If your kidney function drops below 15 percent of normal, you are said to have kidney failure. You may have symptoms from the buildup of waste products and extra water in your body.

To replace your lost kidney function, you may have one of three treatment options:

• hemodialysis
• peritoneal dialysis
• kidney transplant

End-stage renal disease (ESRD) is kidney failure that is treated by dialysis or kidney transplant.

Some people with kidney failure choose not to have dialysis or a transplant but continue to receive care from their health care team, take medicines, and monitor their diet and lifestyle choices.

Work with your health care team and family to consider your options and choose a treatment that’s right for you. Treatment will help you feel better and live longer.

The more you know ahead of time about what to expect, the better prepared you may be to make a treatment choice and take charge of your care. You also need to give yourself time to get used to the big changes that will be happening in your life. Kidney failure will change your day-to-day activities and may change your relationships with friends and family, and how you feel.

Symptoms of kidney failure may begin so slowly that you don’t notice them right away.

Healthy kidneys prevent the buildup of wastes and extra fluid in your body and balance the salts and minerals in your blood—such as calcium, phosphorus, sodium, and potassium. Your kidneys also make hormones that help control blood pressure, make red blood cells, and keep your bones strong.

Kidney failure means your kidneys no longer work well enough to do these jobs and, as a result, other health problems develop. As your kidney function goes down, you may

• have swelling, usually in your legs, feet, or ankles
• get headaches
• feel itchy
• feel tired during the day and have sleep problems at night
• feel sick to your stomach, lose your sense of taste, not feel hungry, or lose weight
• make little or no urine
• have muscle cramps, weakness, or numbness
• have pain, stiffness, or fluid in your joints
• feel confused, have trouble focusing, or have memory problems

Following your treatment plan can help you avoid or address most of these symptoms. Your treatment plan may include regular dialysis treatments or a kidney transplant, a special eating plan, physical activity, and medicines.

Kidney disease can lead to other health problems. Your health care team will work with you to help you avoid or manage:

High blood pressure. High blood pressure can be both a cause and a result of kidney disease. High blood pressure damages your kidneys, and damaged kidneys don’t work as well to help control your blood pressure. With kidney failure, your kidneys can’t get rid of extra water. Taking in too much water can cause swelling, raise your blood pressure, and make your heart work harder.

Blood pressure-lowering medicines, limiting sodium and fluids in your diet, staying physically active, managing stress, and quitting smoking can help you control your blood pressure.

Heart disease. Kidney disease and heart disease share two of the same main causes: diabetes and high blood pressure. People with kidney disease are at high risk for heart disease, and people with heart disease are at high risk for kidney disease.

The steps that you take to manage your kidney disease, blood pressure, cholesterol, and blood glucose (if you have diabetes) will also help you prevent heart attacks or strokes.

Anemia. When kidneys are damaged, they don’t make enough erythropoietin (EPO), a hormone that helps make red blood cells. Red blood cells carry oxygen from your lungs to other parts of your body. When you have anemia, some organs—such as your brain and heart—may get less oxygen than they need and may not function as well as they should. Anemia can make you feel weak and lack energy.

Your health care provider may prescribe iron supplements. In some cases, your provider may prescribe medicines to help your body make more red blood cells.

Mineral and Bone Disorder. Healthy kidneys balance the levels of calcium and phosphorus in your blood and make hormones that help keep your bones strong. As kidney function drops, your kidneys

• make less of the hormone that helps your body absorb calcium. Like one domino knocking over another, the low level of calcium in your blood triggers the release of parathyroid hormone (PTH). PTH moves calcium from your bones into your blood. Too much PTH can also make you feel itchy.
• don’t remove as much phosphorus. Extra phosphorus in your blood also pulls calcium from your bones.

Without treatment, bones may become thin and weak. You may feel bone or joint pain. Changes to your eating plan, medicines, supplements, and dialysis may help.

Malnutrition. As your kidney disease gets worse, it can be a challenge to keep yourself well fed. You may not feel hungry, food may taste different, or you may lose interest in food. Infections and other stresses on your body can make it hard for your body to use the food you do eat. Working closely with a dietitian to be sure you’re eating enough of the right foods can have long-term benefits for people with kidney disease.

Feeling itchy. Itching is common and happens for different reasons. You may feel itchy because you have dry skin. Using a moisturizer may help. Or, you may feel itchy because you have too much phosphorus in your blood. Eating less phosphorus may help stop the itching. Your health care provider may prescribe a medicine called a phosphate binder for you to take with meals. These medicines keep the phosphorus in your food from entering your bloodstream.

UV light from sunlight or a light box helps some people find relief.

How well are your kidneys working? Explaining your kidney test results

What is GFR?

GFR stands for glomerular filtration rate. GFR is a measure of how well your kidneys filter blood.

• A GFR of 60 or higher is in the normal range.
• A GFR below 60 may mean kidney disease.
• A GFR of 15 or lower may mean kidney failure.

What is urine albumin?

Albumin is a protein found in the blood. A healthy kidney does not let albumin pass into the urine. A damaged kidney lets some albumin pass into the urine. The less albumin in your urine, the better.

• A urine albumin result below 30 is normal.
• A urine albumin result above 30 may mean kidney disease.

What your kidneys do

How your kidneys are checked

Two tests are used to check for kidney disease.

• A blood test checks your GFR, which tells how well your kidneys are filtering.
• A urine test checks for albumin in your urine, a sign of kidney damage.

Why your kidneys are being checked

You need to have your kidneys checked because you can't feel kidney disease. Kidney tests are very important for people who have diabetes, high blood pressure, or heart disease. These conditions can hurt your kidneys.

What happens if you have kidney disease

Kidney disease can be treated. The sooner you know you have kidney disease, the sooner you can get treatment to help delay or prevent kidney failure. Treating kidney disease may also help prevent heart disease.

Treatment goals are to:

• Keep your GFR from going down
• Lower your urine albumin

No matter what your results are:

• Keep your blood pressure, blood glucose and blood cholesterol in your target range.
• Choose foods that are healthy for your heart and cut back on salt.
• Be more physically active.
• If you smoke, take steps to quit.
• Take medicines the way your provider tells you to.

Taking an Active Role

It can be a huge shock to learn that your kidneys are failing—even if you knew it was coming. Kidney failure may sound like the end of the world. It’s not. You CAN have a good life and keep doing many of the things you enjoy. The keys are:

• Keep a positive attitude
• Learn all you can
• Take an active role in your treatment

Do you know someone who did not do well on dialysis? Please keep in mind that a poor outcome on dialysis may be due to the disease that caused the kidneys to fail—not the dialysis treatments. And, today, there are more options for dialysis than ever before, so you can choose a treatment plan that is a good fit for your life.

An Emotional Time

It’s normal to have strong emotions when your doctor tells you that your kidneys are failing. You may be afraid, worried, depressed, or angry. You might even have all of these feelings at the same time. If your feelings are getting the best of you, you are not alone. You wouldn’t be human if you weren’t scared and upset! Talk to someone about how you feel—a loved one, your care team, a clergy person, or a counselor.

When you believe that you can have a good life, it will help you to get a grip on your feelings so you can move forward and make decisions—like what treatment to choose.

You CAN Have a Future

The most important thing for you to know is, you CAN have a future with kidney failure. Your kidneys aren’t working right. But, you are still you. You can choose to keep following your dreams—or find new ones. This is a photo of a person with kidney failure who has had a good life for decades after her kidneys failed. Does everyone manage this? No. But it is possible, and that means you can try.

Keep Your Heart Healthy

Health problems that cause kidney failure can also harm your heart. So, if you want to keep doing the things you love, it’s important to take care of your heart. How can you keep your heart healthy? Here are a few ideas:

• Exercise! Talk to your care team if you are out of shape. Just walking can help your heart. Start slow and build up as you get stronger.
• Quit smoking. If you smoke, stopping is one of the best things you can do for your heart. Talk to your care team if you need help.
• Keep your blood pressure in the target range your care team sets. This may mean that you need to take blood pressure pills.
• Keep your cholesterol in the target range your care team sets. This may mean that you need to take pills to lower your cholesterol.
• Eat a healthy diet, with vegetables and fruits. Lose weight if you are overweight. Talk to the dietitian to learn more.
• Drink only moderate amounts of alcohol. How much is moderate? Ask your care team.

Balancing Water and Minerals

The main job of healthy kidneys is to keep water and key minerals in your body in balance. To keep the balance, kidneys measure levels of water and electrolytes in your blood. They send wastes and extra water to the “trash can”—your bladder. Your body removes them as urine. If blood levels of a substance are low, healthy kidneys keep it in the blood and send messages to the rest of your body to get more. These messages are called hormones.

Replacing Kidney Function

If your kidneys fail, you will need treatment to take over the work of the kidneys. Your treatment needs to remove waste, excess water and sodium from your blood and help control blood pressure. And, you may need to take medications to replace the hormones your body needs.

Choosing a Treatment

There are three main treatment options for kidney failure. The first two options—a kidney transplant or dialysis—may help you live. Some people choose the third option—medical care without dialysis—which allows a natural death.

There are two main types of dialysis: peritoneal dialysis and hemodialysis. Peritoneal dialysis is most often done at home. Hemodialysis can be done at home or in a clinic. Visit all the topics in this room to learn more about treatment options for kidney failure.

Treatment Options and Your Life

Life is a journey. You can go to one place or many places on a journey, and get where you are going in a number of ways. You’ll need to think about what you want your life journey with kidney failure to be. The choice you make about how to treat your kidney failure will have an impact on your lifestyle. This includes:

• What you can eat and drink
• How many medications you may need to take each day
• How much energy you may have
• Whether you feel well enough to work
• How easy it is to travel
• How well you sleep
• Your sex life and ability to carry or father children
• How long you may live

Choosing a treatment that is a good fit for you can help you to have a good life. If you have other health problems, they may play a role in the treatment choice you make.

You Can Change Your Treatment Choice Any Time

When you choose a treatment, it doesn’t have to be a permanent choice. If you try a treatment and it doesn’t work out the way you hoped, you can change. Please give your treatment a good try first, though. For medical reasons, some treatments may be a better fit for you than others. Your doctor can advise you about any medical reasons why you can’t do a certain treatment, and can help guide your choices.

The PD Option

Peritoneal dialysis, or “PD,” is one way to replace some of the function of kidneys that don’t work. It is a gentle treatment and is easy to learn and do by yourself at home. Good hygiene is very important for PD success.

You don’t need a partner to do PD. Assist devices can help you to do PD if you don’t see or hear well, or can only use one hand. If you have had major surgery to your belly, PD may not work for you.

Needle-free Treatment Using Your Own Body

Peritoneal dialysis uses your peritoneum as a filter for your blood. A PD catheter—a soft, plastic tube about as thick as a drinking straw, but longer—is placed in your belly by a doctor. A nurse will teach you how to use this tube to fill your belly with sterile fluid.

PD goes on all the time. Wastes and water in your blood flow out of the blood vessels in your peritoneum and into the fluid in your belly. After a few hours, you drain out the used fluid and put fresh fluid in. Draining out used fluid and putting in fresh fluid is called an “exchange.” Each exchange takes about 20 minutes. The rest of the time when you are not doing an exchange, you are free to do other things.

Manual or Automated Exchanges

PD exchanges can be done a few times a day, by hand. Or, people can use a machine called a cycler at night while they sleep. The cycler does the exchanges for you. If you are a larger person, you may need one daytime exchange, too.

Training for PD

PD is quick to learn—it takes a week or two to learn how to do PD. A nurse will visit your home to help you get ready. Each step of the exchange must be done with great care, JUST as you are taught, to avoid infection inside the belly (called peritonitis). You won’t start PD at home until you and your nurse are both confident that you can succeed.

Once you go home with PD, a nurse is on call 24/7 if you have questions. PD fluid has sugar in it, so you may need to limit starchy foods to avoid weight gain. If you have diabetes, you may be able to add regular insulin to the PD bags.

Keeping Your Body in Balance

The job of healthy kidneys is to keep substances in your blood in balance. The closer to balance a treatment for kidney failure brings you, the better you may feel. When you feel better, you can do more of what matters to you.

Continuous Treatment with Fewer Ups & Downs

Dialysis removes water and wastes from your blood. PD is a way to do dialysis every day. It’s a continuous treatment that helps keep your blood in balance all the time. There are no ups and downs in how people feel from one day to the next on PD.

PD and Your Lifestyle

Now that you understand the basics of how PD works, let’s look at how it might affect your life in the areas of:

• What you can eat and drink
• How many medications you might need to take each day
• How much control you would have over your time
• How work-friendly PD is
• How travel-friendly PD is
• How PD may affect your sex life and ability to carry or father children

PD and What You Eat

When you do PD, you may need to make some changes to what you can eat and drink. Most people who do PD need to eat more protein, because a little bit of protein is lost each time you drain out the used PD fluid.

Since PD fluid has sugar in it, you can gain weight if you don’t limit starchy foods.

Your dietitian will go over your lab test results with you each month. If your levels of potassium or phosphorus are too high, you may need to limit foods that have these minerals.

PD and Medications

If you choose PD, you will need to take some medicines each day. Most people on PD need at least some phosphate binders. You may need to take blood pressure pills. You may also need EPO to treat anemia.

If you have diabetes or other health problems, you will still need to take prescribed medicines for them, though the dose may change if your kidneys stop working.

PD and Your Schedule

A treatment for kidney failure that you can do at home, like PD, gives you more control of your schedule. You DO have to fit in all of your exchanges each day to get enough treatment. But, you can shift the time a bit when you need to.

PD and Your Job

Do you want to be able to work? A work-friendly treatment:

• Is not scheduled during the work day—or can be done at work
• Does not cause symptoms that might make you miss work
• Reduces the chance that you might need to go to the hospital—and miss work
• Helps you to have enough energy to work

PD is work-friendly for all of these reasons. Most people use a cycler to do PD at night, but a daytime exchange can be done in a clean room at work. Since PD is gentle and continuous, it does not tend to cause symptoms that bother you. It is vital to do all of your exchange steps as you are taught to avoid infection. Most people who do PD do not need to be in the hospital often.

PD and Travel

When you do PD, you can bring your treatment with you when you travel. A cycler can go in a car, on a cruise, or on an airplane. With advance notice, the companies that make PD supplies will ship them to you in the continental U.S.

PD, Fertility, and Your Sex Life

People who choose PD report a bit less erectile dysfunction and fewer other sexual problems than those who do standard in-center hemodialysis. Women of childbearing age who do PD tend to have a hard time getting pregnant, but some have. To carry a child to term, more dialysis may be needed than the standard PD prescription.

What You Need to Do PD

You don’t need to live in a castle to do PD. People who live in small apartments or mobile homes have done PD. You do need space to store about 40 cubic feet of supplies. The supply company will bring new boxes once or twice a month. They will unload the boxes and put them where you want them—even upstairs. The first batch of supplies will be the biggest to be sure you have all that you need—later ones won’t be quite as big.

You don’t need to have a partner at home to do PD.

Multiple or complex abdominal surgeries can prevent PD success. But, a c-section, hernia repair, or prior transplant should not be a problem if you want to do PD. Talk with your care team if you want to do PD but don’t know if you can.

PD Limits

If you like baths and not showers, PD may not be a good fit for you. Getting your PD catheter wet could cause an infection. So, if you like to swim for exercise, PD may not be the best treatment for you. Talk to your care team about whether you can swim and how to care for your catheter if you get it wet.

The In-Center Hemodialysis Option

Hemodialysis (HD) is one way to replace the function of kidneys that don’t work. HD is most often done in a clinic in one of two ways:

• Three days a week (standard in-center HD)
• Three nights a week while you sleep (nocturnal in-center HD)

It is sometimes called “in-center” HD.

Hemodialysis Access

All HD requires a way to take blood out of the body to be cleaned, and then put it back in. This is called a vascular access, or just access. There are three types of access:

• A fistula, which is your artery + your vein
• A graft, which is your artery + your vein + a piece of man-made vein
• A catheter, which is a plastic tube placed into a large vein that ends in your heart

A fistula is the safest type, if you can have one.

HD Access: Fistulas

Dialysis needs the strong blood flow of an artery (the blood vessels that carry blood away from the heart). But veins (the blood vessels that carry blood to the heart) are closer to the surface of your skin and easier to reach. Linking an artery to a vein gives you the best of both: strong blood flow that is easy to reach.

Some ways of linking the artery and vein to make an access for HD are better than others. A fistula connects your artery directly to your vein. A graft connects an artery to a vein with a piece of man-made vein.

Fistulas can last the longest (sometimes decades) and they have the least chance of developing blood clots or infections that could put you in the hospital. If you want to do HD, a fistula is ideal. Plan ahead! A fistula needs to be made at least a few months before dialysis starts, so it has time to “mature” and be ready to use. It is wise to get a fistula made about 6 months before you need to start HD.

HD Access: Catheters

HD catheters are plastic tubes that are placed in a large vein in the neck, chest, or groin. They are used if someone needs dialysis right away, or has no other choice. A catheter is partly out of your body and partly inside your blood vessels. The tip is in your heart.

Catheters have several problems:

• Germs can climb up the tubing and get into your bloodstream. If this happens, a serious blood infection, called sepsis can occur.
• Catheters are linked to a risk of death that is many times higher than other types of HD access.
• Catheters can’t get wet. So, you may not be able to shower with an HD catheter.
• There may be a scar where the catheter enters your body.

HD Cleans Your Blood Outside Your Body

When you do HD, two needles are placed in your access. A nurse or technician connects the needles to tubing that carries your blood to a dialyzer, or artificial kidney. The dialyzer has filters inside to clean your blood. Wastes and extra water are removed, and then your cleaned blood comes back to you. A blood pump pushes your blood through the tubing at a rate that your doctor prescribes.

3 Days or 3 Nights a Week

HD in a center can be done in two ways:

• Standard HD is done in a clinic three days a week for about 4 hours at a time. You would get a time slot on a Monday, Wednesday, and Friday, or a Tuesday, Thursday, and Saturday. A nurse or technician sets up the treatments, or you may be able to learn to do the set-up yourself. (This is called in-center self-care.)
• Nocturnal HD can be done in a clinic three nights a week, for about 8 hours while you sleep. These treatments are most often done on Mondays, Wednesdays, and Fridays. As with standard HD, a nurse or technician most often sets up the treatments, or they can teach you to do it yourself. Since nighttime treatments are twice as long as standard ones, they are very gentle. And, nighttime treatments don’t take time out of your day.

Keeping Your Body in Balance

The job of healthy kidneys is to keep substances in your blood in balance. The closer to balance a treatment for kidney failure brings you, the better you may feel. When you feel better, you can do more of what matters to you. Nocturnal HD in a center gives you about twice as much treatment as standard HD.

Standard HD: Big Ups & Downs

Between dialysis treatments, wastes and excess water build up in your blood. If you have a 4-hour treatment on Mondays, Wednesdays, and Fridays, you have no treatment on Tuesdays, Thursdays, Saturdays, or Sundays. The ups and downs when wastes and water build up are big with standard in-center HD—and they are hard on the heart.

Nocturnal HD: Very Small Ups & Downs

Nocturnal HD in a center removes much more water and wastes from your blood than standard HD. And, since the treatments are twice as long, it is much more gentle, as you can see from the very small spikes in water and wastes (green) in the picture on the right.

This means that even with three treatments per week, you may feel good from day to day, with fewer symptoms from kidney failure. In fact, most people feel like themselves again about 10 minutes after doing a nocturnal HD treatment.

In-center HD and Your Lifestyle

Now that we’ve seen the basics of how in-center HD works, let’s look at how it might affect your life in the areas of:

• What you can eat and drink
• How many medications you might need to take each day
• How much control you would have over your time
• How work-friendly it is
• How travel-friendly it is
• How it may affect your sex life and ability to carry or father children

Standard HD and What You Eat

Since standard HD is done 3 times a week for only 4 hours, it requires more strict diet and fluid limits than any other option. Your dietitian will go over your lab test results with you each month and help you come up with a plan that includes as many of your favorite foods as possible.

Nocturnal HD in a clinic is done 3 times a week for about 8 hours. More treatment means you have fewer diet and fluid limits. You can eat more of what you like best with this treatment option.

Standard HD Means Limits on Some Foods & Fluids

Most people who do HD must limit their intake of:

• Salty foods, like french fries
• High potassium foods, like fruits
• High phosphorus foods like beans, nuts, and dairy
• Fluids—to about 1 quart per day

If you have diabetes, you still need to limit starchy foods.

If you choose standard in-center treatment, you MUST follow the strict limits to feel your best. If an unrestricted diet is important to you, talk with your care team about other dialysis options that have fewer limits.

Standard HD and Medications

If you choose standard HD, you may need to take as many as 19 pills each day. Most people on standard in-center need phosphate binders and blood pressure pills. You may also need EPO to help treat anemia. If you have diabetes or other health problems, you will still need to take prescribed drugs for them, though the dose may change when your kidneys don’t work.

If you do nocturnal HD in a clinic, you may need fewer—or no—phosphate binders or blood pressure pills. You may need EPO to help treat anemia, but may be able to use a lower dose. If you have diabetes or other health problems, you will still need to take prescribed drugs for them, though the dose may change when your kidneys don’t work.

Standard HD and Your Schedule

If you do standard in-center HD, the clinic will work with you to assign a time slot. Your treatments will be done at the same time on Mondays, Wednesdays, and Fridays or Tuesdays, Thursdays, and Saturdays. If the time slot you are given is not a good fit for your life, your job, your childcare, or your ride to the clinic, talk to your care team.

Standard HD and Your Job

Do you want to be able to work? A work-friendly treatment:

• Is not done during the work day—or can be done at work
• Does not cause symptoms that might make you miss work
• Reduces the chance that you might need to go to the hospital—and miss work
• Helps you to have enough energy to work

Standard in-center HD is not very work-friendly for all of these reasons. It takes time out of the day, when most people need to be at work. It can cause symptoms that make it hard to work, and can lead to more hospital stays than other treatment options. People DO work on standard in-center HD—but it is more of a challenge than it would be with other treatment options.

Standard HD and Travel

When you do HD in a center—during the day or at night—you can travel by finding a clinic at your destination that has a time slot open and can take you. This is best done a few months before you want to travel. Your social worker can help you plan and send the clinic your medical records. You will need to be up-to-date with your vaccines, too.

Standard HD, Fertility, and Your Sex Life

People who do standard in-center HD report more problems with sexuality and fertility than those who do any other treatment option. For men, about half who do this treatment report problems with erections. It is also more difficult to father a child.

Women have problems, too. It is harder to carry a child using this treatment option. Women who become pregnant on standard in-center HD may have a chance of carrying a baby to term if they do longer and/or more frequent treatments.

There are few studies on the sexuality of people who do nocturnal HD treatments. People who do dialysis this way say they feel better, and there are some reports of women being able to carry babies to term.

Standard HD: Facts to Consider

There are things to think about when you do HD in a clinic—during the day or at night. Your risk of infection is very high if you start treatment with a catheter. If you know you want to do HD, get a fistula or graft well ahead of time.

You need to be at the clinic for each treatment at the time that is set for you. If this time is not a good fit for your life, talk to your care team. You may be able to switch to a time that fits better, or to a clinic that has a better time for you. You may have to wait until the time slot you want opens up. Don’t miss any dialysis! Missed treatment time can cost you your life when you are on dialysis.

Some people have a hard time sleeping in a clinic at night. Wearing earplugs and a sleep mask may help. Some even bring in a foam pad for the chair to make it easier to sleep.

Dealing with HD Needles

Fistulas and grafts for HD use needles. If needles bother you, there are lots of things you can do to help:

• You can put a numbing cream on your skin 1–2 hours before treatment. Some numbing creams are prescription and some are not. Talk to your care team.
• A freezing spray can numb just the top of your skin very quickly.
• You can try to relax and take deep breaths.
• Putting in your own needles puts you in charge and distracts you, so the needles hurt much less. No one else can put in your needles as well as you can—you are the only person who can feel both ends of the needle. The clinic staff can teach you how if you want to learn.
• The “Buttonhole technique” is a way of putting dialysis needles into the exact same spots every time to form tunnel tracts (like pierced earring holes). Once Buttonholes form, you can use blunt needles for dialysis, for less pain.

The Home HD Option

Home hemodialysis (HD) is a way to replace the function of kidneys that don’t work. HD can be done at home in one of three ways:

• Three days a week for about 4 hours (standard home HD)
• Five to six days a week for 2.5 to 4 hours (short daily HD)
• Three to six nights a week for about 8 hours (nocturnal home HD)

HD at home is flexible. You can do it on your own schedule with your loved ones around you. Someone from your clinic will do a home visit to help you get set up.

You will need a partner who can be there while you do your treatments. A nurse trains you and your partner until you are confident that you know what to do. And, you don’t need to buy the machine or your supplies. After training, instead of going to the clinic three times a week, you will come in once a month or so to meet with your kidney care team.

Hemodialysis Access

All HD requires a way to take blood out of the body to be cleaned, and then put it back in. This is called a vascular access, or just access. There are three types of access:

• A fistula, which is your artery + your vein
• A graft, which is your artery + your vein + a piece of man-made vein
• A catheter, which is a plastic tube placed into a large vein that ends in your heart

A fistula is the safest type, if you can have one.

HD Access: Fistulas

Dialysis needs the strong blood flow of an artery (the blood vessels that carry blood away from the heart). But veins (the blood vessels that carry blood to the heart) are closer to the surface of your skin and easier to reach. Linking an artery to a vein gives you the best of both: strong blood flow that is easy to reach.

Some ways of linking the artery and vein to make an access for HD are better than others. A fistula connects your artery directly to your vein. A graft connects an artery to a vein with a piece of man-made vein.

Fistulas can last the longest (sometimes decades) and they have the least chance of developing blood clots or infections that could put you in the hospital. If you want to do HD, a fistula is ideal. Plan ahead! A fistula needs to be made at least a few months before dialysis starts, so it has time to “mature” and be ready to use. It is wise to get a fistula made about 6 months before you need to start HD.

HD Access: Catheters

HD catheters are plastic tubes that are placed in a large vein in the neck, chest, or groin. They are used if someone needs dialysis right away, or has no other choice. A catheter is partly out of your body & partly inside your blood vessels. The tip is in your heart.

Catheters have several problems:

• Germs can climb up the tubing and get into your bloodstream. If this happens, a serious blood infection, called sepsis can occur.
• Catheters are linked to a risk of death that is many times higher than other types of HD access.
• Catheters can’t get wet. So, you may not be able to shower with an HD catheter.
• There may be a scar where the catheter enters your body.

HD Cleans Your Blood Outside Your Body

When you do HD, two needles are placed in your access. A nurse or technician connects the needles to tubing that carries your blood to a dialyzer, or artificial kidney. The dialyzer has filters inside to clean your blood. Wastes and extra water are removed, and then your cleaned blood comes back to you. A blood pump pushes your blood through the tubing at a rate that your doctor prescribes.

Three Ways to Dialyze at Home

As you learned, there are three ways to do HD at home:

• “Standard” home HD is done three times a week, or every other day to get rid of the 2-day gap with no treatment. Each treatment lasts about 4 hours, but some people choose to do longer treatments at home (with their doctor’s prescription).

• Short daily home HD is done 5 or 6 days a week for about 2.5–4 hours at a time. Water and wastes are removed nearly every day. Most people who do short daily treatments say they feel better than they did on standard treatments.

• Nocturnal home HD is done at night while you sleep, for about 8 hours. This means that your days are free to do other things. People who use this treatment say they have more energy and they feel good. Some do nighttime treatments three nights a week or every other night. Some do four or five or six nights a week if their doctor prescribes it.

Keeping Your Body in Balance

The job of healthy kidneys is to keep substances in your blood in balance. The closer to balance a treatment for kidney failure brings you, the better you may feel. When you feel better, you can do more of what matters to you.

Standard HD: Big Ups & Downs

Between dialysis treatments, wastes build up in your blood. If you have a 4-hour treatment on Mondays, Wednesdays, and Fridays, you have no treatment on Tuesdays, Thursdays, Saturdays, or Sundays. This schedule leads to waste and water build-up between treatments. The ups and downs when wastes and water build up are biggest when treatments are only three times a week. When treatments are longer and/or more frequent, there is less time for water and wastes to build up. This is easier on your heart and means that you may feel better, too.

If you do standard treatments at home, you can talk to your care team about doing longer treatments or doing them every other day to reduce the ups and downs.

Short Daily HD: Small Ups & Downs

If you do short daily HD, the levels of water and wastes in your blood are kept in better balance. This means you may feel better from day to day, with few symptoms from kidney failure.

Nocturnal HD at Home: Very Small Ups & Downs

Since nocturnal treatments are longer than standard ones, they can remove much more water and wastes from the blood. In fact, the treatments are about twice as long. This means that fluid removal is very gentle, as you can see from the very small spikes in water and wastes (green) in the picture. So, even with three treatments per week, you may feel better from day to day, with few symptoms from kidney failure. With their doctor’s prescription, some people who do nocturnal HD at home do treatments every other night, or even 4, 5, or 6 nights a week. This is the most dialysis you can get.

Home HD and Your Lifestyle

Now that we’ve seen the basics of the three ways home HD works, let’s look at how home HD might affect your life in the areas of:

• What you can eat and drink
• How many medications you might need to take each day
• How much control you would have over your time
• How work-friendly home HD is
• How travel-friendly home HD is
• How home HD may affect your sex life and ability to carry or father children

Home HD: Few Limits on Diet or Fluids

The more dialysis you get, the closer to normal your diet and fluids can be. So, of the three ways to do home HD:

• Standard home HD will have the most diet limits, because the treatments are just done 3 days per week or every other day.
• Short daily and nocturnal HD have fewer limits, because treatments are longer or done more often.

Your dietitian will go over your lab test results with you each month. If your levels of potassium or phosphorus are too high, you may need to limit foods that have these minerals—like chocolate.

Home HD: Fewer Medications?

The more dialysis you get, the fewer medicines you may need to take. So, of the three ways to do home HD:

• Standard home HD requires the most medicines—half of the people who do it need to take 19 pills a day, and about one in four need even more.
• Short daily HD means fewer blood pressure pills and phosphate binders for most people who do it. This can cut your pill count by quite a bit.
• Nocturnal HD may mean that you don’t need blood pressure pills or phosphate binders. In fact, some people who do nocturnal HD need to take phosphate supplements because the long treatments remove so much phosphate.

On any form of HD, you may need EPO to help treat anemia. If you have diabetes or other health problems, you will still need to take prescribed drugs for them, though the dose may change when your kidneys don’t work.

Home HD and Your Schedule

A treatment for kidney failure that you can do at home, like any form of home HD, gives you control of your schedule. You DO have to do all of your treatments to feel your best. But, you can choose to do them in the morning, afternoon, or evening. You can shift the days of the week to go to a special event, too.

Home HD and Your Job

Do you want to be able to work? A work-friendly treatment:

• Is not scheduled during the work day—or can be done at work
• Does not cause symptoms that might make you miss work
• Reduces the chance that you will need to go to the hospital—and miss work
• Helps you to have enough energy to work

Home HD can be work-friendly for all of these reasons. You can schedule it around your work hours, so it doesn’t get in the way of work. The more dialysis you get, the less likely you are to have symptoms from dialysis that cause you to miss work. (You may still have symptoms from the illness that caused your kidneys to fail, though.) People who do home HD say that they have more energy. Studies find that they tend to sleep and eat better, too.

Home HD and Travel

When you do HD at home, one way to travel is by finding a clinic at your destination that has a time slot open and can take you. This is done a few months ahead of when you want to travel, and your social worker can help you. You will need to be up-to-date with your vaccines.

If you use a small, more portable machine for home HD, you may be able to bring it with you on a car trip, or on a plane or boat. Your supplies can be shipped to you for free in the continental U.S.

Home HD, Fertility, and Your Sex Life

People who choose short daily or nocturnal home HD say that their sex lives are better than they were with standard in-center HD. Some women of childbearing age have been able to carry babies to term doing short daily or nocturnal HD, though a pregnancy with dialysis is always high risk.

More HD: Survival May Compare to Transplant

Doing HD at home puts you in charge. And, you are not exposed to so many others who may be ill. Only you or a partner put in your dialysis needles. These are pluses of home HD that may help improve your health.

Studies have found that people who do short daily or nocturnal HD may do even better. They may live about as long as those who get a deceased donor kidney transplant.

Statistics apply to groups, not to individuals. Some people have lived for decades on standard in-center HD and PD, too! But, it makes sense that more dialysis keeps your body in better balance and protects your heart.

Home HD: Things to Consider

There are things to think about when you do home HD. You’ll need a partner who can be there when you do your treatments. It’s best if you can do as much of your treatment as you can yourself—especially putting in your own needles. But a partner can help you with some of the tasks of the treatment or supplies, give you emotional support, or both. In most cases, a partner for home HD is a family member. If you don’t have a family member who can be a partner and you want to do home HD, you may opt for a home dialysis helper in some cases. Talk to your care team about home health care.

You’ll need to set up a room in your home to do your treatments. Your care team can do a home visit and help give you tips about what has worked for others. Your treatment room may need changes to the wiring or plumbing.

Dealing with HD Needles

Fistulas and grafts for HD use needles. If needles bother you, there are lots of things that can be done to help:

• You can put a numbing cream on your skin 1–2 hours before treatment. Some numbing creams are prescription and some are not. Talk to your care team.
• A freezing spray can numb just the top of your skin very quickly.
• You can try to relax and take deep breaths.
• Putting in your own needles puts you in charge and distracts you, so the needles hurt much less. No one else can put in your needles as well as you can—you are the only person who can feel both ends of the needle. When you do home HD, it’s best if you put in your own needles. The clinic staff will teach you how, or will teach your partner if you can’t do it yourself.
• The “Buttonhole technique” is a way of putting dialysis needles into the exact same spots each time to form tunnel tracts (like pierced earring holes). Once Buttonholes form, you can use blunt needles for dialysis, for less pain.

The Kidney Transplant Option

A kidney transplant is one way to replace some of the function of kidneys that don’t work. Survival with a kidney transplant is about three times better, on average, than it is with standard in-center hemodialysis.

Some people think that they can’t have a transplant due to age or some other concern. If you are not sure if you can get a transplant, talk to your doctor and the transplant center staff.

A New Kidney from a Donor

When you have a kidney transplant, a surgeon puts a kidney from a donor into your body. Your original kidneys are above your waist, under your ribs. The new kidney is placed in your belly, protected by your hip. The scar may be long, or it may be shorter and in the middle of your belly.

If you have type 1 diabetes, you could think about a kidney-pancreas transplant. You’d get a kidney and a new pancreas (on the other side). You might get both organs from one donor, or from two. There is an excellent chance (80–85%) that you’d need no insulin or dialysis for at least 1 year. There is a very good chance (70%+) that a kidney-pancreas transplant will still be working 5 years later. Wait time to get a transplant can be shorter when you are listed for two organs, too.

Transplant: Do You Qualify?

Before you can be cleared for transplant, you need a lot of medical tests. The transplant team needs to be sure you are in good health aside from kidney failure. These tests may include:

• Blood tests
• X-rays of your chest, kidneys, ureters, and bladder
• EKG/echocardiogram
• A heart stress test
• Dental exam
• Colonoscopy
• Psychosocial exam
• Men may need a PSA test to check prostate health.
• Women may need a mammogram and pap smear.

These tests will need to be repeated, depending on how long the wait is.

Transplant: A Foreign Object Your Body Tries to Fight

A transplant is different from the rest of your body—like the green fish is different from the orange fish. Your immune system will react to it as “foreign” and attack it. Transplant drugs partly suppress your immune system. The goal is to keep you healthy, and trick your body into accepting the kidney.

Transplant: Getting a Good Match

Besides taking drugs to suppress your immune system, another way to help your body accept a kidney transplant is to choose one that is a good match for you. Three types of matches are looked at:

• First, the blood type of the donated kidney. Is it compatible with your blood type?
• Next, the tissue type. Is it a good match with your tissue type?
• Finally, blood is tested for a crossmatch to reduce the chance that your immune system would attack the new kidney.

Matching Blood Type for a Transplant

Your blood type depends on antigens that are on the surface of each of your red blood cells. You inherit your blood type from your parents. There are four blood types:

• A
• B
• AB
• O

Type O blood is called the “universal donor” because it has no antigens! Type AB blood is called the “universal recipient,” because it has ALL of the antigens. So, someone with type AB blood can get a kidney from a donor with type A, AB, B, or O blood. This means that it can be faster to get a kidney.

Matching Tissue for a Transplant

HLA is a measure of your tissue type. HLA stands for human leukocyte (white blood cell) antigen. We inherit 3 HLA types from each parent, for a total of 6. Identical twins match all 6. This can also happen in unrelated people. There is no minimum number of HLA types that must match for you to get a kidney. A zero HLA match kidney can work just as well as a 6 antigen match—but you may need to take more medicines to avoid rejection.

Crossmatching for a Kidney Transplant

A crossmatch looks for antibodies in your blood that could react against a new kidney. It tests the serum of your blood (plasma) against a donor’s blood cells. A positive crossmatch means a high chance that your body would attack the kidney. A negative crossmatch means that a transplant with that donor can go forward.

Transplant and PRA

Each month or so while you wait for a kidney, your blood will be tested against a panel of 60 HLA markers. If your blood reacts to 30 of them, your panel reactive antibody (PRA) is 50%. The lower your PRA, the better your chance of getting a kidney transplant. A high PRA means that you are “sensitized.” Few kidneys would be a good match for you.

Your PRA can change from one month to the next. Talk with your transplant team about treatments to reduce your PRA if you are sensitized.

Transplantation and Your Lifestyle

Now that we’ve seen the basics of how transplant works, let’s look at how it might affect your life in the areas of:

• What you can eat and drink
• How many medications you might need to take each day
• How much control you would have over your time
• How work-friendly transplant is
• How travel-friendly transplant is
• How a transplant may affect your sex life and ability to carry or father children

Transplant: Few or No Limits on Diet and Fluids

A transplant may require some limits on what you eat. You may gain weight from the transplant drugs and need to limit calories. Your doctor may also want you to eat less salt than in the standard American diet. But, compared to standard in-center hemodialysis, transplant has far fewer limits on what you can eat and drink.

Transplant and Medications

A kidney transplant will require you to take many medications. You will need to take drugs to block your immune system so it does not attack your new kidney. You may also need blood pressure pills. If you have diabetes or other health problems, you will still need to take prescribed drugs for them, though the dose may change when you have a transplant.

Transplant and Your Schedule

A transplant gives you control of your schedule. You need to take your medications each day, and you will have clinic visits, but you won’t need dialysis treatments.

Transplant and Your Job

Do you want to be able to work? Getting a transplant can be work-friendly for many reasons. With a transplant, treatment:

• Just means taking pills every day
• May include some symptoms (from medications), but most people feel well enough to work
• Reduces the chance you might need to go to the hospital—and miss work
• Helps you to have enough energy to work

You will not need to miss work to go to a clinic for regular treatments. You are likely to feel well and have enough energy to work because a transplant can replace up to 50% of lost kidney function, which is more than most kinds of dialysis. And, a transplant works 24 hours a day, just like healthy kidneys.

Transplant and Travel

A transplant is the most travel-friendly treatment option for kidney failure. Since you carry your treatment with you, it goes where you do and doesn’t take time out of your day. Always keep your medications with you when you travel. Don’t leave them in checked luggage.

Transplant, Fertility and Your Sex Life

Both men and women who have had a kidney transplant say that their sex lives improve. Women have safely carried babies to term after having a kidney transplant. (Doctors suggest waiting about 2 years before trying to get pregnant.)

Kidneys from Living Donors

Kidneys for transplant come from either living people or deceased people. Since healthy people have two kidneys, they can choose to donate one. All surgery carries some risk, though the risk of kidney donation is small. A donor must have most of the same tests as you. Living donors must be healthy, so they tend to recover quickly from the surgery. A kidney is a gift—it is not something you can expect from someone else. A living donor can be a relative or friend.

You can get a kidney before you start dialysis (preemptive transplant). Preemptive transplant can be done with living or deceased donor kidneys. It is easier to schedule a transplant if you have a living donor. Laparoscopic surgery can be done to remove a kidney. Healing is much faster for the donor than with standard surgery.

Kidneys from Deceased Donors

Deceased donor kidneys come from people who are brain dead. Their loved ones donate their organs. A non-profit group called the United Network for Organ Sharing (UNOS) keeps a national transplant list of people who are waiting for an organ. The VA is part of the UNOS System. You must have many tests at a VA transplant center to be on the list—you do not get added to the list just because your kidneys are failing.

When your kidney function drops to about 20%, you can be put on the transplant list. Most people start dialysis before they get a transplant, but some people get a transplant first.

Most people have to wait to get a deceased donor kidney. The wait time may be a matter of months, or it may be as long as seven years or more. The wait time depends, in part, on your blood type.

Transplant: What to Expect

Transplant surgery itself takes only 2–3 hours. The kidney may kick in right away, or it may take time. Your hospital stay will usually be 5–7 days. Before you leave the hospital to go home, you’ll get a lot of teaching. The medication regimen is complex and you’ll need to know it. You’ll also learn what sorts of complications to watch for and report to your care team. Total recovery time is about 6–12 weeks.

Choosing No Dialysis

In some cases, when your kidneys fail, you may choose not to have dialysis or a kidney transplant, but to do medical care without dialysis. This means that you will let nature take its course. Most religions do not think of this choice as suicide, even if you decide to stop dialysis after you start treatment.

Studies find that for some older people who are quite ill, dialysis does not extend life any more than good medical care without dialysis. Medical care without dialysis for kidney failure uses active palliative care to help you feel your best until natural death occurs. Palliative means “to cloak with care.” You will have clinic visits, take medications, and see a dietitian and social worker.

Comfort care and support

If you choose not to start dialysis when your kidneys fail, natural death will occur in a few weeks or months. Medical care without dialysis can keep you comfortable, treat your symptoms, and give you emotional and spiritual support. It does not extend life.

You might choose medical care without dialysis if you have other serious health problems. This is not true for kidney failure alone. Feeling helpless or depressed alone is not a reason to turn down dialysis—there are other ways to help you with these feelings.

Strong Emotions Are Normal

In fact, it is very normal to feel depressed when you learn that your kidneys are failing. Depression can make you feel hopeless—as if the best part of your life is over and you have nothing to live for. But many people can and do have good lives with kidney failure and dialysis or transplant. Depression can be treated so you feel better.

Hospice for You and Your Loved Ones

Hospice is a form of palliative care for those with advanced illness such as cancer or heart, liver, lung, or kidney failure. You can get hospice care in a hospice center, or in your own home.

Hospice services may include:

• Pain control
• Symptom relief
• Diet help
• Therapeutic massage
• Physical therapy
• Home health aides to help with bathing or other personal care
• Inpatient care, as needed
• Trained volunteer support
• Emotional and spiritual support for you and your family
• Bereavement support for your family

Choosing Medical Care without Dialysis: What to Expect

A natural death from kidney failure should not hurt. Wastes will build up in your blood until you slip into a coma. If you approve, dialysis may be used just to remove water from your blood so it does not build up in your lungs. Water in your lungs would make it hard to breathe. Eating less salt and drinking less water can help, too. You would receive treatment for any pain you have.

Be sure to fill out an Advance Directive form and share it with your care team and loved ones.

All adults should have an Advance Directive whether or not they have a kidney problem.

You Can Change Your Mind About Your Treatment Choice

If you have kidney failure, you can choose medical care without dialysis at any time—even if you start dialysis. And, you can change your mind if you choose medical care without dialysis, and decide to start dialysis.

Talk to Your Loved Ones

Talk with your family and friends about your choice. They can support you better if they understand what your goals and dreams are.

Why should I keep track of what I eat and drink?

The choices you make about what to eat and drink can help you feel better and can make your kidney failure treatments work better. Eating the right foods may give you more energy and strength.

Healthy kidneys balance the salts and minerals—such as calcium, phosphorus, sodium, and potassium—that circulate in your blood. When you have kidney failure, what you eat and drink may help you maintain a healthy balance of salts and minerals in your body.

The kind of kidney failure treatment you’ve chosen will affect your eating plan. If you have a kidney transplant, you’ll have fewer limits to your diet.

How can I learn what I should eat?

All dialysis and transplant centers have a dietitian who can help you plan your meals. A renal dietitian has special training in counseling people with kidney failure.

Nutrition counseling from a registered dietitian to help meet your medical or health goals is called medical nutrition therapy (MNT). Medicare pays for MNT for people with kidney disease with a written referral from your doctor. If you have insurance other than Medicare, ask if it covers MNT for kidney failure. You will also need a referral from your health care provider to a dietitian for MNT services.

You can find a registered dietitian online through the Academy of Nutrition and Dietetics or through your health care provider. Work closely with your dietitian to develop a meal plan that includes foods and drinks you enjoy eating while maintaining your health.

What will I need to change?

You will need to keep track of what you eat and drink. Changes may need to be made based on your blood test results. Nutrients are substances found in food that your body needs to function and maintain health—for example, water, sodium, protein, phosphorus, potassium, vitamins, and other minerals. Your diet can supply nutrients that are lost through treatment, or you might need to limit certain nutrients you eat that can build up in your body. You may also need to keep track of how many calories are in what you eat and drink.

You may need to keep track of the following:

Water

Water is in drinks such as coffee, tea, and soda; and in foods such as fruits, vegetables, ice cream, gelatin, soup, and popsicles. Your body needs water to function properly; however, in kidney failure, the kidneys can’t get rid of extra water. Taking in too much water can cause swelling, raise your blood pressure, and make your heart work harder.

Sodium

Sodium is a part of salt. You can find sodium in many canned, packaged, processed, and fast foods and in some seasonings. You need sodium to help control the amount of fluid in your body. However, too much sodium may cause high blood pressure. No matter what treatment you’re on, it’s likely you will need to limit sodium intake.

Protein

Protein provides the building blocks that help maintain and repair muscles, organs, and other parts of the body. Protein is in many foods you eat, including foods from animals and plants. Most diets include both types of protein. Too much protein can cause waste to build up in your blood, making your kidneys work harder.

Phosphorus

Phosphorus is balanced with calcium to keep your bones healthy. When you have kidney disease, phosphorus can build up in your blood. Too much phosphorus can weaken your bones.

Phosphorus is found naturally in foods rich in protein, such as meat, poultry, fish, nuts, beans, and dairy products. Phosphorus is also added to many processed foods, such as lunch meats. Phosphorus added to food may cause your blood levels to rise more than the phosphorus that is naturally found in food.

Your dietitian can help you find ways to get the protein you need without getting too much phosphorus.

Potassium

Potassium is a mineral that helps your nerves and muscles work. Potassium is found in fruits and vegetables such as oranges, bananas, tomatoes, and potatoes. Your nerve cells and brain will not work well if your potassium is too high or too low. If you have kidney failure, your potassium level may tend to be high. You may need to limit foods that are high in potassium.

Supplements for people with kidney failure

Supplements help provide some of the vitamins and minerals you may be missing, either because you need to avoid certain foods or because your treatment removes some vitamins from your body. Your health care professional may prescribe a supplement made for people with kidney failure. You should only take vitamin, mineral, or dietary supplements that your provider has recommended. Over-the-counter (no prescription needed) supplements not recommended by your providers may be harmful to you.

Calories

You need energy to fuel your body. Energy is measured in calories. Taking in more calories than your body uses can cause weight gain and high blood sugar. Taking in fewer calories than your body uses will result in weight loss.

Work with your dietitian to learn how you can make changes to what you eat and drink. Learn more about eating right for hemodialysis.

Learn about CKD from a primary care doctor or a kidney doctor (nephrologist) to better understand treatment options and protect the kidneys. People with glomerulonephritis, polycystic kidney disease, or other kidney disease should talk about specific treatment options with a kidney doctor.

Monitor and Manage Blood Sugar and Blood Pressure

• Have blood sugar and blood pressure checked regularly.
• Use medicines if prescribed to lower blood sugar and blood pressure.

People with diabetes, high blood pressure, or CKD need to talk to their doctor about how to protect their kidneys.

Manage CKD

• Make lifestyle changes (e.g., healthy eating, physical activity) to prevent more kidney damage. Meet with a dietitian to create a kidney-healthy eating plan that is low in salt and fat and has the right amount and source of protein. As CKD gets worse, the plan may also include limiting phosphorus and potassium.
• Use medicines as directed to slow the decline in kidney function.
• Stop smoking or do not start smoking.
• Avoid exposures that can harm the kidneys or cause kidney function to suddenly get worse:
  • Certain medicines:
    • Over-the-counter pain medicines like ibuprofen and naproxen, which are also called non-steroidal anti-inflammatory drugs.
    • Some antibiotics.
  • Certain herbal supplements.
  • Excessive alcohol intake.
• Review with health care providers all prescription and over-the-counter medications to make sure they are safe for the kidneys. Always talk to a doctor before taking any supplements.
• Check with a doctor about other behaviors or substances that can harm the kidneys or about special precautions to take when doing medical tests or procedures, such as imaging studies or colonoscopies.

Doing well with kidney failure is a challenge. You will feel better if you

• stick to your treatment schedule
• review your medicines with your health care provider at every visit and take your medicines as prescribed
• work with a dietitian to develop an eating plan that includes foods you enjoy eating while also helping your health
• stay active—take a walk or do some other physical activity that you enjoy
• stay in touch with your friends and family

Treatment with dialysis or transplant will help you feel better and live longer. Your health care team will work with you to create a treatment plan to address any health problems you have. Your treatment will include steps you can take to maintain your quality of life and activity level.

Your eating plan plays an important role. When you have kidney failure, what you eat and drink may help you maintain a healthy balance of salts, minerals, and fluids in your body.

Yes. Physical activity is an important part of staying healthy when you have kidney failure. Being active makes your muscles, bones, and heart stronger. Physical activity also makes your blood travel through your body faster so your body gets more oxygen. Your body needs oxygen to use the energy from food.

You may find that physical activity can also improve your mood and make you feel better.

Talk with your doctor before you start a new exercise routine. Start slowly, with easier activities such as walking at a normal pace or gardening. Work up to harder activities such as walking briskly. Aim to be active on as many days as possible.

People who have kidney failure may have trouble sleeping. Sleep loss can affect your quality of life, energy level, and mood. Restless leg syndrome, sleep apnea, pain, or itching may make it hard for you to sleep.

You can take a number of steps to improve your sleep habits. For example, physical activity during the day and a warm bath before bed may help you sleep better at night. Avoid caffeine after lunchtime. Avoid alcoholic drinks before bed. Avoid smoking.

Talk with your health care provider if you often feel sleepy during the day or have trouble sleeping at night. Health care providers can treat sleep disorders such as sleep apnea or restless leg syndrome.

Kidney failure will affect your emotions, nerves, hormones, and energy levels, all of which may change your sexual relationships. Taking good care of yourself by managing your kidney disease and controlling your blood pressure and blood glucose levels can help prevent some sexual problems, such as erectile dysfunction. Getting counseling may help with some emotional problems, such as anxiety and depression, which can get in the way of having satisfying sex.

You may feel shy asking questions about your sex life, but your health care team has heard the same questions from other people. Your provider is trained to help you address concerns about your sex life.

Many people with kidney failure continue to work. KidneyWorks is a program to help people with kidney disease keep working. The program focuses on Americans with CKD whose kidneys have not yet failed or who are living with a transplant. If you are on dialysis, the information in the KidneyWorks paper may also provide tips to help you keep your job.

The Americans with Disabilities Act means that an employer can’t legally fire you just because you’re on dialysis or have had a kidney transplant. The law requires an employer to make reasonable changes to the workplace for a person with a disability. For example, your employer may give you lighter physical jobs or schedule your work hours around your dialysis sessions. If you’re on peritoneal dialysis, you’ll need space and time to change the dialysis solution in the middle of the work day. Most employers can make these adjustments.

If your employer isn’t willing to meet your needs, your dialysis clinic’s renal social worker may be able to help find a way to satisfy both you and your employer.

Coping with kidney failure can be stressful. Some of the steps that you are taking to manage your kidney disease are also healthy ways to cope with stress. For example, physical activity and sleep help reduce stress.

Depression is common among people with a chronic, or long-term, illness. Depression can make it harder to manage your kidney disease. Ask for help if you feel down. Your health care team can help you. Talking with a support group, clergy member, friend, or family member who’ll listen to your feelings may help.

Treatment for depression is available.

Vaccines are especially critical for people with health conditions such as renal disease.

If you have renal disease or kidney failure, talk with your doctor about:

• Influenza vaccine each year to protect against seasonal flu
• Tdap vaccine to protect against whooping cough and tetanus
• Pneumococcal polysaccharide vaccine to protect against pneumonia and other pneumococcal diseases
• Hepatitis B vaccine series to protect against hepatitis B
• Zoster vaccine to protect against shingles if you are 60 years and older
• HPV vaccine to protect against cancers and genital warts caused by human papillomavirus if you are an adult through age 26 years (HPV vaccine is not recommended for everyone older than age 26 years, but some adults age 27 through 45 years who are not already vaccinated may decide to get HPV vaccine after speaking with their doctor about their risk for new HPV infections and the possible benefits of vaccination. HPV vaccination in this age range provides less benefit, as more people have already been exposed to HPV.)
• MMR vaccine to protect against measles, mumps, and rubella if you were born in 1957 or after and have not gotten this vaccine or do not have immunity to these diseases
• Varicella vaccine to protect against chickenpox if you were born in 1980 or after and have not gotten two doses of this vaccine or do not have immunity to this disease