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رعاية مرضى الكلى في المرحلة المتاخرة من المرض
End-stage kidney disease is the point at which kidney function is no longer sufficient to clear the blood and regulate fluids and salts, so the patient needs treatment that replaces kidney function: dialysis or transplantation, or supportive conservative care for those for whom neither is appropriate. The decision is not made on a laboratory number alone; it rests on symptoms, overall condition and the patient's own choice after a clear explanation of the options. Haemodialysis is usually performed at a dialysis centre in repeated weekly sessions, in which blood passes through an external filter and is returned to the body. It requires vascular access: an arteriovenous fistula is preferred and should be created well before dialysis begins, because it needs weeks to mature, whereas a venous catheter is a temporary solution with a higher infection risk. Peritoneal dialysis uses the membrane of the abdomen itself as the filter through a permanent catheter, and is carried out daily at home or overnight with a machine. It offers greater independence and flexibility for work and travel, but demands strict aseptic technique because its main complication is peritonitis. Neither method is universally better; the choice balances medical condition, heart and vascular status, housing circumstances, family support and patient preference. One point is widely misunderstood: adherence to the number and length of sessions and to fluid and salt limits is part of the treatment itself, not a secondary detail. Cutting a session short, skipping one, or exceeding the fluid allowance causes fluid to accumulate in the lungs and potassium to rise to potentially life-threatening levels. Kidney transplantation is the best option for quality of life and survival when its medical conditions are met, but it is not a final fix that ends the matter. A transplanted kidney requires immunosuppressive medication for life, permanent follow-up and regular testing; immunosuppression raises the risk of infection and certain diseases; and the graft may lose function over time, returning the patient to dialysis. Transplant eligibility is decided by a specialist team after cardiac, vascular, infectious, psychological and social assessment. Care at this stage also includes treating anaemia and calcium-phosphate and bone disorder, calculated nutrition, protective vaccination, blood pressure control, and psychological and social support for the patient and family. Each patient's plan is set by clinical assessment, not by comparison with others.
The team gathers kidney function and electrolyte results, fluid status, symptoms and cardiovascular assessment, then explains the options neutrally: haemodialysis, peritoneal dialysis and transplantation, along with conservative care for some patients. The decision is made together with the patient and family rather than announced to them.
If haemodialysis is chosen, an arteriovenous fistula is created early in a small operation under local anaesthesia; it needs weeks to mature and the patient is taught how to protect it. If peritoneal dialysis is chosen, an abdominal catheter is inserted and the patient and carer are trained step by step in exchange technique and aseptic precautions.
Sessions begin with a set schedule and duration, a target dry weight is defined for the end of each session and adjusted according to blood pressure and swelling, electrolytes, potassium, phosphate and anaemia are monitored, and medication is titrated gradually. Adherence to the schedule and to fluid limits between sessions is what keeps this stage safe.
Associated problems are treated: anaemia, high phosphate and bone disease, high potassium, blood pressure, and problems with the vascular access or catheter. A dietitian sets a calculated plan for protein, potassium, phosphate and fluid, and recommended vaccinations are completed because immunity is weaker in kidney failure.
The patient is assessed for transplantation with cardiac, vascular, infectious and tissue-typing tests plus psychological and social evaluation, and any potential donor is assessed medically and legally. After transplantation, permanent follow-up continues with lifelong immunosuppressive medication and regular testing to detect rejection or infection early.
Before the clinic visit, write down your questions about the available options and bring the family member who shares decisions with you, because the choice affects your work, home and travel. Bring a complete list of your medicines and supplements, and tell your physician about any painkillers or herbal products you take, since these will be stopped. Bring cardiac, diabetes, blood pressure, liver and infection screening reports if you have them. If you are a candidate for an arteriovenous fistula, protect the veins of your non-dominant arm and ask nursing staff not to draw blood or place a cannula in that arm. Tell your team if you do physical work or night shifts, and whether your home has a clean space suitable for peritoneal dialysis, because these practical points genuinely affect the choice.
Attend every dialysis session for its full duration and do not shorten or skip it, and keep to the fluid, salt, potassium and phosphate limits your team has set. Weigh yourself daily on the same scale and record it, since rapid gain means fluid retention. Protect your fistula: do not sleep on that arm, carry heavy loads with it, or allow blood pressure measurement or blood sampling from it, and check its pulsation daily. On peritoneal dialysis, disinfect your hands and workspace at every exchange. Seek urgent care if you develop: **a sharp drop in urine output**, **sudden swelling of the face and feet**, breathlessness or inability to lie flat, **fever with flank pain**, **blood in the urine**, cloudy peritoneal fluid or abdominal pain with fever, redness, pain or bleeding at the access site, loss of the fistula pulse, or palpitations with severe muscle weakness.
A haemodialysis session usually lasts three to four hours and is repeated several times a week, while a peritoneal dialysis exchange takes around half an hour and is repeated daily or run overnight by a machine. An arteriovenous fistula needs weeks before it can be used, transplant work-up may take weeks to months, and follow-up afterwards continues for life.
Dr Ismaeel Qatash is a consultant nephrologist with American board qualifications in internal medicine and nephrology. His practice includes kidney function ass…
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