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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 CKD G5 or ESKD. Patients with severe frailty are often recommend conservative care to optimize their quality of life and health-span.
In particular, they may be placed on a Very-Low Protein Diet with essential keto-amino acid supplementation program, and 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, or 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. A team of nephrologists, kidney transplant surgeons, other, coordinators, and nurses provides long-term care integrated care, and coordinates the pre- and post-transplant care of transplant patients and donors.
Unless there are medical reasons not to do so, the initial kidney dialysis therapy is Peritoneal Dialysis (PD). In the life-cycle of ESKD, PD is started 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.
Continuous Ambulatory Peritoneal Dialysis (CAPD) and Automated Peritoneal Dialysis (APD) are offered. Patients and their care givers are trained to perform PD at home or at convenient places. The PD program is run by a team of nephrologists, renal dietitians, and specialist nurses. Regular follow-up, surveillance testing, and dietary counselling provides holistic care to PD patients to minimize avoidable complications of ESKD.
Patients who are unsuitable for, or can no longer undergo peritoneal dialysis are placed on haemodialysis. 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 haemodialysis. Where suitable, patients can perform home haemodialysis (short daily dialysis or nocturnal dialysis). More often, patients travel to an outpatient dialysis centre three times a week, and undergo dialysis, each time for about five hours.