Conventional advice says the first decision in kidney failure is simply choosing dialysis. That approach misses the bigger picture. I use a broader frame: renal replacement therapy is a set of modalities with different trade-offs, rhythms, and risks. Each pathway changes daily life, not just lab numbers. This guide sets out the options, how I think through selection, and what living well on treatment can look like.

Types of Renal Replacement Therapy Available Today

Haemodialysis

Haemodialysis removes solutes and fluid using a dialyser and vascular access. I regard it as the most familiar form of renal replacement therapy, and for many it is the initial bridge to stability. It requires a regular schedule, usually three sessions per week in centre. The routine can be demanding, yet predictable scheduling helps with work and family planning.

• Strengths: reliable solute clearance, close nurse oversight, swift correction of hyperkalaemia.

• Limitations: post-dialysis fatigue, intradialytic hypotension, and travel to units.

In practice, success rests on three pillars: adherence to sessions, medication alignment, and diet discipline. Miss any one, and outcomes suffer. Consistency wins.

Continuous Renal Replacement Therapy (CRRT)

CRRT runs slowly and continuously in the intensive care setting. I reserve it for patients with acute kidney injury who need tight haemodynamic control. This modality allows nuanced fluid balance and steady acid-base correction with less blood pressure volatility.

• Typical triggers: refractory fluid overload, severe metabolic acidosis, or fragile circulation.

• Technical notes: dosing precision and anticoagulation strategy matter to reduce filter clotting.

Timing remains case specific. Evidence suggests early initiation is not universally superior; clinical context should guide the start. It is basically a tool for stability first, clearance second.

Peritoneal Dialysis

Peritoneal dialysis uses the peritoneum as a living membrane for exchange. I consider it the most self-managed form of renal replacement therapy and often the most compatible with work and schooling. A catheter is placed in the abdomen, dialysate flows in, waste diffuses across, and the fluid drains out on a set schedule.

• Key advantages: autonomy, fewer hospital visits, and preservation of residual urine in many.

• Main risk: peritonitis, which drops sharply with meticulous technique training.

For motivated adults and many adolescents, it offers continuity of life routines. Younger patients and those awaiting a donor often value its flexibility.

Kidney Transplantation

Transplantation replaces kidney function with a donated organ. When suitable, I view it as the modality most likely to restore energy, diet freedom, and long-term independence from machines. Evaluation covers immunological matching, comorbidities, and readiness for lifelong immunosuppression.

• Post-operative reality: clinic surveillance is intense early, then tapers to predictable follow-up.

• Trade-offs: infection risk, medication side effects, and the possibility of rejection.

Not every candidate proceeds at once. Some start with dialysis and transition when a compatible organ becomes available. A clear plan for both scenarios reduces anxiety.

Haemodiafiltration

Haemodiafiltration combines diffusion and convection to clear a broader range of toxins. I use it when middle molecule removal is a priority, or when patients feel unwell despite adequate haemodialysis doses. The technique adds substitution fluid to boost convective clearance.

As New England Journal of Medicine reported, high-dose haemodiafiltration reduced all-cause mortality by 22.7% versus conventional haemodialysis in a large trial.

Those data are compelling, though delivery depends on water quality, machines, and staff expertise. Where feasible, I consider haemodiafiltration for symptomatic patients or those with high inflammatory burden. Better clearance is not abstract. People often report clearer thinking and easier fluid control.

Making the Right Choice: Selecting Appropriate RRT Modality

Criteria for RRT Selection

Choice is structured. I start with clinical criteria and then layer practical constraints. The goal is the safest and most sustainable renal replacement therapy for that individual.

• Physiology: haemodynamic stability, electrolyte derangements, acid-base status, and urine output.

• Access: feasibility of fistula or catheter, or peritoneal catheter placement.

• Home set-up: clean space, power reliability, and caregiver support where needed.

• Health system factors: centre proximity, training availability, and follow-up capacity.

In children, size, tolerance of extracorporeal volume, and the course of illness weigh heavily. Peritoneal dialysis is often preferred where cost and vascular access are constraining. Adults face similar trade-offs, though work schedules and comorbidities add complexity.

When to Start RRT

Timing hinges on symptoms and complications, not serum creatinine alone. I watch for fluid overload unresponsive to diuretics, refractory acidosis, or hyperkalaemia with ECG changes. Uraemic complications like encephalopathy or pericarditis demand action.

1. Assess indications and reversible causes.

2. Optimise medical therapy, including diuretics and bicarbonate where appropriate.

3. Escalate to renal replacement therapy when organ-threatening features persist.

Large trials suggest early initiation in the ICU does not consistently lower mortality. That does not make delay a virtue. It makes judgement central, with close monitoring and a clear threshold to proceed.

Patient-Specific Considerations

Two people with the same eGFR may need different pathways. Preferences, job demands, and tolerance of procedures matter to an extent that is often underestimated. Some patients prioritise needle-free therapy at home. Others want in-centre oversight and predictability.

I frame the choice as a joint decision. I provide probabilities and practicalities. The patient brings values and constraints. That is the right division of labour.

Cost and Accessibility Factors in India

Affordability and access are decisive in India. For critically ill patients, CRRT can be costly. As Pace Hospitals lists, therapy may cost between ₹28,000 and ₹65,000 per day depending on the regimen.

Capacity is also uneven. As Pradhan Mantri National Dialysis Program notes, roughly 2.2 lakh new ESRD cases emerge annually, which pressures public services. District hospital expansion and public-private partnerships are narrowing gaps, though coverage remains variable by state.

• Urban-rural divide persists in machine availability and trained staff.

• Peritoneal supplies may be available, yet reimbursement can be patchy.

• Transplant evaluation clusters in tertiary centres, raising travel costs.

Here is the practical point. Modality choice often follows finance and geography as much as physiology. Planning must include both.

Living with Renal Replacement Therapy: Practical Considerations

1. Home-Based Treatment Options

Home haemodialysis and peritoneal dialysis can restore control over time. I propose home options when patients are willing to train and have a safe set-up. Schedules can be tailored, including short daily sessions or gentle nocturnal runs.

• Benefits: flexibility, fewer travel hours, and often better blood pressure control.

• Requirements: structured training, emergency plans, and caregiver readiness.

Barriers are real, including anxiety about machines and supply logistics. A staged training plan, with practice runs and 24-hour support lines, usually resolves early concerns. Confidence grows with repetition.

2. Managing Complications and Side Effects

Side effects cluster into three groups: intradialytic symptoms, access issues, and infection risks. I teach patients to recognise patterns and act early. Rapid ultrafiltration can trigger cramps and hypotension; small rate adjustments often fix both.

• Haemodialysis access: keep sites clean and inspect for redness or pain.

• Peritoneal care: strict sterile technique to minimise peritonitis risk.

• Medication review: adjust antihypertensives to reduce post-dialysis dips.

For CRRT in ICU, anticoagulation strategy and circuit surveillance reduce downtime. For all modalities, the basics matter. Adequate salt control, good anaemia management, and timely vaccinations prevent many downstream problems.

3. Nutritional Requirements During RRT

Nutrition is therapy. I align diet with the chosen renal replacement therapy and the person’s goals. Energy targets prevent protein-energy wasting, while protein intake supports repair and immune defence.

Regular dietitian follow-up keeps plans realistic. Food diaries help identify sneaky sodium or phosphate sources. Perfection is not required. Consistent, small improvements are.

4. Quality of Life Considerations

Treatment success is not only biochemical. I measure quality of life alongside Kt/V. Work capacity, sleep, intimacy, and the freedom to travel all matter. A modality that harms these repeatedly is a poor fit, even if labs look tidy.

And yet, the most important variable remains agency. When patients feel in control, adherence improves and symptoms ease. Autonomy is clinical.

5. Long-Term Outcomes and Prognosis

Prognosis depends on age, comorbidity, modality, and engagement with care. Transplant generally offers the longest survival and greatest day-to-day freedom. Haemodiafiltration may improve outcomes for some on long-term extracorporeal therapy.

• Consistent attendance and target achievement correlate with better survival.

• Residual kidney function, if present, is worth protecting.

• Access health predicts stability; fistulas outperform catheters over time.

There is no single curve. There are many. The right path is the one a person can sustain.

Conclusion

Renal replacement therapy is not one decision but a sequence of choices. Start with immediate safety, then optimise for fit and durability. I recommend framing the discussion in three layers: clinical need, life design, and system realities. Revisit the plan at each transition point, including after hospitalisations or when work or family circumstances change.

Most importantly, choose a modality that supports both health and identity. Kidneys filter blood. Good plans protect a life.

Frequently Asked Questions

What is the difference between haemodialysis and peritoneal dialysis?

Haemodialysis uses a machine and dialyser to clean blood through vascular access. Peritoneal dialysis uses the abdominal lining as a filter via a catheter and dialysate exchanges. I weigh haemodynamic stability, lifestyle, and home readiness when comparing both renal replacement therapy options.

How much does kidney transplant cost in India?

Costs vary by centre, donor type, and complications. The invoice includes surgery, hospital stay, tests, and early immunosuppression. I advise obtaining a written package estimate and checking insurance coverage. Consider travel and accommodation as part of total renal replacement therapy costs.

Can children undergo peritoneal dialysis?

Yes. Peritoneal dialysis is commonly used in paediatrics because it suits smaller body size and avoids large extracorporeal volumes. Families need training, supplies, and close follow-up. The modality can be an effective bridge to transplant within a paediatric renal replacement therapy plan.

What are the eligibility criteria for kidney transplantation?

Eligibility includes advanced kidney failure, acceptable cardiovascular risk, and suitability for immunosuppression. Screening checks infections, cancer risk, and compatibility with a donor. Motivation and adherence history also matter. These determine whether transplant is the right renal replacement therapy step.

How long can someone survive on dialysis?

Survival varies widely by age, comorbidities, and treatment quality. Many patients live for years with consistent attendance, good nutrition, and well-functioning access. Prognosis improves when complications are minimised. Each renal replacement therapy pathway is individual.

Is home dialysis available in India?

Yes, in selected centres and cities. Home haemodialysis and peritoneal programmes are expanding, though availability differs by region. Training and support are essential. I encourage centres to build clear escalation plans to sustain home renal replacement therapy safely.

What dietary restrictions apply during dialysis?

Typical advice covers sodium, potassium, and phosphorus control, with adequate protein and energy intake. Fluid targets are personalised. Vitamin supplementation may be needed, especially water-soluble vitamins. Diet should align with the chosen renal replacement therapy and regular lab review.