Looking for Information on Dialysis

[dtwilkinson]

HI - 38 year old female with extremely high uncontrollable hypertension. Meds ae not controlling the hypertension, and we cannot find the cause. Kidneys are now functioning at 10% and 80%. Doctor wants me to start dialysis in hopes that the hypertension will be controlled, and that he can save what function is left. However, he has also stated that it is possible that I may have to continue the dialysis forever, even if the hypertension is controlled. I am trying to find some information on this aspet of dialysis and not being able to discontinue it later. Can anyone point me to some information on this? ThankYou

[DoriSchatell]

Whoa! We are not doctors here, but using dialysis to treat recalcitrant high blood pressure seems extreme--plus, I'm not sure how this would be paid for, since I doubt that your level of kidney function would justify it. I'd get a second (third, fourth) opinion at the very least.

The U.S. Government keeps a website that is a "National Guideline Clearinghouse," and on it, there are guidelines (updated in 2005) for diagnosis and treatment of high blood pressure. Here is the link:
http://www.guideline.gov/summary/summary.aspx?doc_id=8326&nbr=004658&string=hypertension+AND+differential+AND+diagnosis .

It's very important to get high blood pressure under control, as it can raise your risk of stroke, heart attack, blindness, and kidney failure. Some conditions your doctor should be considering that may cause it include:

-- Chronic kidney disease/obstructive uropathy
-- Thyroid and parathyroid disease
-- Drugs (prescription, over-the-counter, herbal supplements, illicit drugs)
-- Excessive alcohol use
-- Obstructive sleep apnea
-- Primary aldosteronism
-- Renal artery stenosis
-- Pheochromocytoma
-- Cushing's syndrome
-- Aortic coarctation
-- Obesity

If it were me, I'd want these conditions ruled out before trying something as drastic, costly, and life-altering as dialysis before you need it due to kidney failure (which I sincerely hope never happens).

[dtwilkinson]

Thank you for the prompt reply DoriSchatell. I realize you are not doctors. Have been dealing with the unexplained high hypertension now for several months, and hypertension in general for years, and they cannot find anything at all that explains the constant high numbers.. meds are not helping to lower it, and the nephrologist is worried that my kidneys will keep failing, as they have been doing.... 10% in the one is getting fairly low. He mentioned that one of the problems that I could experience with starting dialysis is that even if they do get the hypertension under control I may not be able to stop using dialysis because my kidneys may not be performing well because of the dialysis... I was looking for websites that talk particularly about the inability to come off of dialysis even if the hypertension is controlled. I am looking to get some idea of why this may happen and the statistics of how often this is a problem. 38 is fairly young to have this problem. The only thing that they have not ruled out is an abnormal adrenal gland or growth in the adrenal gland... had a test for this on Friday afternoon, results should be back today.... after that I am doing a full body scan (insurance will not cover that) before making any decisions on the dialysis. Thanks again.

[DoriSchatell]

Not all doctors are good diagnosticians--being able to diagnose is a special gift/skill, and some hospitals actually have departments especially for that purpose. It takes time, careful thought, and an open mind to make a diagnosis when the situation isn't typical. Doctors are taught "when you hear hoofbeats, think of horses, not zebras." But what you have may be a zebra.

Tell us more, if you don't mind:
-- How high is your blood pressure?
-- How did your high blood pressure come to be diagnosed in the first place?
-- Do you check your BP at home? How often/day?
-- Is it high all the time, or are there variations based on the time of day, day of the week, or other factors?
-- Do you have other symptoms besides high blood pressure?
-- Have you actually taken ALL of the BP meds you've been prescribed as they are meant to be taken? (Sorry, but sometimes MDs believe the drugs have failed when, in fact, they were too costly to buy or too difficult to remember to take)
-- What do you normally eat--is your diet high in sodium? (Are you even among the 10% of the population that is sensitive to sodium?)

In general, hemodialysis done three times a week for a few hours in a clinic (which 91% of U.S. patients end up on) tends to wipe out any remaining kidney function you have in relatively short order. So, even if dialysis would somehow control your blood pressure, chances are, after a while on it, you would have to stay on it because your kidneys would fail pretty nearly completely.

Also, the way that hemodialysis is done in the U.S. (as I just described above), it tends to cause high blood pressure even in people who didn't have it before. The problem is, healthy kidneys work 24/7. So in just 9-12 hours of dialysis spread out over 3 days/week, trying to remove all of the excess fluid that has built up over the previous 2-3 days between treatments leads to severe ups and downs in fluid balance--and high blood pressure. In other countries where they dialyze longer and slower, blood pressure is much better controlled. But not here--unless you were to do either PD or nocturnal home hemo. To learn more about those treatments, visit another of our sites: Home Dialysis Central at http://www.homedialysis.org.

In 16 years in this field, I've never heard of anyone trying to use dialysis to control high blood pressure--though in the past, there were occasions where they would remove the kidneys (if they were the source of the high blood pressure), and the patient would then require dialysis.

I assume that by a "growth on the adrenal gland," you're talking about a pheochromocytoma? If so, these tumors that cause extremely high blood pressure (usually not all the time) can be very tiny--even microscopically small--and can be located anywhere in the body, not necessarily just on the adrenals. It can be a hereditary problem--did anyone else in your family ever have one? Your full body scan may be useful to find it, even if insurance doesn't pay.

To me, this sounds as if this idea of dialysis to control blood pressure is outside regular medical practice and could harm you severely. Please don't rely only on the opinion of this one doctor. Any good doctor would urge you to get a second opinion in a case such as yours.

[dtwilkinson]

Blood Pressure is running as high as 170 to 204 / 98 to 109...It is checked several times a day and does sometimes drop to 140 over low 90's. I have had hypertension since collecge but did not do anything about it until about 7 years ago... then meds which controlled it until I stopped taking tham..I know, I know... Regular visits to my doctor recently resulted in my diagnosis of the uncontrollable hypertension. I cannot find any factors that determine when it is high or when it is low.... Also no other symptoms except the failing kidney functions....

I guess I misstated ny doctor's intention here. Doctor is not trying to control the blood pressure with dialysis, he is worried that I will lose all kidney function while trying to find the reason for the high blood pressure... he mentioned that sometimes dialysis can "clean" out the kidneys, and restore some function to them, but that dialysis may also become permanent, which is my concern about dialysis.... I don't know about the growth on the adrenal gland... A test waqs performed by my primary doctor but she did not realize that one of the meds I was on could cause a false negative to be returned... after redoing that test they wanted to do a CAT scan on my adrenals....

I am taking all meds as prescribed now....hereditary problems are not known as I was adopted. Thanks for all the info, especially the info about how dialysis can cause the kidneys to shut down permanantly. DO youknow of any good sources of info on the web regarding this that I can read and refer to?

Thanks Again.

[DoriSchatell]

he mentioned that sometimes dialysis can "clean" out the kidneys, and restore some function to them
This is not likely. I suspect it's your primary doctor who is suggesting this, not a nephrologist (kidney specialist). It's really not true. And dialysis is not paid for by Medicare (the usual payer unless you have an employer group health plan--and even if you do, they're likely to use Medicare criteria) until total kidney function is less than 15%. It's not covered preemptively.

I found this study on loss of residual renal function. I think you can tell from the phrases I bolded that starting hemodialysis with high blood pressure is a risk factor for loss of residual renal function, and that hemodialsyis is more likely to cause loss of residual renal function than PD. In effect, starting hemodialysis is likely to cause exactly what your doctor says he is trying to prevent.

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Kidney Int. 2002 Sep;62(3):1046-53.
Predictors of the rate of decline of residual renal function in incident dialysis patients.

Jansen MA, Hart AA, Korevaar JC, Dekker FW, Boeschoten EW, Krediet RT; NECOSAD Study Group.

Division of Nephrology, Department of Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. mjansen@knmg.nl

BACKGROUND: Residual renal function (RRF) influences morbidity, mortality and quality of life in chronic dialysis patients. Few studies have been published on risk factors for loss of RRF in dialysis patients. These studies were either retrospective, performed in a small number of patients, or estimated GFR without a urine collection. METHODS: We analyzed the decline rates of residual GFR (rGFR) prospectively in 522 incident HD and PD patients who had structured follow-up assessments. GFR was measured as the mean of urea and creatinine clearance, calculated from urine collections. The initial value was obtained 0 to 4 weeks before the start of dialysis. The measurements were repeated 3, 6, and 12 months after the start of dialysis treatment. After logarithmic transformation, differences in rGFR changes over time were analyzed using repeated measurement analysis of variance. RESULTS: Baseline factors that were negatively associated with rGFR at 12 months were a higher diastolic blood pressure (P < 0.001) and a higher urinary protein loss (P < 0.001). Primary kidney disease did not affect rGFR. Averaged over time, PD patients had a higher rGFR (P < 0.001) than HD patients. This relative difference increased over time (P = 0.04). Investigation of possible effects of the dialysis procedure on the decline rate between 0 and three months showed that dialysis hypotension (P = 0.02) contributed to the decline in HD and the presence of episodes with dehydration contributed in PD (P = 0.004). CONCLUSIONS: rGFR is better maintained in PD patients than in HD patients. The associated factors such as a higher diastolic blood pressure, proteinuria, dialysis hypotension and dehydration can either be treated or avoided.
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So-called "non-compliance" with BP meds is extremely common. Have you tried any other ways to lower your blood pressure, such as:
-- Exercise
-- The DASH diet (put "Dash Diet" into Google to find a govt. site on it)
-- Meditation/relaxation training

You have very little to lose and much to gain by combining approaches and not relying only on drugs to help lower your blood pressure. We have a whole module on "Heart Health and Blood Pressure" in our Kidney School on-line learning center that you may want to go through at http://www.kidneyschool.org.

[Beth Witten MSW ACSW]

I've been reading through this thread. After working as a social worker with people with kidney disease I wonder how the doctor can tell that one of your kidneys is functioning at 10% and the other at 80%. It is possible to tell on a scan that someone has a small kidney and that kidney is not functioning very well. It's possible that the kidney was always small or has shrunken as kidney tissue is damaged. However, kidney function measurement from blood and urine is based on the combined functioning of both kidneys. The test that is recommended now is the glomerular filtration test (GFR) that is calculated from certain labs and information about you.
http://labtestsonline.org/understanding/analytes/gfr/glance.html

Has anyone checked to see if you have blockage in the artery to the kidneys? There is a condition called renal artery stenosis that can cause the blood pressure to go up and kidney tissue to shrink.

http://www.nlm.nih.gov/medlineplus/ency/article/001273.htm

http://www.mayoclinic.com/health/shrinking-kidney/AN00408

Has anyone measured the level of renin and/or aldosterone in your blood? These are hormones that can cause high blood pressure.

http://labtestsonline.org/understanding/analytes/aldosterone/glance.html