re ready to go. Your trainer will continue to support you at home and there is 24/7 access to expert help on any aspect of your treatment. Your trainer will visit you at home as needed whilst you adapt, and you’ll continue to receive support from your trainer during your time on home haemodialysis. You will come to the Home Dialysis Unit at regular intervals for reviews where you can discuss all aspects of your treatment with the home haemodialysis nurses, doctors and dietitians. If needed, you can return to the Home Dialysis Unit for a period of time for a rest from doing your own treatments (respite care), if for example you or family members are unwell.

Haemodialysis is a treatment that cleans and filters your blood by removing the waste products and extra fluid that your kidneys can no longer eliminate. Haemodialysis requires a machine and an artificial kidney that is called a dialyzer. During the haemodialysis treatment your blood is pumped by the machine through tubing to the dialyzer. In the dialyzer, your blood is filtered, waste products and extra fluid are removed. The filtered or 'cleaned' blood is then returned to your body. In order to remove and return blood to your body, an access to your blood vessels must be made. This access is made during a surgical procedure in which a fistula is created. The fistula is put in the lower arm (if possible) or the upper arm; other places can be used if the arm is not suitable. Your surgeon will determine which access is best for you. If treatments must be started before a fistula is created, a temporary catheter may be placed externally (outside your body) to allow for immediate access to your blood vessels. Such a catheter is usually a temporary solution until real access can be created by the surgeon. Because of waiting lists for that procedure, or in some patients that face major problems regarding creation of vascular access, a so-called tunnelled line may be inserted. The tunnelled line runs under the skin of the chest and is held in place by a little cuff under the skin. This catheter can stay in place for a few years if necessary. Once your fistula has healed (matured) it can be used for treatment. Two needles are placed in the access at the start of each treatment and taken out at the end of each treatment. One needle is used to remove your blood for cleansing (filtering) and the other is used to return the filtered blood to your body. Haemodialysis treatments are usually performed three times each week. The length of your treatment is decided by your doctor but usually lasts from 4 to 5 hours. The time depends on your body size, any remaining kidney function and activity level. During your treatment you can read, watch TV or socialise with others close to you in the facility.

Transplantation places one healthy kidney into your abdomen. This one kidney is sufficient to replace the work of your two failed kidneys. In New Zealand, kidney transplantations are done in Auckland (Auckland City Hospital), Wellington and Christchurch. A kidney transplant can be the first form of treatment you receive or it can be selected later after receiving dialysis treatments for some time. Transplantation is the preferred treatment of end stage renal failure, but not all patients can profit from this option. Factors like severe heart or lung disease, malignant diseases etc. are contraindications i.e. you are not suitable to have a transplant operation. You may receive a transplant from a living related donor, a donor who is not related but willing to donate a kidney, or you may receive a kidney from someone who has recently died (deceased donor). There is a national matching service. It updates the list of those waiting for a kidney, does the blood typing and tissue matching for the possible deceased transplant. The waiting list is not a waiting list in the strict sense of the word. Since every kidney from deceased donors that becomes available is linked in the computer to the best match, some people are lucky and receive a kidney after just 6 months whereas others have to wait more than 8 years. The average waiting time overall is roughly around 4 to 5 years. If a living donor is willing to give you a healthy kidney, this donor must be evaluated for medical fitness and compatibility. Depending on the type of donor, waiting time for a kidney will vary. A deceased donor wait will be longer than a living donor due to the shortage of deceased donors. The surgery will take from 2 to 4 hours and your stay in the hospital will be 5 to 7 days. Your doctor will prescribe several new medications to prevent rejection by your body of your new kidney. You will have to take these medications as long as the transplanted kidney works. Transplantation can offer you the greatest potential to return to a healthy and productive life.

Kidney stones are a common problem. The lifetime incidence of kidney stones in Western Nations is 13% for men and 7% for women. The average age for first presentation is 40-50 but kidney stones can occur in virtually any age group. People at greater risk include those from the Middle East, those with obesity and/or “metabolic syndrome”. Many people pass only one kidney stone in their lives but around 50% are recurrent stone-formers. Pain is the most common symptom when passing a kidney stone and some people will notice blood in their urine. When patients present with acute renal colic they should be referred to Urology usually via the Emergency Department (refer Urology Guidelines in Healthpoint) Those with a high risk for recurrent kidney stones should be referred to the Renal Service for Metabolic Risk assessment and management. In many cases this will include Renal Physician and Dietitian assessment with recommendations based on the results of investigations. Some patients will also be managed with medications depending on the risks identified. In virtually all cases patients should be encouraged to drink enough water or other beverages (such as tea, coffee or orange juice) in order to pass 2.5 litres of urine per day so as to dilute promoters of stone formation. It is essential if possible to undertake a stone analysis. Any stone passed should be brought and sent to the laboratory for stone analysis. Further details can be found on the Auckland Health Pathways site.

Not all individuals with stage 5, also known as end-stage chronic kidney disease, wish to have dialysis or transplantation to treat their disease and some groups are unlikely to benefit from these treatments. For such people, it is reasonable to consider forgoing dialysis or transplantation and be referred to the kidney supportive care service. The Te Toka Tumai (Auckland hospital) Kidney Supportive Care service consists of a renal physician, nurse specialist, registrar and clinical dietitian. We provide multidisciplinary, holistic care for people who are not having dialysis for advanced chronic kidney disease after engaging in a shared decision making process with the Nephrology team. We aim to preserve functional capacity and quality of life for as long as possible with symptom management and referral to appropriate community services such as social work and occupational therapy. We aim to engage our patients and their families in advance care planning. We liaise closely with community palliative care services as the end-of-life approaches for our patients to make our patients’ deaths as comfortable as possible.