According to recent statistics by National Kidney Foundation (NKF), about 5.7 new patients are diagnosed with end-stage kidney disease (ESKD) daily and there are currently more than 8,500 people in Singapore requiring dialysis.

These numbers are expected to rise with an ageing population.

It is important for patients who are diagnosed with ESKD to plan ahead for dialysis or get a kidney transplant.

Some may choose not to pursue either option if they feel that dialysis may not extend their life or improve their quality of life. These patients are usually managed by palliative physicians and nephrologists.

Kidney dialysis is a process to remove waste products and excess fluid from the blood when the kidneys fail. There are two main forms of dialysis:

  1. Haemodialysis and

  2. Peritoneal dialysis

Haemodialysis is more common and the one most people are aware of. During the procedure, blood is passed from the blood vessels in your arm to the dialysis machine which filters out waste products and removes excess fluid before returning it to your body via another needle. This is usually done at a dialysis center 3 times a week for 4 hours each session.

Peritoneal dialysis uses the lining of your abdomen (the peritoneum) as a filter (instead of a machine!). The peritoneum contains many small blood vessels which makes it a useful filtering device. A dialysis catheter, in the form of a thin tube, needs to be inserted into the abdomen and is left there permanently.

Dialysis fluid enters the abdomen via the catheter and while in the abdomen excess fluid and waste products are removed from the bloodstream into the dialysis fluid. The used fluid is drained after a few hours and replaced with fresh fluid. This process can be done overnight via a machine while you are sleeping, or a couple of times during the day.

Peritoneal dialysis is a home-based treatment and can give patients and their caregivers some flexibility. Patients and their caregivers would be trained to do this dialysis themselves at home, and the training usually takes about 1 week.

In this 'Ask the Specialist' Q&A forum, Dr Lee Pei Shan, Consultant from the Department of Renal Medicine at Sengkang General Hospital (SKH), answers your questions about end-stage kidney disease (ESKD) and dialysis. SKH is a member of the SingHealth group.

This Q&A forum is closed. Thank you for your participartion.

1. Question by uhctanwb
What are the sign and symptoms of kidney failure?

Answered by Dr Lee:
Patients with early stages of kidney failure are typically asymptomatic. Sometimes, they may have subtle symptoms of fatigue, itch or loss of appetite. However, many people only find out when taking routine blood or urine tests during check-ups. 

In the later stages of kidney failure, patients may experience fluid retention with leg swelling or breathlessness. Other symptoms may include nausea, vomiting and lethargy. Family members may also notice increasing confusion, and in severe cases, seizures can happen.

2. Question by jchen0110
How does it usually take before the kidney loses its function totally, from the day doctor diagnosed end stage? Based on Singapore's food, what would be appropriate for the patient in his/her daily meals?

Answered by Dr Lee:
The time from diagnosis of final stage of chronic kidney failure to time of dialysis depends on the underlying cause of the kidney disease. It can range from more than 1 year to just weeks! It would be best to speak to your renal physician to find out what is the expected trajectory.

Depending on the severity and cause of kidney disease, generally we would advise patients to reduce the amount of high potassium and phosphate food in their diet. Patients may also need to restrict the amount of fluids they consume. 

Some modifications you may want to consider include reducing the amount of additional sauces (eg. soy/fish sauce, curry, sambal), choose food made with fresh ingredients instead of processed food and choosing steamed instead of fried options.

Followup question by jchen0110
For kidney transplant from a living donor, what's the timeline from evaluation to the actual operation if everything matches well? For a type 2 diabetic whose kidney is affected, what's the chance of a recovery from a transplant?

Answered by Dr Lee:
The average time for evaluation of both the donor and recipient is about 6 months, although it can vary if there are other medical issues that needs addressing. 

Kidney transplant does not treat diabetes and the patient would need to continue to manage it with a healthy lifestyle, diet and medications, as advised by their doctor.

Followup question by jchen0110
What are the things to take note as a caregiver to a diabetic renal patient?

Answered by Dr Lee:
It is important to make sure that the patient’s diabetes is well controlled – this can be done by having a healthy diet and taking your medications. It is also important to manage other medical conditions such as hypertension and gout, which may contribute to the worsening of their kidney disease. Avoid medications such as NSAIDs (Eg. Ibruprofen) as well.

3. Question by CYSS
My 22 yr old childhood survivor son has chronic kidney disease as a side effect. It was well under control at stage 2 but last yr it is deteriorating towards stage 3.Dr has reccomended a strict low salt n low protein diet. Thinking if it is possible for family members to donate one kidney to him? Thankfully its seem under control w strict diet n active lifestyle however as his mother will like to explore this option. Thank you.

Answered by Dr Lee:
Currently, if he is in chronic kidney disease (CKD) stage 3 and remains stable, he does not need a kidney transplant or dialysis. However, should his CKD progress to stage 5, kidney transplant should be discussed as one of the treatment options. If planned early, a pre-emptive transplant can be arranged. This means that the patient gets a transplant even before being started on dialysis. 

The donor does not necessarily need to be related by blood or be of the same blood group (Eg. From a spouse), but would need to go through medical checks to ensure that he/she is fit to be a donor. I would encourage you to bring this up with his nephrologist so that the team looking after him is aware of your family’s consideration for a kidney transplant should the need arise. Most of all, I hope your son’s condition remains stable.

4. Question by Marshall
Hi Dr Lee, 
My dad has started on HD in Feb '22 under an emergency circumstance. He had difficulty breathing and had to be warded. Subsequently, at the ICU, he had to start off his 1st ever dialysis. 

Since then, he's been going for his dialysis 3X a week. 
My dad is almost 80yo this year, has a weak heart(about 20% apparently). He's diabetic, has high blood pressure & high cholesterol as well. 

My siblings & I are contemplating to convert my dad to PD in the long run cos we know for fact that it'll be a lot more gentle for his heart. However, we are extremely fearful if he's strong enough to withstand the procedures involved in the switch over. (Eg. the catheter insertion op) I'm not sure if he can handle the GA in the event it's needed.

Additionally, I'm also as fearful of the potentially higher risk of infection of doing daily PD. Cos an infection would mean, my dad needs to be hospitalized again! 

Currently, he seems to be coping fine with the HD seasons. Considering his age and the uncertainties, we are also as tempted to leave things, status quo. 
Please Dr Lee, kindly share your views, if my dad should or should not switch over to PD ultimately. Thanking you in advance.

Answered by Dr Lee:
I am sorry that your dad has had a difficult time, but glad to hear he is better! 
I think your dad should be undergoing hemodialysis (HD) via a hemodialysis catheter (or you may hear your physician calling it a tunneled dialysis catheter) as he was started in an urgent setting. 

Dialysis via the tunneled dialysis catheter typically has a higher risk of infection than peritoneal dialysis (PD). As you mentioned, PD does require some commitment from the patient and caregiver to keep the home surroundings clean and learn how to manage the PD daily. However, PD does comes with potential benefits of being able to dialysis in the comforts of your home, without any needling involved and it typically causes less fluctuations in the blood pressure. 

My advice would be to avoid using the tunneled dialysis catheter for a prolonged time which increases his risk of infections (unless not possible for other reasons). He can choose to switch to (1) HD via an arteriovenous fistula or (2) consider PD. Both options require an additional procedure although creation of the fistula can potentially be done under sedation/local anesthesia which may pose a lower risk compared to general anesthesia. 

You may want to speak to a renal coordinator to understand more about peritoneal dialysis and its implications on caregivers. Additionally, you can discuss with your renal physician about your concerns about the various risks involved before committing.

About Dr Lee Pei Shan

Dr Lee Pei Shan graduated from University College London. She completed both her residency training in Internal Medicine and Nephrology in SingHealth and was the chief resident during her junior and senior residency training.

Dr Lee is currently a consultant in the Department of Renal Medicine (General Medicine) at Sengkang General Hospital (SKH). She has a special interest in Peritoneal Dialysis (PD), a home-based dialysis, and is also currently the PD lead for SKH.

She believes in empowering patients to take charge of their own health. Additionally, she hopes to help patients with end-stage kidney disease (ESKD) on dialysis achieve a good quality of life despite having to live with a chronic medical condition that potentially can have profound implications on their mental and physical wellbeing.

Ref: J22