hemodialysis

Treatment Options for End Stage Renal Disease (ESRD)

The treatment options for people who is diagnosed with End Stage Renal Disease (ESRD), also known as End Stage Kidney Disease (ESKD) – GFR level less than 15 mL/min/1.73m² or Stage 5 kidney disease – are to get a kidney transplant or to undergo regular dialysis.

Kidney transplant is a good option if there is a kidney donor (humans can survive with one functioning kidney), a right match, and have no problem to go for surgery.

If kidney transplant is not possible, then the only available treatment option is to undergo regular dialysis 2 or 3 times per week as prescribed by your Nephrologist.

What is Hemodialysis?

Hemodialysis is a therapy that filters waste, removes extra fluid and balances electrolytes (sodium, Potassium, bicarbonate, chloride, Calcium, magnesium and phosphate).

In hemodialysis, blood is removed from the body and filtered through a man-made membrane called a dialyzer, or artificial kidney, and then the filtered blood is returned to the body. The average person has about 10 to 12 pints of blood; during dialysis only one pint (about two cups) is outside of the body at a time.

Access Types for Hemodialysis

To perform hemodialysis there needs to be an access created to get the blood from the body to the dialyzer and back to the body. There are three access types for hemodialysis: arteriovenous (AV) fistula, AV graft and central venous catheter. The AV Fistula is the vascular access most recommended.

When a patient goes to hemodialysis, a nurse or technician will check vital signs and get the patient’s weight. The weight gain will tell how much excess fluid the patient has to have removed during the treatment. The patient is then “put on the machine”. Patient with a vascular access (AV fistula or AV graft) will get two needle sticks in their access; one needle takes blood out of the body, the other needle puts it back.

Dialysis Machine

The dialysis machine is like a big computer and a pump. Blood never actually goes through the dialysis machine. It keeps track of blood flow, blood pressure, how much fluid is removed and other vital information.

It mixes the dialysate, or dialysis solution, which is the fluid bath that goes into the dialyzer. This fluid helps pull toxins from the blood, and then the bath goes down the drain. The dialysis machine has a blood pump that keeps the blood flowing by creating a pumping action on the blood tubes that carry the blood from the body to the dialyzer and back to the body. The dialysis machine also has many safety detection features.

Dialyzer

The dialyzer is the key to hemodialysis. The dialyzer is called the artificial kidney because it filters the blood — a job the kidneys used to do. The dialyzer is a hollow plastic tube about a foot long and three inches in diameter that contains many tiny filters. (Dialyzers are made in different sizes so doctors can prescribe the best one for their patients.) There are two sections in the dialyzer; the section for dialysate and the section for the blood.

The two sections are divided by a semipermeable (capable of penetrating or passing through only to certain small molecules) membrane so that they don’t mix together. A semipermeable membrane has microscopic holes that allow only some substances to cross the membrane. Because it is semipermeable, the membrane allows water and waste to pass through, but does not allow blood cells to pass through.

Blood needs to flow through the dialyzer for several hours to adequately clean the blood and rid the body of excess fluid. Traditional, in-center hemodialysis is generally done three times a week for about four hours each session. Some people feel that dialysis lasts a long time; however, healthy kidneys work 24 hours a day, 7 days a week and dialysis must do the job in only 12 or so hours (4 hours X 3 days) a week.

Dialysate

Dialysate, also called dialysis fluid, renal fluid, dialysis solution or bath, is a solution of pure water, electrolytes and salts, such as bicarbonate and sodium. The purpose of dialysate is to pull toxins from the blood into the dialysate.

The way this works is through a process called diffusion. In the blood of the hemodialysis patient, there is a high concentration of waste, while the dialysate has a low concentration of waste. Due to the difference in concentration, the waste will move through the semipermeable membrane to create an equal amount on both sides.

The dialysis solution is then flushed down the drain along with the waste. The electrolytes in the dialysis solution are also used to balance the electrolytes in the patient’s blood. The extra fluid is removed through a process called filtration. The fluid is pushed off by higher pressure on the blood side than on the dialysate side.

There are different sizes of dialyzers. These sizes are related to the blood volume that will go through them, which depends on the patient’s size and weight. Your kidney doctor will prescribe the right-sized dialyzer for you.

Diet, Fluid Restrictions, & Medicines

Hemodialysis is an effective treatment for those with End Stage Renal Disease (ESRD) or End Stage Kidney Disease (ESKD). However, hemodialysis alone will not provide a complete treatment for those with kidney failure. Diet and fluid restrictions need to be followed, and medicines may need to be taken to replace other functions of the kidneys, such as regulating blood pressure and stimulating production of red blood cells to prevent Anemia.

Protein restrictions are not recommended for patients with ESRD or ESKD on dialysis. Instead presence of good protein will prolong the life of patients on Dialysis. Dialysis patients should be checked every month to check their protein level in their blood Albumin which should be greater than 4.0. So dialysis patients should not restrict their diet instead should consult Nephrologist and dieticians.

Patients on dialysis must restrict their water intake, especially those who cannot urinate. Too much water or fluid will lead to volume overload causing swelling, even fluid can build up in the lungs causing shortness of breath or respiratory distress. Too much water between dialysis can also stress your heart causing abnormal heart rhythm.

Additionally, the diet restrictions include limiting foods that contain Phosphorous, Potassium, and Sodium.

For those who choose in-center hemodialysis, some of the benefits are that they will have their treatments performed in a dialysis center by trained professionals. They can spend their time in dialysis sleeping, reading, listening to the Quran or doing other quiet activities. There are four days a week when they will not have to go to dialysis.

Dialyzer Reuse for Dialysis

Dialyzers can remain functional after more than one use. Patients who choose to reuse their dialyzers are given an individual dialyzer that they will continue to use for the number of times specified by their doctor or until it is no longer efficient. Patients do not “share” dialyzers.

Patients only reuse their own dialyzer, meaning that no other patient has or will ever use it. After your dialysis session is complete, a facility member will take you off the dialysis machine and seal your dialyzer, which is labeled with your name, in a plastic bag. The dialyzer is then sent to a reuse technician who will follow strict procedures to make sure your dialyzer is clean, sterile and in good working condition before you use it again.

The automated reuse/reprocessing machine cleans the dialyzer using water treated with reverse osmosis. This water is highly purified and cleans the dialyzer without leaving traces of particles and chemicals. After cleaning, the reprocessing machine performs a pressure test and blood volume test. The pressure test checks for any holes in the dialyzer. The blood volume test ensures that the dialyzer’s capacity is above 80% of the dialyzer’s stated size. If there are any holes in the dialyzer, or if the blood volume is less than 80% of the dialyzer’s size, it is replaced with a new one. If any problems are detected during the reuse test, the reprocessing machine indicators let the reuse technician know, and the dialyzer is disposed of in the proper manner.

How Does My Doctor Know if Dialysis is Working?

When you begin dialysis treatments, you should begin to feel better as your blood is getting cleaned. To make sure you are getting adequate dialysis, your Nephrologist will order lab work to see how well dialysis is working for you. If your doctor sees that your blood is not being adequately cleaned, changes can be made to help you get better treatments.

URR (Urea Reduction Ratio)/ BUN (Blood Urea Nitrogen)

The urea reduction ratio (URR) is one way of measuring dialysis adequacy—how much waste is removed by hemodialysis. If you receive hemodialysis three times a week, each treatment should reduce your urea level (also called BUN or blood urea Nitrogen) by at least 65 percent.

Kt/V

Kt/V, like URR, is a measure of dialysis adequacy.

K = clearance—the amount of urea your dialyzer can remove (liters/minute)
t = time—the duration of treatment (minutes)
V = volume—the amount of body fluid (liters)

For patients undergoing hemodialysis three times a week, K/DOQI (Kidney Disease Outcomes Quality Initiative) national guidelines in the U.S.A. recommend a delivered Kt/V of at least 1.2.

Your Kt/V should be at least 1.2 or
Your URR should be at least 65 percent.

Ideal Blood Flow Rate for Hemodialysis

During hemodialysis, a blood pump is set to a constant speed to push your blood through the dialyzer and back to your body. Your Nephrologist prescribes the blood flow rate. It’s usually between 300 and 500 mL/min (milliliters per minute). Ask your Nurse or technician to show you how to see the blood flow rate on your machine. With many dialyzers, blood flow rates greater than 400 mL/min can increase the removal of toxins. Blood flow rate is limited by the size of your access, the tubing and the needles.

URR and Kt/V Tests

These lab tests are drawn monthly. Ask your dialysis nurse what your values are each time. If your values do not reach adequate numbers, work with your healthcare team to raise your dialysis dose.

If your Kt/V and URR numbers are below the recommended levels, your doctor will adjust your dialysis treatment to improve waste removal from your blood by:

Checking to make sure you have good vascular access
Increasing the blood flow rate through the dialyzer
Increasing the duration of dialysis—for example, if your treatments have been 3 hours in length, they may be increased to 4 hours

While Kt/V and URR are important, they’re not the only tests you need to know about. For example, Hemoglobin (HgB), Albumin, Creatinine, Calcium, Potassium (K), Phosphorous, Parathyroid, etc.

Tips for the Family Members of Dialysis Patients

As a care giver and family members of the patients undergoing dialysis, there are certain things you need to know and do to help them and to take care of yourself as well.

Commitment – In-center dialysis can be a 2 to 3 days a week and each session can last 4 hours or more. So it will require firm commitment from both patient and family members as care givers.

Knowledge – Before beginning dialysis, the patient you care for will need to make a lot of choices and you might be asked to help to make those choices for or with them. So it’s important that you read this health guide in full. Write down the information you may not be able to remember including questions you want to ask your Nephrologist.

Stick to the schedule – Maintain schedule at the day and time specified to have an effective dialysis. Be sure to arrive 15 minutes early for dialysis appointment, so they have time to get ready for the full treatment. Missing even a few minutes of one treatment can make dialysis less effective and have a negative impact on their health.

Keep important information with you – You want to be sure that you have your loved one’s medical information written down, including all medications and the names of their doctors. Keep it with you at all times so you can be prepared for an emergency — before there’s an actual emergency.

Know their limits – Dialysis can be a very tiring process. So it’s a good idea not to schedule a lot of other activities on dialysis days.

Keep track of their symptoms – Flu-like symptoms, such as feeling tired or weak and having chills, are common for people on dialysis. You may notice they sleep more or are more forgetful. These symptoms are most often due to Anemia—a shortage of red blood cells—and can be treated. Be sure to keep the nephrologist and treatment team informed about how the person you care for is doing.

Staying active is important – People on dialysis do better when they move around and stay active. And, in fact, so will you. Go for a walk with the person you care for as often as possible. Encourage them to stay engaged with their work or hobbies. Studies show that people on dialysis do better when they stay active. As always, check with their doctor before encouraging them to start a new exercise routine.

You may be overwhelmed at first – There will be a lot of new information, and the person you care for may not be in the right frame of mind to remember it all. The good news is that, eventually, going to the dialysis center with them will become routine—and you’ll know exactly what to do. And, of course, we’re here to help you every step of the way.

Take time for yourself – Being a care giver is hard work, emotionally and physically. Make sure you take time to do some of the things you enjoy on your own, such as visiting other families and friends, or doing relaxing activities. Prayers, supplications, and meditations can also be very beneficial and reassuring. Finding healthy ways to relieve stress can do a surprising amount of good for your energy and mood.