Lyvia Choo Xinyan, 16

School: CHIJ St. Nicholas Girls’ School

Topic: Letter to a friend suffering from kidney failure

Award: High Distinction, Senior Category, 2021

Dear Sam,

I am writing this letter because I wanted to check on how you are feeling thus far, especially after hearing that you need to decide on a treatment option soon for your kidney. As your closest friend, I can probably understand how anxious you may be feeling about your current condition but do stay hopeful and look at things positively. Before you decide on your actual treatment option, I want you to make the right decision so that you will be more prepared and well-informed about the entire process. As a result, I researched both options and collated the benefits and drawbacks of both dialysis and kidney transplant and will be presenting it in this letter.

Firstly, you will need to understand what dialysis is, including its risks and benefits. Dialysis is defined as the process of removing waste products and excess fluid from the body and is vital when the kidneys are no longer able to perform most of its functions to adequately filter the blood (Medical Definition of Dialysis, 2021). Dialysis gives patients with end-stage kidney failure a chance to still lead decent lives, such as being able to exercise moderately, driving, working etc. However, patients who opt for haemodialysis will have to take time off to go to dialysis centres almost thrice a week to carry out the dialysis, which lasts approximately for four hours, depending on condition and body size (What is Haemodialysis, n.d.). A minor operation will be needed to create a fistula, which is a connection of an artery to a nearby vein under the skin to create a larger blood vessel. Blood is pumped from the arteriovenous fistula into the dialyzer and filtered blood is pumped from the dialyzer and returned back to the arteriovenous fistula. It is a recommended choice of access since it lasts longer and has fewer issues (About Dialysis for Kidney Failure, n.d.). Some people are not able to have one due to stenosis and blood clot, but it is possible to switch from fistula to other modes of access (What Happens When an AVFistula Fails, 2019).

Besides haemodialysis, there is also peritoneal dialysis, which uses a cleansing fluid pumped into the peritoneal space of the body through a plastic tube (catheter) to remove the excess waste products and fluids from the body (What is Dialysis, n.d.). Both dialysis treatments serve the same outcome for patients with end-stage organ failure, but the important contrast is that peritoneal dialysis does not require one to take weekly trips to the dialysis centre because it can be done manually at home, even while travelling, which is less restrictive than haemodialysis and better for those who have a strict work schedule. (Cunha, 2017). Like Haemodialysis, peritoneal dialysis needs one to undergo minor surgery to insert a permanent catheter outside the body.

Dialysis is expensive but fortunately, there are programmes in Singapore such as Medishield Life and the National Kidney Foundations (NKF) dialysis programmes that cover the treatment at subsidised rates in which you can also apply for if you are eligible under the terms and conditions. Patients undergoing dialysis may require special and restricted diets related to protein, water or salt intake which are possible factors that can affect the treatment (Eating Right for Dialysis Patients, n.d.). Side effects are also expected after dialysis, such as nausea and light-headedness (Dialysis(Hemodialysis), n.d.). When one goes through dialysis, they will have to make adjustments to their diets, lifestyle, work schedule which can be quite difficult to get used to in the earlier stages. But overall, dialysis allows patients with end-stage organ failure maintain their current health until they can receive a kidney transplant.

Other than dialysis, the second option you have is a kidney transplant. A kidney transplant is the process where a kidney is surgically removed from a donor, either living or deceased, and implanted into a patient with end-stage kidney failure. In Singapore, patients can receive a kidney from a living related donor, meaning a family member, relatives or friends or from a complete stranger (altruistic donation). The kidney can also come from deceased donors, retrieved under the Human Organ Transplant Act (Organ Transplantation, n.d). Beth Israel Deaconess Medical Center found that “the average life expectancy for a patient on dialysis is generally five years, while a living donor kidney functions, on average, 12 to 20 years, and a deceased donor kidney from 8 to 12 years”. Thus, kidney transplant allows patients to live longer. (Kidney Transplant, n.d.). A survey done by BMC Nephrology which aims to understand quality of life mentioned that for many who had undergone kidney transplant could now use the time freed up from dialysis sessions to participate in activities they could not do beforehand, resulting in a strong sense of normalcy (Tucker, 2019). As a result, kidney transplant does remarkably improve a patient’s quality of life as one will no longer have to frequent dialysis centres per week, lesser restrictions for diet and a lot more freedom to do activities that they long to do which they could not before due to dialysis.

When a donor’s kidney becomes available, tissue typing is carried out to ensure that the organ is extremely similar to the tissues of the recipient so as to prevent mismatched kidneys which can trigger a transplant rejection in which a recipient’s immune system recognises it as foreign and tries to attack the organ. Transplant rejection is one of the largest disadvantages of kidney transplant because all recipients do go through some amount of acute rejection, most common amongst three types of rejection and it occurs spontaneously up to 3 months after the transplant. If detected, it can be treated quickly with immunosuppressive drugs, but repeated episodes can lead to chronic rejection and at this point, only another kidney transplant can save the patients life. The risk lies in the new kidney failing even after kidney transplant and one has to end up getting another kidney or go back to dialysis (Transplant Rejection, n.d.). Almost all organ transplant recipients will have to take immunosuppressive drugs to prevent rejection of the transplanted organ. Taking such drugs results in a weakened immune system and subsequently increases chances of getting infected by common diseases and opportunistic organisms, thus putting you at a higher risk for cancer, heart attack and stroke, especially if you have a history of high blood cholesterol, high blood pressure or diabetes (Kidney Transplant Surgery, n.d.).

Not everyone is eligible for a kidney transplant as they have certain conditions that can affect their transplant candidacy such as not being healthy enough to survive the operation, substance abuse or smoking (Kidney Transplant Waitlist, n.d.). Like dialysis, NKF is offering more financial subsidies to cut transplant costs for low income patients to encourage more live donors to come forward (Tai, 2018). Unlike dialysis which is an immediate treatment for one with end-stage kidney failure, a kidney transplant can take years to happen, especially when a live donor is not available and the patient is placed on the kidney waiting list for an organ transplant which has over 400 individuals (Facts about Organ Donation, n.d.). Though the benefits of kidney transplant outweigh the dialysis, the demand in Singapore for a kidney has outstripped the supply from live and brain-dead donors, thus majority of people with kidney failure end up carrying on with dialysis as only a few will have a chance at getting a transplanted kidney.

With that said, I still believe that a kidney transplant is the most favourable treatment as it can prolong one’s lifespan much more significantly than one on dialysis as mentioned above. It is also a lot more convenient for the patient. The main concern is definitely the shortage of organs from donors and thus, kidney transplant may be the best but not exactly the most available option for all who need it. This is why most patients undergo dialysis treatment first while on the waiting list for a kidney transplant and I recommend you to do the same. Dialysis is not necessarily the best long term solution but it provides additional time for the doctors and team to find a suitable kidney for you in the meantime. Until a kidney is available, dialysis is the best treatment option for now. Whether it is haemodialysis or peritoneal dialysis, you should go for the treatment that best suits your lifestyle and preferences or you can choose to follow your doctor’s advice. However, it is possible to switch from one to the other if you ever do change your mind.

To end off, I hope that this letter was of some help to you as you decide on which treatment option to go forth. Remember that going on dialysis does not mean the end of the world so stay optimistic and have the faith that your condition can and will get better. Talk to you soon!

Your dearest friend,
Lyvia

References

1. Cunha, J. P. (2017, December 11). What Is Dialysis? Peritoneal, Hemodialysis, Fistula, Diet & Life Expectancy. MedicineNet. https://www.medicinenet.com/dialysis/article.htm#dialysis_definition_and_facts

2. Eating Right for Dialysis Patients. The National Kidney Foundation NKF Singapore. (n.d.). https://nkfs.org/treatment-options/eating-right-for-dialysis-patients/

3. Facts about Organ Donation. Live On I Facts. (n.d.). https://www.liveon.gov.sg/facts.html

4. Key points: About Dialysis for Kidney Failure. National Kidney Foundation. (2020, June 16) https://www.kidney.org/patients/peers/dialysis

5. Khatri, M. (Ed.). (n.d.). Dialysis (Hemodialysis): Purpose, Procedure, and Complications. WebMD. https://www.webmd.com/a-to-z-guides/kidney-dialysis

6. Kidney Transplant Surgery, Procedure & Benefits. Fresenius Kidney Care. (n.d.). https://www.freseniuskidneycare.com/treatment/transplant

7. The Kidney Transplant Waitlist- What You Need to Know. National Kidney Foundation. (2020, November 5). https://www.kidney.org/atoz/content/transplant-waitlist

8. Kidney Transplant. BI DMC of Boston. (n.d.). https://www.bidmc.org/centers-and­-departments/transplant-institute/kidney-transplant

9. Marks, J. W. (Ed.). (2021, March 6). Medical Definition of Dialysis. Medicine Net. https://www.medicinenet.com/dialysis/definition.html

10. Organ Transplantation - National University Hospital. National University Hospital. (n.d.). https://www.nuh.com.sg/our-services/Specialties/Organ-Transplantation/Pages/default.aspx

11. Tai, J. (2018, September 16). NKF offers more subsidies to boostkidney donor number. The Straits Times. https://www.straitstimes.com/singapore/health/nkf-offers-more-subsidies-to-boost­-kidney-donor-number

12. Tucker, E. L., Smith, A. R., Daskin, M. S., Schapiro, H., Cottrell, S. M., Gendron, E. S., Hill-Callahan, P., Leichtman, A. B., Merion, R. M., Gill, S. J., & Maass, K. L. (2019, May 16). Life and expectations post-kidney transplant: a qualitative analysis of patient responses. BMC Nephrology https://bmcnephrol.biomedcentral.com/articles/10.1186/s12882-019-1368-0#citeas

13. U.S. National Library of Medicine. (n.d.). Transplant rejection: MedlinePlus Medical Encyclopedia.MedlinePlus. https://medlineplus.gov/ency/article/000815.html

14. What Happens When an AVFistula Fails?Azura Vascular Care. (2019, November 4). https://www.azuravascularcare.com/infodialysisaccess/what-happens-when-an-av-fistula­ fails/.

15. What is Dialysis? Fresenius Kidney Care. (n.d.). https://www.freseniuskidneycare.com/treatment/diaIysis

16. What is Haemodialysis? The National Kidney Foundation NKF Singapore. (n.d.). https://nkfs.org/treatment-options/what-is-haemodialysis/
    

Disclaimer: Please note that the views and opinions expressed in the essays for the Live On Festival 2021 are those of the participants and are not endorsed by the National Organ Transplant Unit (Ministry of Health).

To learn more about organ donation and organ transplantation in Singapore, please visit www.liveon.gov.sg