What Are Your Options After Kidney Failure? An Overview of Kidney Replacement Therapy

When Is Kidney Replacement Therapy Needed?

Kidney replacement therapy (KRT) means taking over the work of failed kidneys, either artificially or with another kidney.

It does not start automatically when eGFR drops below 15. KDIGO recommends basing the decision on symptoms and complications, not a single number:

• Uremic symptoms: nausea, vomiting, loss of appetite, severe fatigue, altered consciousness, pericarditis
• Fluid overload (pulmonary edema) or hypertension unresponsive to medication
• High potassium or metabolic acidosis unresponsive to medication
• Progressive deterioration in nutritional status

Most people begin dialysis at an eGFR between 5 and 10. The IDEAL trial showed no survival advantage to starting "early" in the absence of symptoms.

The Four Options

1. Hemodialysis (HD)

Blood is drawn out of the body, filtered through an artificial kidney (dialyzer), and returned.

• Where: a dialysis center (most common in Taiwan) or at home
• Schedule: typically 3 sessions a week, 4 hours each
• Requires: vascular access (arteriovenous fistula, graft or catheter)
• About 90% of Taiwan's dialysis patients use HD

2. Peritoneal Dialysis (PD)

Uses the lining of your own abdominal cavity (peritoneum) as the filter. Dialysis fluid is instilled into the abdomen; waste and water cross the peritoneum into the fluid, which is then drained.

• Where: at home, at work, or while traveling
• Schedule: continuous ambulatory PD (CAPD) with 3–5 manual exchanges a day, or automated PD (APD) run by a machine for 8–10 hours overnight
• Requires: a permanent catheter implanted in the abdomen
• About 8–10% of Taiwan's dialysis patients use PD

3. Kidney Transplantation

A healthy kidney from a living or deceased donor is placed in the lower abdomen and connected to blood vessels and the bladder.

• Offers the best survival and quality of life of all options
• Requires lifelong anti-rejection medication
• Can be done before dialysis ever starts (preemptive transplant); with a living donor, evaluation should begin when eGFR < 20
• In Taiwan roughly 8,000–9,000 people wait for a deceased-donor kidney, with only about 300–400 transplants a year — waits are long, so living donation is an important way to shorten them

4. Conservative Kidney Management

Choosing not to have dialysis, focusing instead on medications, diet and symptom control, together with palliative care — prioritizing quality of life over length of life.

• Suitable for: older adults, people with multiple serious comorbidities, or those for whom dialysis is unlikely to improve quality of life or survival
• This is a legitimate medical option explicitly listed in KDIGO and international guidelines, to be decided jointly by patient, family and care team
• Taiwan's Patient Right to Autonomy Act allows advance decisions to be recorded in advance

How to Choose

This is a classic setting for shared decision-making. Factors to weigh:

Key concept: the choice is not permanent. Many people move between therapies over a lifetime — PD first, switching to HD years later when the peritoneum wears out, then transplant, then back to dialysis if the graft fails. This is called "integrated kidney care."

Why Preparing Early Matters

KDIGO recommends starting KRT education at eGFR < 30 (G4) because:

1. Vascular access takes time to mature: a fistula needs 6–12 weeks after surgery before use; if there is no time, a catheter must be placed first, with far higher infection and complication risk
2. A PD catheter should ideally rest 2 weeks before use
3. Transplant evaluation is complex; living-donor workup takes months
4. Psychological readiness: time to absorb the news, tour a dialysis unit and talk with other patients beats being forced to decide in the emergency room

Taiwan's National Health Insurance runs a Pre-ESRD care program for patients with eGFR < 45, where nephrologists, educators and dietitians follow patients together and explain each therapy at the right time.

Key Takeaways

1. Four options — hemodialysis, peritoneal dialysis, transplant, conservative care — all legitimate medical choices
2. Dialysis timing depends on symptoms, not numbers alone
3. Transplant offers the best survival and quality of life; with a living donor, consider a preemptive transplant
4. Start preparing at G4, especially vascular access
5. Therapies can be switched — it is not a once-and-for-all decision

References

• KDIGO. 2024 Clinical Practice Guideline for the Evaluation and Management of CKD, Chapter 6: Kidney failure. 2024.
• Cooper BA, et al. A randomized, controlled trial of early versus late initiation of dialysis (IDEAL). N Engl J Med. 2010.
• NIDDK. Choosing a Treatment for Kidney Failure.
• Taiwan Society of Nephrology. Taiwan Renal Data System Annual Report.
• Taiwan Organ Registry and Sharing Center. Waiting list statistics.
• Taiwan National Health Insurance Administration. Pre-ESRD Patient Care and Education Program.

This article summarizes publicly available medical information for educational purposes only and is not medical advice. For any questions about your health, illness or physical care, please seek help through professional medical channels and consult your physician.