The kidneys are a pair of bean shaped organs that act as filters, and are located at the back of the body around the level of the waist. Each kidney measures 10-15cm in length and weighs approximately 160 grams.

There is a constant flow of blood filtered through millions of small, thinly walled blood vessels. The fluid filtered out is called urine, which is collected in the central part of the kidney and passes through the urinary ducts, or urethras, down to the bladder. Each day the two kidneys excrete about one to two litres of urine.

Kidneys function as filters and perform the vital job of cleaning the blood of waste products and removing excess fluid. In other words, they filter the blood and keep our body clean of harmful toxins.

Kidneys maintain the body's balance of various salts such as sodium, potassium, calcium, phosphate, and acid. They release hormones, which influence the bone structure (Vitamin D), the generation of red blood cells (erythropoietin), and the regulation of blood pressure.

Picture a pool filter that removes leaves, bugs and impurities from the water while letting chlorine and clean water through. In a nutshell, this is precisely how your kidneys function. While most parts of our bodies and organs absorb oxygen and nutrients, our kidneys act as the pool filters of the body by sifting through unwanted and dangerous chemicals.

Kidneys retain the substances we need to be healthy, while eliminating toxic waste in the form of urine. According to statistics from the National Kidney Foundation of South Africa, our kidneys filter 200 litres of blood per day and produce approximately 150 litres of urine daily. They reabsorb almost 149 litres of useful substances like proteins and nutrients, before excreting plus minus two litres of waste like drugs, medicines, chemicals, and hormones that our bodies do not need. All while controlling the amount of acidity and alkalinity (pH) in your body. Whenever the kidneys filters are damaged or do not function properly, it can result in kidney disease.

Many kidney diseases can be prevented by following these tips:

• Quit smoking – this is one of the most important lifestyle changes to reduce your risk of developing kidney disease. Smokers are three times more likely to have reduced kidney function

• Limit your alcohol intake – excessive alcohol consumption can lead to heart disease and high blood pressure that increases the risk of kidney disease

• Good nutrition – the food we eat plays a huge role in our health. By ensuring that you eat a balanced, nutritious diet, you can help prevent kidney disease. A healthy diet can also help you shed some unwanted kilos as people who are overweight have a greater risk of developing diabetes and high blood pressure – both of which are major risk factors in kidney disease

• Drink six to eight glasses of water a day this will help your kidneys in flushing out harmful toxins

• Get some exercise by walking, opt for the stairs instead of the lift, and get your heart pumping blood to your organs. It can reduce your risk of developing heart disease and diabetes that in turn can increase your risk factors for kidney disease

Kidney disease occurs when the filters (i.e.) are damaged. This occurs slowly over a long period of time. The damage usually occurs in both kidneys and you cannot feel when the filters are damaged.

You have a high risk of developing kidney disease, if you have any of the following:

1. Uncontrolled Diabetes Mellitus (high blood sugar problems)

2. Uncontrolled Hypertension (high blood pressure – is your blood pressure above 130/80?)

3. Close family relatives with renal disease (hereditary kidney disease)

Unfortunately, kidney disease shows no symptoms in the early stages. The best way to detect kidney disease is through a blood test to check your estimated glomerular filtration rate (eGFR).

Unfortunately, kidney disease is not curable. It can, however, be treated successfully when detected at an early stage. People with kidney disease have an increased tendency to suffer from heart attacks and strokes. That is why it is important to test for kidney disease regularly, especially for people who have increased risk.

A sign is a physical manifestation of an illness, injury or any other bodily disorder. A symptom is what the patient is experiencing.

Early on, people may not have any symptoms to tell them that their kidneys are not functioning properly. That is why regular physical check ups at your GP, including blood tests and urine tests, are so important. Test results may show signs of kidney disease even when a patient feels fine.

As the kidney disease progresses, a person may feel sick sometimes. The change may be so slow that he or she does not do anything about these feelings. Symptoms may also be due to another illness or problem.

• Headache

• Puffiness around the eyes

• Diarrhoea

• Decreased sexual interest

• Increased thirst

• Feeling cold

• Drowsiness or confusion

• Decrease of urine output

• Trouble with concentrating

In chronic (long-term) renal failure (CRF) the kidney function decreases gradually and possibly progressively over a period of time. It is a lifelong condition that can lead to end-stage renal disease in some patients. It is mostly caused by underlying chronic kidney disease.

The common causes of kidney failure are:

• Hypertension (high blood pressure)

• Diabetes mellitus (having raised blood sugar or glucose levels)

Other causes include:

• Glomerulonephritis (inflammation of the kidney)

• Chronic infection

• Hereditary factors, such as a family member also having kidney disease

• Accidents and injury caused by medication, drugs, poisons, and radiation

Kidney failure is life threatening unless treated by dialysis or transplantation.

Complete kidney failure causes many changes in the body and symptoms may vary from person to person. One person may experience many of the symptoms that follow, but another person may not.

• Feeling generally sick – when the kidneys begin to fail, waste products will build up in the blood. This may cause a person to feel generally sick. Symptoms may include fatigue, nausea, vomiting, and loss of appetite, itching, and/or disturbed sleep

• Fluid retention – as the kidneys produce less urine, which may cause extra fluid to build up in the body, this is called oedema. People with this problem may have swollen hands and ankles. They may gain fluid weight, and/or may be short of breath doing activities such as walking or climbing a few stairs

• Anaemia – the body will not produce as many red blood cells when the kidneys are not working. People with anaemia may feel weak, cold and tired. A drug that acts like the body's own hormone, erythropoietin, stimulates the production of red blood cells. The drug may be used to treat this type of anaemia

• Toxin build up – when the kidneys are not working to clean the blood, waste products called toxins will build up in the body. This may cause fatigue, loss of appetite, and may make the person's skin feel itchy

Kidney failure occurs when the kidneys stop working or the level of efficiency is less than 10%. When the kidney function deteriorates, the waste products and excess fluid remain in the body – imagine all the toxins building up in your body?

These waste products and fluids are toxic in large quantities, and their accumulation could eventually lead to kidney failure. Kidney failure can lead to blood deficiency (anaemia) and brittle bones.

Acute renal failure occurs when the kidneys suddenly stop working. This condition is temporary. The cause may be disease, injury, major surgery or toxic agents. Chronic renal failure can occur suddenly, or develop gradually over a period of time. This is not reversible. Kidney function never returns

Dialysis is the major treatment for kidney failure. It is the medical word for filtering waste products and removing fluid from your body that your kidneys are no longer able to remove.

There are two forms of dialysis: haemodialysis and peritoneal dialysis.

Haemodialysis cleans and filters your blood using a machine to temporarily rid your body of harmful wastes, extra salt, and extra water. Haemodialysis helps control blood pressure and helps your body keep the proper balance of important chemicals such as potassium, sodium, calcium, and bicarbonate.

Haemodialysis uses a special filter called a dialyser that functions as an artificial kidney to clean your blood. During treatment, your blood travels through tubes into the dialyser, which filters out wastes and extra water. Then the cleaned blood flows through another set of tubes back into your body. The dialyser is connected to a machine that monitors blood flow and removes wastes from the blood.

Haemodialysis is usually needed three times a week. Each treatment lasts from three to five or more hours. During treatment, you can read, write, sleep, talk, or watch TV.

If you choose haemodialysis several months before your first treatment, access to your bloodstream will need to be created. You may need to stay overnight in the hospital, but many patients have their access placed on an outpatient basis. This access provides an efficient way for blood to be carried from your body to the dialysis machine and back, without causing discomfort. The two main types of access are a fistula and a graft.

Vascular access problems are the most common reason for hospitalisation among people on haemodialysis. Common problems include infection, blockage from clotting, and poor blood flow. These problems can keep your treatments from working. You may need to undergo repeated surgeries to get a properly functioning access.

Other problems can be caused by rapid changes in your body's water and chemical balance during treatment. Muscle cramps and hypotension (low blood pressure), or a sudden drop in blood pressure, are two common side effects. Low blood pressure can make you feel weak, dizzy, or sick to your stomach.

You'll probably need a few months to adjust to haemodialysis. Side effects can often be treated quickly and easily, so you should always report them to your doctor and dialysis staff. You can avoid many side effects if you follow a proper diet, limit your liquid intake, and take your medicines as directed.

Even in the best situations, adjusting to the effects of kidney failure and the time you spend on dialysis can be difficult. Aside from the lost time, you may have less energy. You may need to make changes in your work or home life, giving up some activities and responsibilities.

Adjusting to a new routine now that your kidneys have failed may be difficult, and accepting this new reality can be very hard on you and your family. A counselor or social worker can help you cope.

Many patients feel depressed when starting dialysis, or after several months of treatment. If you feel depressed, you should talk with your social worker, nurse, or doctor because this is a common problem that can often be treated effectively.

Haemodialysis is usually done in a dialysis centre by nurses and trained technicians. In some parts of the country, it can be done at home with the help of a partner, usually a family member or friend. If you decide to do homedialysis, you and your partner will receive special training.

To have chronic haemodialysis, you need to have surgery to create access, as a way for the blood to move through the dialyser.

The most common type of chronic access used is arterio-venous (AV) fistula and the arterio-venous (AN) graft. The fistula is created internally and is used for a prolonged length of time. Your surgeon makes a fistula under the skin by joining an artery and vein, allowing arterial blood to flow directly into the vein. Due to arterial pressure, the vein will increase in size and thicken. It takes about four to eight weeks for the fistula to mature.

A fistula makes it easy to put a needle into the vein to allow blood flow through the dialyser using the blood pump. The graft is an artificial blood vessel used to join an artery and vein. It is used when patients' own blood vessels are too small for fistula construction. The graft may be either straight or looped and is close to the surface of the skin. The graft may be of an artificial material or can be obtained from the patient’s own body, e.g. vein in the thigh.

Temporary access can be created in cases that need urgent dialysis and cannot wait for a few weeks for the fistula to mature. These include the subclavian catheter, an internal jugular catheter , and arterio-venous shunt. The subclavian catheter is a set of tubing, which is inserted into the subclavian vein near the neck. The internal jugular catheter is placed into the veins at the side of the neck. The subclavian and internal jugular catheter cannot be used beyond a few weeks, as it tends to get blocked or the site of insertion may become infected. The shunt is surgically created with artificial material and has a short life span, i.e. six months.

Haemodialysis and a proper diet can help reduce waste that builds up in your blood.

A dietitian is available at all dialysis centres to help you plan meals according to your doctor's orders. When choosing foods, you should remember to:

• Eat balanced amounts of high-protein foods such as meat, chicken, and fish

• Control the amount of potassium you eat. Potassium is a mineral found in salt substitutes, some fruits (bananas, oranges), vegetables, chocolate, and nuts. Too much potassium can be dangerous

• Limit how much you drink. When your kidneys aren't working, water builds up quickly in your body. Too much liquid makes your tissues swell and can lead to high blood pressure, heart trouble, cramps and low blood pressure during dialysis

• Avoid salt. Salty foods make you thirsty and make your body hold water

• Limit foods such as milk, cheese, nuts, dried beans, and dark-coloured cooldrinks. These foods contain large amounts of the mineral phosphorus. Too much phosphorus in your blood causes calcium to be pulled from your bones, which makes them weak and brittle, and can cause arthritis. To prevent bone problems, your doctor may give you special medicines, which you must take with meals, every day, as directed

• Keep the area clean and dry

• Feel for thrill sensation at both ends of fistula/graft at least twice weekly

• Inspect the fistula for redness, swelling, tenderness, or warmth to touch to detect infection

• Avoid constrictive clothing, jewellery, etc. that may block the fistula

• No blood pressure, blood taking, or intravenous administration should be done on the fistula arm

• Avoid excessive pressure on puncture sites after dialysis

• Rotate needling sites to prevent an aneurysm

• If an injury occurs at the site of the fistula/graft, apply pressure over bleeding and seek immediate medical help

Advantages:

• Staff performs the treatment at the dialysis unit

• No equipment needed to be kept at home

• Treatment three times per week

• Regular contact with staff and other patients which can help with a feeling of being cared for, and develop compassion to see other patients also going through the treatment

Disadvantages:

• Having to travel to the dialysis unit for treatment three times a week can cause disruptions in work and home life.

• Fixed treatment times at the dialysis unit can make schedules very tight and stressful.

• Two needles are inserted with each treatment.

• Toxic waste builds up between treatments causing patients to feel ill.

• Diet and fluid restrictions.

The most common forms of peritoneal dialysis used today are continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD).

Peritoneal dialysis is performed by introducing dialysate solution into the peritoneal (abdominal) cavity through a silastic catheter. The natural membrane lining of the peritoneal cavity acts as a filter, through which waste products and excess fluid from the body pass through the membrane into the dialysate solution.

The dialysate solution used is sterile and contains salts and a high content of glucose (sugar). The glucose will cause water from the blood stream to be drawn into the peritoneal cavity.

A peritoneal dialysis procedure is called an exchange because the used solution is removed and replaced with fresh solution. You connect long tubing set to the short tubing you are wearing (attached to the catheter). The lower bag is for draining used solution from the peritoneal cavity, and when empty, you are ready to fill with fresh dialysate solution from the upper bag. The fluid surrounds the internal organs – it does not go into the stomach or other organs. The dialysate solution is left in the peritoneal cavity for several hours to collect waste products and excess fluid from the blood.

Continuous ambulatory peritoneal dialysis (CAPD) functions much like the kidneys do. CAPD constantly cleans the blood provided there is sufficient dialysate solution in the cavity.

Typically, you would do four exchanges per day, every five to six hours, i.e. when waking up, at lunch time, during the late afternoon, and bedtime. CAPD gives you constant dialysis, 24 hours a day, seven days a week.

Automated peritoneal dialysis (APD) is dialysis at home with a cycler machine. Each night before you go to sleep, you connect your set to a long tubing set, attached to dialysate bags on the cycler. The machine does the exchanges while you sleep, and is quiet and does not wake you. The tube is long enough for you to sleep comfortably and walk several feet.

The peritoneal catheter, called a tenckhoff, is a small soft tube placed into the peritoneal cavity surgically. You will typically stay overnight in the hospital. Just a few inches of the catheter is outside your body. Most are inside your body. The catheter is left in place so dialysis can be done. It provides a small opening in which the dialysate solution can be placed.

Training for peritoneal dialysis is offered at all National Renal Care units, countrywide, and is normally done on an out-patient basis.

• Self-care

• No needles

• Greater independence

• Flexible diet

• Flexible schedule

• Blood pressure control

• Blood sugar control

• Less stress on the body

• Patients on peritoneal dialysis lead very normal lives – many patients continue to work, go to school or are active in the community and can travel more easily

• Disposables are delivered to your home or travel destination free of charge

• Daily exchanges

• You aren't able to take a day off from the dialysis treatment

• Permanent catheter

• Some risk of infection

• Some possible weight gain

The dependence on artificial life support devices, adherence to strict medical regimes, along with an increase in financial obligations and a decrease in physical and social functioning, frequently result in feelings of depression, anxiety, worthlessness, and hostility.

All members of your family unit are affected by your renal disease. Family members may need to assume new roles. For the person who is ill, losing former roles either temporary or permanently can be frightening and depressing. These include unemployment or being too ill to do family chores. There are changes in roles or lifestyles that may occur in your own family, which cause stress as the family adjusts.

Family members who may need to be responsible for you at first but continue to treat you as if you are too sick to care for yourself, can place a huge burden on the family. Due to your illness, you may need to depend on your family at first, and this may be hard to accept, especially if you are a very independent person.

Sex may be a difficult topic for many, but it is important to discuss it to understand the physical and emotional changes that occur with renal failure.

A chronic illness such as renal failure will change one's desire for sexual intimacy. For men, impotence or the inability to maintain an erection may occur, and women may experience difficulty with arousal.

Men and women may show a lack of interest in sex, which can strain a sexual relationship. It is important to talk these concerns over with your doctor or nurse. Being a kidney patient doesn't mean you can't have a satisfying relationship.

Kidney failure and the treatment may be difficult to accept at first, however, with time, support and education you can adjust.

You must learn to live with dialysis as part of your life. You will need to learn to understand and accept your illness, and learn what it means to be a kidney patient. You will need to learn to eat and drink the right things, to take medication and exercise appropriately.

Communication is vital – talk about your feelings and experiences with someone you trust. Talking and sharing about what is happening to you will decrease your feelings of loneliness and increase your feelings of being supported and loved. Share your thoughts and feelings with family, friends and your medical treatment team. Talking to other patients is helpful too.

Once you are feeling better, it will be important to return to as many of your past activities as possible. With your doctor's permission, you may return to work, your hobbies, clubs, etc. Getting back into old routines will help you feel that sense of normality again. Your overall physical and mental adjustment depends on you and what attitude you chose to have.

Chronic kidney disease is a major health problem, with the incidence steadily growing over the last few years. The commonest causes of kidney failure, diabetes mellitus, and hypertension, are also independent risk factors for cardiovascular disease.

Individuals at risk for chronic kidney disease also include family members of patients with end stage kidney disease. Family members of chronic kidney disease patients are often unaware of existing renal disease. For people who still have some kidney function, there are many ways to keep the kidneys functioning for longer.

Visit your doctor regularly. If your doctor finds you are at risk for kidney disease or are showing signs of kidney disease, he or she will take several steps to improve your health.

You will have a common goal: to slow progression of the disease and to delay dialysis. First, your doctor will want to determine the cause and whether the cause is reversible or not. If the cause is an underlying condition like diabetes or hypertension, your doctor will assist you in trying to control this condition.

Lifestyle and diet changes may also be initiated. Dieticians play a significant role in helping patients delay kidney failure. This kind of intervention, however, may be effective only if the signs of kidney disease are diagnosed early.

• Do not wait to see your doctor – as soon as you are showing signs of ill health go for a check up with your GP and follow all your doctors’ advice

• Maintaining good blood glucose control if you have diabetes

• Follow your doctors’ orders to control your blood pressure, if you have high blood pressure

• Become educated about kidney disease and find out what the signs and symptoms are

• If you are currently at risk of developing kidney disease all medication, dietary supplements and vitamins may only be taken with the approval of your doctor

• Seek support if you are at risk and try to maintain a positive attitude about your condition

There are two types of urine tests.

One type requires a small amount of urine, which shows if there is blood, infection, protein, or cells in the urine.

The other type requires collecting all the urine produced for a certain amount of time, usually 24 hours. This test will show how much urine your kidneys produce in one day. It also measures how much protein is passed from the kidneys into the urine in a day.

Your doctor will be able to determine if your protein levels are normal, and may also measure the amount of waste from muscle cells (called creatinine) or from the protein you eat (called urea) in your urine to see how well the kidneys are functioning.

Everyone's blood test results are different. They are affected by three things:

1. What the person eats

2. How well the person's kidneys are functioning

3. How much urine the person passes and how much waste leaves the body through the urine

For many people, dialysis and transplantation not only extend but also improve quality of life. For others who have serious ailments in addition to kidney failure, dialysis may seem like a burden that only prolongs suffering. You have the right to refuse or withdraw from dialysis if you feel you have no hope of leading a life with dignity and meaning.

You may want to speak with your spouse, family, religious counsellor, or social worker as you make this decision. If you withdraw from dialysis treatments or refuse to begin them, you may live for a few days or several weeks, depending on your health and your remaining kidney function. Your doctor can give you medicines to make you more comfortable during this period.

Should you change your mind about refusing dialysis, you may start or resume your treatments at any time.

An advance directive may be a living will – a document that details the conditions under which you would want to refuse treatment. You may state that you want your healthcare team to use all available means to sustain your life. Alternatively, you may direct that you be withdrawn from dialysis if you become permanently unresponsive or fall into a coma from which you won't awake.

In addition to dialysis, other life-sustaining treatments that you may choose or refuse include:

• Cardiopulmonary resuscitation (CPR)

• Tube feedings

• Mechanical or artificial respiration

•Antibiotics

• Surgery

• Blood transfusions

Another form of advance directive is called a durable power of attorney for health care decisions or a health care proxy. In this type of advance directive, you assign a person to make healthcare decisions for you if you become unable to make them for yourself. Make sure the appointed person understands your values and is willing to follow through on your instructions.

Even if you're satisfied with your quality of life on dialysis, you should think about circumstances that might make you want to stop dialysis treatments. At some point in a medical crisis, you might lose the ability to express your wishes to your doctor. An advance directive is a statement or document in which you give instructions either to withhold treatment or to provide it, depending on your wishes and the specific circumstances.

The Healthy Start Clinic is unique to National Renal Care.

The primary function of this program is to educate and manage patients with early kidney disease. The aim is to ensure that the patient remains as healthy as possible and maintains a high quality of life. Preventative strategies include early detection and treatment, meticulous hypertension control, strict glycaemia control, anaemia management, and appropriate dietary and lifestyle changes.

All our centres countrywide offer this program, which includes education, dietary advice, and psychosocial support.

Yes, it is possible to go on holiday if you have with kidney disease and need dialysis. All you need to do is contact the nearest renal unit before you go on holiday to make the necessary arrangements for you to receive treatment.