Zhang Ruoyao, 16

School: CHIJ St. Nicholas Girls’ School

Topic: Letter to a friend suffering from kidney failure

Award: Distinction, Senior Category, 2021

Dear John,

How are you feeling? It must be difficult for you after being informed that you have to start on dialysis soon or have a kidney transplant after the doctor consultation yesterday. I am so sorry to hear that you had to experience this. I hope my following research will be helpful to you.

There are two types of dialysis treatment - hemodialysis (HD) and peritoneal dialysis (PD). Hemodialysis is a treatment to cleanse the blood of toxins, extra salts and fluids through a dialysis machine, helping to control blood pressure and balance important minerals in your blood. At the start of HD, two needles will be inserted into your arm, one to remove your blood and one to return cleansed blood to the body.

Blood is then continuously pumped through the dialyser where waste products and excess water are removed before the purified blood returns to your body. It is performed thrice a week at a dialysis centre, with the duration of each session, which would be advised by the doctor depending on the body size and medical condition, lasting about 4 hours (The National Kidney Foundation Singapore, 2021b).

PD is performed at home and involves a special sterile fluid being introduced into the abdomen through a permanent tube called the catheter that is placed in the peritoneal cavity. The fluid then circulates through the abdomen to draw impurities from surrounding blood vessels in the peritoneum, which is then drained from the body (The National Kidney Foundation Singapore, 2021c).

There are two types of PD - Continuous Ambulatory Peritoneal Dialysis (CAPO) and Automated Peritoneal Dialysis (APD). CAPO is machine-free and done while you go about your daily activities. It is done by hooking up a plastic bag of cleansing fluid to the tube in your abdomen in which raising the bag to shoulder level causes gravity to pull the fluid into your abdomen. The fluid which has wastes removed from your blood is drained and thrown away afterwards (The National Kidney Foundation New York, 2021b). This process is usually done four times a day for 30 to 40 minutes while the fluid is kept in the abdomen for 4 to 6 hours or more. Timings for your exchanges are more flexible as you are able to sleep with the fluid in your abdomen at night without having to wake up at night to do an exchange (National Institute of Diabetes and Digestive and Kidney Diseases, 2018). On the other hand, APO is usually done at night with a machine that will change the dialysate solution while you are asleep, but that means you will have to be attached to the machine for eight to ten hours (The National Kidney Foundation Singapore, 2021b). Professional training is required on how to hook yourself up to the machine.

An advantage of HD is that you would have four dialysis-free days a week. However, a disadvantage is that it may be inconvenient to travel to the dialysis centre so frequently, hence home hemodialysis is also an option, but you would have to be trained to use the equipment at home. HD patients are also at an increased risk of developing sepsis where bacteria enter the body and spread through the blood, potentially leading to multiple organ failure (United Kingdom National Health Service,2018a). Frequent hemodialysis also increases the risk of vascular access complications (Suri et al., 2013).

Compared to in-center HD, PD offers greater flexibility to patients regarding time management as PD patients are able to adapt the PD prescription to their daily activities and a PD clinic visit is scheduled every four to twelve weeks compared to thrice weekly for patients treated with in-center HD. The technical simplicity of PD also allows patients to perform dialysis while traveling, without the need for facility support (Francois & Bargman, 2014). However, PD needs to be carried out every day, which may affect your daily routine. A common side effect of PD is peritonitis, the bacterial infection of the peritoneum (United Kingdom National Health Service, 2018b). Morbidity resulting from PD-related peritonitis is significant, with some episodes being complicated by hospitalization and temporary or permanent transfer to HD. Inflammatory processes during severe, recurrent, relapsing, repeated or refractory peritonitis can lead to peritoneal membrane failure and the need to discontinue PD (Franc;ois & Bargman, 2014).

For both HD and PD, there are also restrictions regarding physical activity. Low­ impact exercises are advised before increasing the intensity. HD patients should avoid carrying heavy weights on the limb of their dialysis access site while PD patients should avoid excessive flexion, extension or torsion movements in the abdomen (The National Kidney Foundation Singapore, 2021a).

You can also consider the option of kidney transplant, which refers to removing an organ from one person (the donor) and surgically placing it in another (the recipient) whose organ has failed (Cleveland Clinic, 2021), either from a living person (Mayo Clinic, 2021a) or from a person who had been declared dead by established medical criteria (World Health Organization, 2009) as a one-off permanent solution.

One of the advantages of living-donor transplant is that the organ is generally healthier as in order to donate, donors are evaluated for their kidney function, compatibility and overall physical health (University of Minnesota Masonic Childrens Hospital, 2017). Compared to deceased-donor transplants, living donor kidneys will be of better quality and tend to function immediately because surgeons transplant the kidney immediately after removing it from the donor, improving the chances that the transplanted organ will function right away, reducing the risk of kidney transplant failure (University of Pittsburgh Medical Center, 2017) and the risk of needing any dialysis after transplant to less than 4%. Conversely, kidneys from deceased donors usually spend a longer time in a cold preservation solution while they are being transferred between hospitals, which temporarily reduces organ function. Roughly one-third of kidneys from deceased donors take days or weeks to become fully functional after the transplant, making the recipients more vulnerable to complications after surgery (University of Minnesota Masonic Childrens Hospital, 2017).

Living donor kidneys also tend to have a greater longevity than those transplanted from a deceased donor. A living donor kidney functions on average for roughly 14 years and about 20 years on average if the recipient makes it through their first year following a living donor kidney transplant without any major complications, compared to 10 years for a kidney from a deceased donor (University of Minnesota Masonic Childrens Hospital, 2017).

However, if a compatible living donor is not available, you may be placed on a kidney transplant waiting list to receive a kidney from a deceased donor. The waiting time depends on the degree of matching or compatibility between you and the donor, time on dialysis and on the transplant waitlist, and expected survival post-transplant. Some people get a match within several months, and others may wait several years (Mayo Clinic, 2021b).

Kidney transplants have their own risks as well, such as the risk of organ rejection and the need for immunosuppressive drugs. Acute rejection typically results from T cells infiltrating the organ, causing local inflammation that damages the organ, typically occurring in the first year after transplant or months and even years after the transplant if the recipient stops taking the immunosuppressants. To stave off acute rejection, patients take drugs that suppress immune function (Arnaud, 2018). However, immunosuppression may increase the prevalence of fungal and viral infections, failure of immunisation, risk of developing cancers and risk of cardiovascular complications (Christians et al., 2011), as immunosuppressant drugs weaken your immune system, also making you less resistant to infections (Giorgi, 2019). Meanwhile, during chronic rejection, the person’s immune system continually attacks the transplanted organ. Eventually the damage builds up enough that the organ stops working and patients experience no symptoms until the situation is too advanced to do anything about it. No treatment for the condition yet exists (Arnaud, 2018).

For the foregoing reasons mentioned above, I would recommend that you put your name on the waiting list for a living kidney transplant for a relatively normal life instead of life-long dialysis while performing either HD or PD at your convenience. You may also want to speak with your family members about donating a kidney to you as having a better genetic match may lessen the risks of rejection (The National Kidney Foundation New York, 2020a). You will need to create a new normality in your life, and I will be supporting you to the best of my ability every step of the way.

Please discuss in great detail with your doctor and family members to come up with the most preferable solution for you according to your health and your wishes. Let me know if you want me there too. I hope that my research is helpful in your decision­ making. My sources are included at the end of this letter, if you want to look deeper into it. I wish the best of health and hope to see you soon at our annual Christmas Dinner gathering!

Regards,
Tom

References

1. Arnaud, C. H. (201 8, January 29). Uncovering The Hidden Signs Of Organ Transplant Rejection. C&EN. https://cen.acs.org/articles/96/i5/uncovering-the%C2%AD%20hidden-signs-of-organ-transplant-rejection.html%20

2. Christians, U., Klawitter, J., Klawitter, J., Brunner, N., and Schmitz, V. (2011, February). Biomarkers of immunosuppressant organ toxicity after transplantation: status, concepts and misconceptions. Expert opinion on drug metabolism & toxicology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3079351 /#:-:text=The%20risks%20 associated%20with%20immunosuppressants,and%20risk%20of%20developing% 20cancers

3. Cleveland Clinic. (2021, April 5). Organ Donation and Transplantation: How it works. Cleveland Clinic. https://my.clevelandclinic.org/health/articles/11 750-organ­ donation-and-transplantation

4. Francois, K., & Bargman, J. M. (2014, December 4). Evaluating the benefits of home-based peritoneal dialysis. International journal of nephrology and renovascular disease. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4260684/

5. Giorgi, A. (201 9, January 9). lmmunosuppressant Drugs: A Complete Overview. HealthIine. https://www.healthline.com/health/immunosuppressant-drugs#side­-effects

6. Mayo Clinic. (2021, April 27 - a). Living-donor transplant. Mayo Clinic. https://www.mayoclinic.org/tests-procedures/living-donor-transplant/about/pac- 20384787

7. Mayo Clinic. (2021, April 27 - b). Kidney transplant. Mayo Clinic. https://www.mayoclinic.org/tests-procedures/kidney-transplant/about/pac- 20384777

8. National Institute of Diabetes and Digestive and Kidney Diseases. (201 8, January). Peritoneal Dialysis. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/kidney-disease/kidney­ failure/peritoneal-dialysis

9. The National Kidney Foundation New York. (2020, April 14 - a). General Information on Living Donation. National Kidney Foundation. https://www.kidney.org/transplantation/livingdonors/general-information-living­-donation

10. The National Kidney Foundation New York. (2021, June 1 - b). Peritoneal Dialysis: What You Need to Know. National Kidney Foundation. https://www.kidney.org/atoz/contenUperitoneal

11. The National Kidney Foundation Singapore. (2021 - a). Keeping Fit for Dialysis Patients. The National Kidney Foundation NKF Singapore. https://nkfs.org/treatment-options/keeping-fit-for-dialysis-patients/

12. The National Kidney Foundation Singapore. (2021 - b). What is Haemodialysis? The National Kidney Foundation NKF Singapore. https://nkfs.org/treatment­ options/what-is-haemodialysis/

13. The National Kidney Foundation Singapore. (2021 - c). What is Peritoneal Dialysis? The National Kidney Foundation NKF Singapore. https://nkfs.org/treatment-options/what-is-peritoneal-dialysis/

14. Suri, R. S., Larive, B., Sherer, S., Eggers, P., Gassman, J., James, S. H., Lindsay, R. M., Lockridge, R. S., Ornt, D. B., Rocco, M. V., Ting, G. 0., Kliger, A. S., and the Frequent Hemodialysis Network Trial Group. (201 3, March 1 ). Risk of Vascular Access Complications with Frequent Hemodialysis. American Society of Nephrology. https://jasn.asnjournals.org/contenU24/3/498.short

15. United Kingdom National Health Service. (2018, June 14 - a). Pros and Cons. NHS Choices. https://www.nhs.uk/conditions/dialysis/pros-cons/

16. United Kingdom National Health Service. (2018, June 14 - b). Side effects. NHS Choices. https://www.nhs.uk/conditions/dialysis/side-effects/

17. University of Minnesota Masonic Children’s Hospital. (201 7, July 5). Why Do Living Donor Kidney Transplants Offer Better Outcomes? Why do living donor kidney transplants offer better outcomes? MHealth.org.
    https://www.mhealth.org/childrens/blog/2017/july-2017/why-do-living-donor-kidney­transplants-offer-better-outcomes

18. University of Pittsburgh Medical Center. (201 7, January 7). Benefits and Risks of Kidney Donation. UPMC Transplant Services. https://www.upmc.com/services/transplanUkidney-pancreas/living-donor/benefits­ risks

19. World Health Organization. (2009). Global glossary of terms and definitions on donation and transplantation. World Health Organization. https://apps.who.inUiris/handle/10665/341813
    

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