Haemodialysis

• ? Rigid timing—usually 4 hours three times a week plus transport to and from dialysis unit.
• ? HD units usually have two to three shifts a day with little flexibility of timing for patients on shift work.
• ? Difficult to arrange treatments at other units, particularly at short notice, making travel difficult.
• ? Intermittent treatment so dietary and fluid restrictions.
• ? Patients often feel washed out for some hours after dialysis and can be relatively hypotensive, though this is very variable and some patients are well enough to drive to and from their dialysis sessions.
• ? Presence of arteriovenous fistula in arm—need to avoid heavy lifting with that arm.
• ? If patient opts for home HD, some weeks dialysing at hospital needed to accustom patient to dialysis, and to train patient to needle their own fistula and manage machine.

Peritoneal dialysis

• ? Home-based treatment allowing flexibility round work routine.
• ? Travel relatively easy—patient can transport own fluid for short trips or fluid can be delivered to many parts of the world.
• ? Can be difficult to fit in four exchanges a day if on CAPD and working, but some patients can arrange a clean and private place at work to do an exchange.
• ? More freedom during day if patient on APD—at most, one bag exchange is needed and this can be done at a time convenient for patient.
• ? Continuous treatment, so no ‘swings’ in well-being of patient.
• ? Heavy lifting should be avoided because of the increased risk of abdominal hernias and fluid leaks.
• ? PD usually started 2 weeks after catheter insertion with a training period of 1 week.

Patients can lead a normal life after successful transplantation, but need to continue daily immunosuppressive therapy (the actual immunosuppressive regimen will vary from unit to unit, as many different agents are now available—prednisolone, azathioprine, ciclosporin, tacrolimus, sirolimus, mycophenylate). Transplant patients are therefore at increased risk of infection. In the first few months, patients are advised to avoid people with bad colds, influenza, and chicken pox. This is particularly important for teachers working in schools and others in similar situations.

Transplant patients have a slightly increased risk of developing malignancy. Skin malignancies are among the most common, so patients should be advised to make liberal use of sunscreens when working outside. There are complications related to specific immunosuppressive drugs such as hirsutism with ciclosporin or diabetes with tacrolimus. Many patients also remain hypertensive after transplantation. Cardiovascular disease remains a major cause of morbidity and mortality but less so than in patients on dialysis.

Long-term follow-up studies in relation to work are encouraging. A study of 57 adult survivors from childhood transplantation showed a high level of employment (82 per cent) and 95 per cent reported their health as fair or good.¹³ This was despite a high retransplantation rate and significant morbidity such as hypertension, bone and joint symptoms, fractures, hyper- cholesterolaemia, and cataracts. A study of 267 Japanese transplant recipients found patient and graft survival rates of 80 per cent and 51 per cent at 10 years and 56 per cent and 33 per cent at 20 years.¹⁴ The main causes of death long-term were cancers and hepatic failure due to viral hepatitis. In 15 patients with grafts surviving beyond 20 years, 11 remained in full-time employment.