Today’s Kidney Dialysis Options for People With Diabetes
By Hope Warshaw
For people with diabetes who require dialysis, there are a growing number of options for treatment.
A common cause of kidney failure continues to be many years of elevated glucose levels and blood pressure. People diagnosed with kidney failure, also referred to as stage 5 chronic kidney disease, need regular dialysis and/or a kidney transplant to stay alive.
According to recent statistics, nearly 800,000 people in the US live with End Stage Kidney Disease (ESKD), about half of whom have diabetes. Roughly 70 percent of these people are on regular dialysis and about 30 percent have had a kidney transplant.
The best ways to prevent kidney disease and/or prevent progression to ESKD is awareness, regular screening, proper diagnosis, and if need be, comprehensive treatment. Unfortunately, about 9 in 10 people who have chronic kidney disease (CKD) are unaware that they have it (at any stage), including 2 out of every 5 people with severe CKD. This grim reality greatly impacts efforts to delay progression to kidney failure.
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Delaying Dialysis or Transplant
The keys to delaying or preventing dialysis are early and regular screening, early diagnosis, and starting an aggressive and comprehensive treatment plan.
“We now have good tools to screen and identify kidney disease early along with newer medications to protect kidneys and slow disease progression, including the SGLT2 inhibitors for glucose management and Kerendia [also known as finerenone] specifically for the kidneys,” says Joshua Neumiller, professor of Pharmacotherapy, Washington State University.
“Our challenge is making sure people get two key tests done regularly: Urinary Albumin Creatinine Ratio (UACR) and estimated Glomerular Filtration Rate (eGFR),” adds Neumiller.
According to the American Diabetes Association (ADA) 2023 Standards of Care, people with kidney disease should get these tests one to four times per year based on their kidney function. The ADA also now recommends that people with continuously rising levels of UACR and declining eGFR be referred to a nephrologist (kidney specialist).
Daily diabetes self-care, which includes healthy eating with prescribed changes to preserve kidney function (if need be), physical activity and other behaviors, can also help delay progression of kidney failure.
“Ask for a referral to a registered dietitian nutritionist (RDN) specialized in kidney disease for Medical Nutrition Therapy (MNT) for an individualized eating plan and support,” says Katy Wilkens, a RDN who recently retired from Northwest Kidney Centers in Seattle and who served on the 2022 Kidney Disease Improving Global Outcomes Guidelines for CKD and Diabetes.
Pointing to US data, Wilkens says, “Studies show working with a RDN and following an individualized eating plan precisely can postpone the need for dialysis by over two years, maybe more.”
To find an RDN, ask a nephrologist, call a dialysis center, or use the National Kidney Foundation directory.
*Note: For Medicare beneficiaries with stage 3 kidney disease or beyond, Medical Nutrition Therapy is a covered benefit.
People need to start dialysis when their kidneys are no longer able to adequately filter waste products from the body. At this point kidney function is usually down to 10 to 15 percent of normal, and eGFR is 15 or less. That’s the reason it’s called ESKD or kidney failure.
People also tend to have one or more of these signs and symptoms.
Signs of ESKD
Holding on to excess fluid
Uremic/uremia (build up of waste products in the blood to unsafe levels)
Anemia (low red blood cell count)
Increase in occurrence of hypoglycemia (if you take insulin)
Symptoms of ESKD
Nausea and/or vomiting
Loss of appetite
Weakness, tiredness (malaise)
Itchy skin (pruritus)
Muscle cramps (especially in the legs)
For long-term survival on dialysis, it’s best to not delay starting it. It’s also important to prepare for this change mentally and physically. People are typically referred to a health system-based dialysis center or a dialysis clinic, which is often part of a chain of clinics, such as DaVita, Inc, Dialysis Clinics, Inc. and Northwest Kidney Centers.
“Dialysis centers have a team of healthcare providers including technicians, nurses, social workers, RDNs and nephrologists,” says Gloria Brien, diabetes specialist at Dialysis Clinic Inc. in Jackson, Tennessee. “Staff members help people learn about the types of dialysis, the optimal eating plan to follow, adjusting to dialysis and ongoing support.” She encourages people to have an open mind and learn all they can to be successful on dialysis.
Dialysis Options Today
There are two main types of dialysis. Hemodialysis, by far the most common, is typically done in a center. The other, peritoneal dialysis (PD), is most commonly done at home with assistance from a trained helper.
Each type of dialysis has pros and cons. A person’s personality, life and medical situation should be considered, and the type of dialysis a person starts with can change over time.
Hemodialysis – Requires a dialysis machine, called an artificial kidney, and filter, called a dialyzer. Through access to a vein, waste and excess fluid is filtered from the blood as it circulates through the dialysis machine. The filter has two parts, one for the blood that circulates through and one for the washing fluid. A thin membrane separates the two parts. Components that must remain in the blood are too big to pass through the membrane, while smaller waste products pass through and are rid from the body.
In-center hemodialysis is at scheduled times and regular intervals, about three times a week. Each session can last for four to six hours. A center nephrologist will prescribe the amount of dialysis a person needs and will, along with other staff, monitor and track progress along with the results from regular lab tests.
Home hemodialysis – similar to in-center hemodialysis, however, it needs to be done more often (four to seven days a week) because the machines are not as powerful. There are three ways to do home hemodialysis: conventionally (similar to in-center dialysis), everyday for a short period, or every night. The machines for at home hemodialysis have gotten easier to set up, use, clean and disinfect, however, people need a trained helper to assist them. The person receiving dialysis and their helper need to receive training and pass a test prior to starting.
Peritoneal dialysis (PD):
To do peritoneal dialysis, a catheter (soft plastic tubing) is placed in the abdomen with a minor procedure. Through the catheter, a sterile cleansing fluid flows into and out of the peritoneum (lining of the abdomen) in cycles. In essence, the lining of the peritoneum acts as a natural filter. After a set period of time, when the filtering process is complete, the excess fluid and waste products are removed through the catheter and thrown away. PD is generally done at home.
There are two main types of PD. They work similarly but the way treatments are completed is different. PD is particularly advantageous for people who live a long distance from a dialysis center, such as in rural areas.
Continuous Ambulatory Peritoneal Dialysis (CAPD): CAPD is done continuously without connection to a machine (artificial kidney). Roughly two quarts (comes in plastic bags) of cleansing fluid are put into the peritoneum. The excess fluid and wastes are drained out from the catheter into bags later in the day. Each exchange takes about 30 to 40 minutes and an individual requires four to six exchanges a day.
CAPD allows the person on dialysis to go about their usual life more easily, however it’s obviously time consuming. CAPD requires training and some assistance from a trained helper.
Automated Peritoneal Dialysis (APD), also called Cyclic PD: It’s similar to CAPD, however, with APD a person uses a machine, called a cycler, that delivers the cleansing fluid and then drains it. APD is usually done while a person sleeps, and takes about eight to 10 hours.
Brien (diabetes specialist at Dialysis Clinic) says that APD allows people to use technology, specifically a portable jump drive integrated with the cycler, to track blood pressure, glucose levels and dialysis treatment data simultaneously. People bring the jump drive to the center for download and analysis. Nearly 90% of people on PD use APD.
While there is an effort in the US to increase the use of home dialysis (mainly PD), the stats on types of dialysis used still skew towards in-center dialysis. In 2020, roughly 84 percent of people used in-center hemodialysis whereas 13% used home dialysis, an increase from 7 percent in 2010.
For perspective, Wilkens says, “The low use of home dialysis in the US, in contrast to other countries, is interesting because research shows it’s the treatment that produces the best outcomes at a lower cost.”
Diet, Medications and Dialysis
Being on dialysis requires attention to one’s eating plan, even more so than with diabetes alone. People need to track protein, potassium, phosphorus, sodium and fluid intake. As usual, people with diabetes need to track carbohydrate intake and glucose levels. “Medicare requires every person on dialysis (any type) to work with a RDN which is very valuable,” says Wilkens. “Every person’s diet is unique and will change as kidney function changes along with medications and doses.”
Speaking of medications, Many glucose-lowering medications are cleared from the body by the kidneys, so the types and doses of each medication will require review and change as kidney disease progresses.
“Medication options are more limited in people with kidney failure; one example is metformin which must not be used,” says Neumiller.
Another example of a medication that needs adjustments is insulin. Glucose management remains critical for people on dialysis, but being on dialysis leads to a higher risk of hypoglycemia; as a result, these individuals will have to take insulin in lower doses.
“It’s fairly common for people on dialysis to use an insulin pump and continuous glucose monitor (CGM) to more easily deal with changing glucose levels,” says Brien. Neumiller agrees that CGM can be, “incredibly helpful to detect and prevent hypoglycemia.”
People on dialysis may develop a type of anemia that can impact A1C levels and make it appear lower than it actually is. Measuring time in range from a CGM device, if it is an accessible and affordable option, may prove invaluable.
Covering the Cost of Dialysis
Once a person has ESKD they are eligible to become a Medicare beneficiary no matter their age and whether they are on any type of dialysis or get a transplant. Medicare pays roughly 80 percent of all the costs of dialysis as well as the services of the center’s health care providers. Private health insurance or state Medicaid may also help cover some of these costs.
Some people, if available, may receive a kidney transplant. There are 2 main types of kidney transplants: a living related donor transplant and a donor kidney taken from a deceased person. Family members or others who are a good match may be able to donate one of their kidneys. People who donate a kidney can live healthy lives with just one healthy kidney. A living related donor transplant may be possible much sooner than waiting for a deceased organ donor.
Although dialysis is lifesaving, it is very time consuming and can cause issues that shorten life expectancy. A successful working kidney transplant means that dialysis is no longer needed. Transplant patients usually live longer and have a better quality of life than those who stay on dialysis. Most people say they have extra energy and feel more able to cope with everyday activities after kidney transplant. People who have had a transplant are more able to work and go on vacation, and their sex life and fertility are likely to improve. There are also fewer restrictions after transplant on what one can eat and drink.
For more about kidney health, read Keep your Kidneys Healthy – Latest ADA Standards of Care to learn why subpar glucose levels and blood pressure results cause kidney damage, actions to take to prevent kidney disease and/or delay progression, and the stages of chronic kidney disease (CKD).