End-stage Kidney Disease

Patients with ESKD or Chronic Kidney Disease (CKD G5) will receive comprehensive evaluation of psychosocial functioning, clinical evaluation, intensive counselling, and education on management options.

Based on the evaluation, your doctor will recommend a preferred course of therapy, while considering your choices. He/she will also help you develop a long-term kidney plan.

On average, ESKD patients can expect to live more than 10 years (more than 50% of patients), and it is important to develop a long-term treatment plan for the best outcomes. The commonest causes of death in ESKD patients are due to heart disease and infection.

Patients who are sure that they do not wish to undergo kidney replacement therapy (dialysis or kidney transplantation) will enrol into a program where the goal is to slow the progression of CKD and appearance of symptoms associated with ESKD or CKD G5. Patients with severe frailty are often recommend conservative care to optimise their quality of life and health-span.

In particular, they may be placed on a Very-Low Protein Diet with an essential keto-amino acid supplementation program, coupled with regular dietitian follow-up. Patients able to successfully adhere to the diet are often able to be symptom-free for a long time.

Once patients with ESKD who are no longer able to undergo dialysis or are developing symptoms while on conservative treatment program, they are enrolled into a palliative care program, where the goals of management are to reduce symptoms and discomfort. At this time, you are referred to specialist doctors and nurses in palliative care.

Palliative care may be performed at home by visiting staff. Where appropriate, patients are admitted to a hospice.

Kidney transplantation is the initial preferred option for ESKD, and can be performed for suitable patients even without embarking on dialysis (pre-emptive transplantation). Kidney transplantation offers the best clinical outcomes for ESKD. Patients are evaluated for suitability for transplantation, and potential donors are assessed for suitability to donate. Singapore citizens may be placed on the National Deceased Donor kidney transplantation program. Because of the long wait-time for deceased donor kidneys, where suitable and available, all ESKD patients are encouraged to undergo living (related or unrelated) kidney transplantation.

Unless there are medical reasons not to do so, the initial kidney dialysis therapy is PD. In the life-cycle of ESKD, PD is used to take advantage of the remaining very low kidney function (residual kidney function). This allows a patient to start with low doses of PD, and increase the intensity of treatment as the CKD G5 progresses in severity.

Patients who are unsuitable for, or can no longer undergo peritoneal dialysis are placed on hemodialysis. Patients undergo minor surgery to connect a vein to an artery and create an arterio-venous fistula (AVF). Once this is mature, needles are inserted. Blood is removed and passed through a machine for processing (removing waste and excess water), and finally returned to the patient. There are several formats of undergoing hemodialysis. Where suitable, patients can perform home hemodialysis (short daily dialysis or nocturnal dialysis). More often, patients travel to an outpatient dialysis centre three times a week, and undergo dialysis for about five hours each time.