Handbook for Mortals : Learning about specific illnesses : Concerns about kidney failure

Loss of kidney function leads to serious illness, affecting many aspects of physical well-being. The kidneys filter by-products of body chemistry and adjust the amount of liquid in the bloodstream. Many people have progressively diminished kidney (sometimes called "renal") function as they grow old, but usually this slow decline can be managed with diet and drugs. When the kidneys fail completely, you cannot live for long unless you have dialysis or a kidney transplant. A transplant that works relieves the person of kidney failure. However, transplants are not always available, appropriate, or successful. Dialysis is the name for the process of artificially replacing the main functions of the kidneys. Hemodialysis refers to filtering the blood through a machine; peritoneal dialysis refers to using fluid exchanges through the abdomen. Either procedure can be used to sustain life for years, but they do burden you and your caregiver, and each procedure has complications.

Sometimes a person whose kidneys no longer work decides not to continue or even not to start dialysis and to let death come from kidney (renal) failure. If you are considering this option, you need to know what is likely to happen. Usually, dying from kidney failure is fairly gentle and most symptoms can be suppressed. The characteristics of your renal failure and your other medical problems help to predict which symptoms may arise.

As the by-products of the body's chemistry accumulate in renal failure, these substances cause an array of symptoms. You almost always lose energy and become sleepy and lethargic, but you may find it hard to sleep at night. Over time, the typical patient just slips into deeper and deeper sleep and gradually loses consciousness completely. However, early on, mild confusion and disorientation are common, and usually require only reassurance as treatment. Sometimes, though, upsetting hallucinations or agitation arise. These can be treated very quickly with tranquilizers and anti-anxiety drugs. Certain minerals in the blood-stream can also accumulate and cause twitching of muscles, tremors and shakes, and even seizures. The tremors are usually of no importance to your comfort, but their onset can signal a need to prevent seizures. Medications to prevent or treat seizures are usually quite effective. Some patients develop mild or more severe itching before they become too sleepy to notice. This can be treated with creams, massage, erythropoietin, and antihistamines. Sometimes a fine white powdery substance covers the skin, but it is not the cause of itching and is of no importance. Appetite decreases very early, again to no one's surprise. The accumulation of acids in the bloodstream causes rapid, shallow breathing; this is not an uncomfortable feeling, and the rapid breathing is not changed by oxygen.

Many people with kidney failure pass very little or no urine. If you pass little urine, without dialysis you have to be careful to avoid problems with salt and water overload. Restricting your fluid intake to less than one quart of liquid a day will keep you from having much trouble. Fluid overload results in swelling of the body (edema), particularly of the legs and the abdomen. The excess fluid can also cause congestion of the lungs and the heart, leading to rapid breathing and shortness of breath. Sitting upright helps relieve the breathing difficulties, at least for a while, as it shifts the fluid away from the chest and toward the legs; it may be impossible for persons in this condition to lie flat. Oxygen and morphine may also ease any feelings of struggling to breathe.

It is important to know that persons with some urine output have lived surprisingly long times after stopping dialysis - sometimes for months. People with no urine output are likely to die within a week or two. If this is your choice, or the choice of someone you love, try to be sure that you have a doctor and nurse who are familiar with the problems that might arise. Make sure that medications to treat those problems are readily at hand, especially if you are in a nursing home or at home. In such situations, having a knowledgeable and experienced hospice team involved is often worth exploring, as they will make it their business to get you any urgently needed medications. You probably will have a kidney specialist by this point, and that doctor may be a real help both in making decisions and in keeping you comfortable. So, on the whole, when you have to die, allowing kidney failure to take its course is not generally a hard way to go. In years past, before dialysis, kidney failure had a reputation of being a gentle death.

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Handbook for Mortals book cover Copyright © 1999, 2006 by Joanne Lynn. This extract from the Handbook for Mortals by Joanne Lynn, M.D. and Joan Harrold, M.D. is used with permission. To learn more about improving care at the end of life visit the main web site for Americans for Better Care of the Dying.
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