Dialysis

Our fist-sized kidneys have the function of filtering our blood by eliminating waste and surplus fluids from our bodies. This waste further proceeds to our bladder so that we can dump it out of our systems when we urinate.

Dialysis is the process that comes into the picture when our kidneys are unable to perform that function of filtering efficiently or have failed. End-stage kidney failure occurs when the rate of filtration is below 10% to 15% of what a normal kidney does.

Dialysis is a process or treatment that screens and cleans the blood using a machine and/ or external substance (generally a fluid). This supports keeping the fluids and electrolytes present in the blood to be balanced when our kidneys fail to do their jobs.

Fun fact: the first successful dialysis was performed in 1943.

Dialysis

Use Of Dialysis

The very basic functions of our precious little kidneys are to avert access to water, waste, and impurities from building up in our bodies. Apart from that, they help us regulate our blood pressure and control the levels of minerals and nutrients in our blood. These minerals and nutrients include sodium and potassium. Believe it or not our kidneys even activate a certain form of Vit D that improves the absorption of calcium in our body, especially bones, and deficiency of it weakens our bones.

 So, when your kidney is unable to perform these functions due to damage or an ailment, dialysis comes to the rescue and assists us to keep our system in as orderly and normal a manner as it can. Without dialysis, the salts and other impurities will build up and collect in our blood, which will further make our system toxic, and eventually damage the whole system. 

However, if a person chooses to not do dialysis for whatsoever reason, other ways can help the patient according to their needs. 

Types Of Dialysis?

three different kinds of dialysis procedures can help a person with kidney issues: hemodialysis, peritoneal dialysis, and CRRT.

Hemodialysis

This is the most recurrent type of dialysis. In this process we use a kind of artificial kidney commonly known as a hemodialyzer that is used to terminate the waste and extra salts running through our veins. When this blood is passed through it purifies all of it by filtering it. The pure filtered blood then is sent back to the body with the help of a machine. For the nephrologist to stream the blood through this apparatus, he /she needs to make an entry point to the veins. This entrance point is called vascular access. there are three different types of access or entry points: 

  1. Arteriovenous (AV) fistula: as the name suggests this kind of entry point is which connects the artery and a vein. This is also the one that is preferred by the nephrologists.

AV_fistula

AV graft: 

  1. This is usually an artificial tube made via grafting a transplanted animal or human vein.
  2. Vascular access catheter: in a vascular access procedure, nephrologists insert a catheter (tube) into a blood vessel so that direct big amounts of blood can be drawn as soon as possible. 

The first two types are created for long-term dialysis of the patient. Catheters are made for temporary usage.

Hemodialysis generally takes 4 hours each time and is usually done 3 times a week. though one can opt for a shorter duration, more frequent sittings. 

Though hemodialysis is performed at hospitals or dialysis centers, it can also be performed at home once the nephrologist is assured that you are ready for dialysis at home. This is an option for long-term patients. The duration of the whole dialysis treatment depends on many factors including the size of your body, the eGFR of your kidneys, and also your overall health.

Hemodialysis filters all the fluids of your body in the same manner your kidneys did, they regulate the blood pressure and minerals salts in the blood. It helps you live longer, but it’s not a cure for failed kidneys.

 

During hemodialysis, the blood is passed via a filter known as a dialyzer or artificial kidney as it does the same job. At the beginning of the whole process, a nurse or staff member inserts two needles into the arm. Each of these needles is attached to a tube that is further attached to the dialyzer and the whole machine. While hemodialysis, your blood is sent through a dialyzer, and when it is filtered and purified they send it back to your body. During this process, the machine also checks your blood pressure and regulates the salts and minerals essential for blood and the body.

When the blood comes through one end of the machine, it is pumped into tiny hollow strands while a solution called the dialysis solution is passed through the other end of it. like a sieve, the only pureblood remains in the hollow strand-like fibers while all the waste gets washed away. The blood is then returned to the patient’s body. The dialysis solution usually has water and other substances that are combined to remove and filter out the waste. 

You can get the treatment at a dialysis center or even at home, depending upon your need. Most people opt for a dialysis center as everyone can’t buy such expensive machines. And if they are not long-term patients then it is not worth buying one even if they can afford it. In dialysis centers, patients not only get the help of the professionals, they also get the finest types of equipment and other staff like the dietician, the technician, the nurse, even a social worker.

 If you do home hemodialysis then you can choose the duration and or frequency of the dialysis. Since the whole system is compact and one can sit and do the whole process, you can have extra time for other duties. though you can’t skip seeing a nephrologist once a month.

It is preferred if you have a trained partner in your home for your home hemodialysis, so it is better if you ask a family member or a close friend to go to these training sessions with you to the center or clinic. Training might take several, 5 days a week for at least a month or more. Knowing how to place needles into the access may take less time. 

Dialysis is a very intricate treatment and it takes a lot of time to understand. no nephrologists tell you to start dialysis until needed so it’s very much possible to feel just fine while the nephrologist is explaining it to you. you need to have some knowledge about it before going through the procedure. mental preparation is as important as physical preparation.

Take care of the blood vessels in your arms

It’s essential to protect your veins in the arms before the starting of your dialysis procedure. If you need to draw blood for tests, ask your health care provider to insert the needle at the back of your hands instead of your arm vein. you might not be able to use the arm vein for dialysis if it is damaged by the repetition of drawing blood for it. 

Vascular access surgery

 A significant step before starting hemodialysis is having a small surgery to create vascular access in your body. The vascular is the most important part of your dialysis process as it is the entrance that connects you with the dialyzer for the treatment. 

During dialysis your blood goes through the filter at very high rates and more than a pint of blood is pumped through and out of the filter every minute. Vascular access is a place that has to survive the pressure of this high blood flow during dialysis. 

Work with your nephrologist and the vascular surgeon to plan out everything in such a manner that there is plenty of time to do the vascular access surgery. Healing posts the vascular surgery also requires several months. With your nephrologist and vascular surgeon to make sure the access is in place in plenty of time. Healing may take several months. The aim is to make you ready for dialysis as soon as you need it. The surgeon attaches the artery to a vein to create an AV fistula. 

AV fistula

fistula

AV fistula is the best type of long-term access. In this a surgeon attaches an artery to a vein, generally in your arms, to make an AV fistula. One should be clear about the difference between artery and vein. An artery is a blood vessel that transports blood away from the heart and a vein is a blood vessel that transports blood towards the blood. When the surgeon connects these two, the vein becomes comparatively broader and copious, making it easier to position the needles for starting the dialysis. creating an AV fistula allows a bigger diameter for the blood to flow in and out of the body and since the walls of the veins are thicker, they are more capable of handling the high rate of blood flow that the dialyzer creates.

The AV fistula is a blood vessel especially made in such a manner to handle the blood flow and for the inserted needle to stay put while dialysis. The reason AV fistula is the access point is because 

  • It lets us have the highest amount of blood flow at high rates
  • It is unlikely to get infected or even clot
  • It usually lasts longer because of its thickness 

Most people can go home after the surgery. The creation of AV fistula is a minor surgery and the patient’s area that had been used to make the access is numbed by giving a local anesthetic. Depending on some factors, the patient may choose to get an anesthetic and not be aware of the whole procedure. 

Most people can go home after outpatient surgery. You will get local anesthesia to numb the area where the vascular surgeon creates the AV fistula. Depending on your situation, you may get general anesthesia and not be awake during the procedure.

AV graft

Some patients are unable to get an AV fistula. In that case, they simply need to get an AV graft instead. For a surgeon to connect your vein to the artery through an AV graft, they require a man-made or artificial loop-like tube similar to the AV fistula that does the job. An AV graft can be used immediately after the surgery for the use of dialysis treatment. Although artificial is not as good as natural in most cases, there are higher chances of getting an infection or a blood clot. And since clots will block the passage of blood flow, it can create a different kind of a problem for everyone, making it very hard to continue the dialysis.

 

Catheter for temporary access

Many times, we find out about the kidney disease in the last stage itself or maybe it is progressing very swiftly, and you didn’t get a chance to do the vascular access surgery before the dialysis is needed, then you have to get a venous catheter for creating temporary yet quick access. A catheter is a soft tube that has to be inserted in your neck, chest, or leg near your groin, according to the requirement to start the dialysis immediately. Your nephrologist places this venous catheter in a place best suited for temporary use and will suggest an AV surgery according to your situation later. You get to choose to get an anesthetic to stay calm during the making of this access. This surgery can be performed at a hospital or a clinic.

Take care of your access

Your access is the gateway to life, and you must be aware of the procedures and precautions you must take to protect it. Wash the surrounding area of the access with some soap and warm water daily so that it remains clean and away from infections. Keep a check on signs and symptoms of infections, that may be redness of the skin or warmth (more comparative to the body). You must also keep in mind that when you are going through dialysis and the blood is flowing through the access you have a sense of vibration in the area and around it. you should always inform your nephrologist or the dialysis center, in case you are not feeling that sensation. 

Make changes to what you eat and drink

Forgoing through dialysis, one needs to take care of your intake. you might need to limit some certain food items, like:

  • You need to limit sodium 
  • Limit the foods rich in phosphorus
  • Check on the amount of liquid your intake, because fluids build-up 

 

One might also need to check on the level of protein in your diet as it is also filtered in hemodialysis. The right amount of potassium is also a must. You must see that you take the right amount of vitamin supplement specially made for patients with kidney diseases. 

Since lost appetite is also one of the major symptoms of kidney disease you need to find ways to add up more calories to your daily intake. For all these things you can simply book a slot for a dietician who can guide you for a fuller, and apt diet which would suit your needs. You can even ask out about a diet that suits you in home hemodialysis. Eating the right food becomes essential for the overall betterment of health and therefore in your kidneys.

Some risks and issues can occur in home hemodialysis. 

You can be having issues with your vascular access. For this reason, it is preferred to have hemodialysis at a hospital or clinic, where you get immediate aid for issues related to your vascular access too. your vascular access may:

  • be infected 
  • have blockage because of some clotting 

Though these issues might sound like a minor thing they can put a stop to the whole dialysis and you need to create another vascular access all over again, and these kinds of situations can be life-threatening to an end-stage kidney failed person. Also, adjustment with the whole hemodialysis might take time. You should always consult a nephrologist if needed, and it is better to follow the diet chart that has been provided by the dietician.

Peritoneal dialysis

This is just another way of removing all the waste and impurities from your blood when your kidneys fail to it. In this process, we use a different technique than what we generally use, in hemodialysis.

In peritoneal dialysis, a special kind of solution called the dialysis solution is passed from a tube called a catheter, into the abdomen of the patient where it purifies the blood by absorbing all the waste leaving behind pure blood. the lining of the patient’s abdomen or peritoneum performs the function of a filter and removes all the impurities from the blood. Then after a fixed amount of time, this liquid with the waste flows out of the abdomen and is then disposed of. 

This kind of treatment is easier in the sense that it can be performed anywhere from home to office to the time when you are traveling. But one must remember that peritoneal dialysis is not an option for every patient with failed kidneys. You need to be skillful enough to handle the whole change of liquid and taking out of used solutions along with the ability to take care of yourself. You might also want a reliable person to help you out if you can’t do it yourself.

Why it's Done

One needs dialysis when their kidneys don’t work well enough for normal body function and/or hinders them too. Since kidneys are so efficient that you don’t even need both of them if they are healthy enough for normal functioning of the body, you might develop a kidney disease because of some other long-term disease like diabetes, high blood pressure, glomerulonephritis, polycystic kidney disease, etc.

 In hemodialysis, the blood is drawn out of the body, filtered, and then sent back to the body.

In peritoneal dialysis, the blood remains in the body but is filtered by a solution in the area of the abdomen created for the same purpose i.e., filtration.

 Even though both types of dialysis is efficient enough, the edge peritoneal dialysis has over hemodialysis are listed below:

  1. It gives felicity and the chance to be independent, which is a plus factor if you live away from home for work or are alone.
  2. The diet is not as restrictive as in hemodialysis because of the greater frequency of change of solution which does not let sodium or potassium accumulate in the body.
  3. It helps in longer-lasting residual kidney function unlike in hemodialysis.

 It’s always preferred that you discuss this with your nephrologist and decide which kind of dialysis is better suited for you. while discussing it you might want to consider the following factors:

  • Your kidney function: if it works a bit or has fully failed 
  • Your overall health: what other diseases you have 
  • Your personal preferences: if you live far away from the clinic 
  • Your home situation: If you don’t have someone you can rely on for this 
  • Your lifestyle: If your work includes fieldwork or not 

You should also know which kind of dialysis is better for you. you should choose peritoneal dialysis if:

  • You are not able to bear the speedy variations of fluid balance related to hemodialysis
  • You want to curtail the disturbance of your day-to-day events
  • You want to work where need to travel a lot 
  • You still have a bit of residual kidney function

While we jot down the advantages of it, we should also keep in mind when it is not suitable for us to pursue peritoneal dialysis. it might not work if:

  • You have Widespread surgical scars in your abdomen area 
  • You have hernia 
  •  You have no one to rely on for care support or you are lacking in self-care abilities 
  •  You have recurrent sessions of diverticulitis or have Inflammatory bowel disease

Also, people having peritoneal dialysis eventually might have deterioration in the kidney function and will eventually require hemodialysis or maybe even a kidney transplant.

Risks and Complications of peritoneal dialysis:

  • Infections: having an infection on the lining of the abdomen is a common complication of peritoneal dialysis. So, one should be skilled enough to avoid that situation.
  • Weight gain: the special solution used in peritoneal dialysis, that absorbs the waste, also contains sugar. This sugar is absorbed by the body and can easily lead to weight gain and high sugar levels too, if you have diabetes.
  • Hernia: Holding fluid in your abdomen for an extended time may overburden your muscle in that area and can cause a hernia 

Inadequate dialysis: if you are looking for long-term dialysis then you might not want to do peritoneal dialysis as it becomes ineffective after a prolonged period.

How You Prepare

The first step you need to take to start the peritoneal dialysis is to do a surgery to make space for inserting the catheter that transports the dialysate (the dialysis solution that absorbs waste), in and out of the abdomen. This insertion can take place under general or local anesthesia. The tube or catheter is usually positioned near your belly button.

After this insertion, the nephrologist generally recommends a month’s rest and waiting so that the area where they positioned the catheter heals nicely and can stay put while they start with the peritoneal dialysis.

It is also important to know the whole process of dialysis because you generally receive training for the same. 

 You can expect many things during peritoneal dialysis including things:

  • The dialysate streams into your abdomen and then stays there for a particular period (mostly 4-6 hours)
  • Dextrose (sugar-based) in the dialysate helps separate waste, chemicals and access fluid in your blood 
  • When the staying time of dialysate along with the waste is over it is drained out of the abdomen and a new batch is poured in 

This process of filling and then streaming out of your abdomen is known as an exchange and different methods of peritoneal dialysis use different exchange schedules. The two main types of schedules are:

  • Continuous ambulatory peritoneal dialysis (CAPD)
  • Continuous cycling peritoneal dialysis (CCPD)

Continuous ambulatory peritoneal dialysis (CAPD)

In this schedule, you simply fill your abdomen with dialysate, let it reside there for a particular dwell time, then drain out that fluid. Gravity does the task of moving the fluid through the catheter and in and out of your abdomen.

With CAPD:

  •  You may require approx. 3-5 exchanges daily with longer dwell hours while you sleep
  • You can perform the exchanges at home, work, or any place that can be considered a clean environment 
  • You’re free to do your normal daily activities while the dialysate resides in your abdomen

Continuous cycling peritoneal dialysis (CCPD)

It is also known as APD (automated peritoneal dialysis). In this method, a machine called an automated cycler is used to perform multiple exchanges during the time you are sleeping (generally at night). The cycler automatically does the task of filling and raining and hence is called so. You simply have to discard the used solution in the morning. 

With CCPD:

  • You remain linked to the automated cycler for about 10 to 12 hours at night.
  •  Since you won’t be connected to the machine during the day you need to exchange in the morning with a dwell time such that it lasts the whole day.
  •  Also, because your frequency of connection and disconnection is less than what it is in CAPD, you have a lower risk of peritonitis

For you to determine the best type of exchange for you must always talk to your nephrologist and discuss all the factors including lifestyle, preference, and medical conditions.

Results

The factors that affect how well peritoneal dialysis works include:

  • Body size
  • Rate of filtering through peritoneal dialysis 
  • Amount of dialysate used each time
  • The frequency of exchanges
  •  Duration of each dwell time 
  • The concentration of sugar in the dialysate.

for checking if your dialysis is removing the right amount of waste, your nephrologist might recommend tests like:

  • Peritoneal equilibration test (PET). In this test, a sample of your blood and your dialysis solution is compared. This test informs whether the dialysis would improve if the solution dwelled in your abdomen for a shorter or longer period.
  • Clearance test. In this test, a blood sample and a sample of used dialysate are analyzed to determine how much urea is being removed in each dwelling. 

If the test results confirm that the dialysis exchange schedule is unable to remove enough wastes, your nephrologist might suggest you either increase the frequency of exchanges or increase the amount of dialysate used each time or replace a dialysate with a higher dextrose concentration.

 

 You’re over heath and the results of dialysis can improve if you take care of your eating habits and eat the right food. A dietitian becomes an absolute necessity if you want help in developing a suitable meal plan according to your preferences and taste. This diet plan will be based on various things like your weight, your preferences, your remaining kidney function, and also your medical conditions, including diabetes and high blood pressure. Intake of medicines that are prescribed by the nephrologists is also important if you want fast and good results.

Continuous Renal Replacement Therapy (CRRT)

This treatment is used for patients who have acute kidney failure and are in the intensive care unit (ICU). This type of dialysis treatment is also called hemofiltration. 

In this, a machine is used to pass the blood through the tube and then a filter is used to sieve out the waste and fluids. This blood is then returned to the body with replacement fluid. This is a long procedure that can take from 12 to 24 hours a day, each day or even last for 2 to 3 days.

 

Alternatives to dialysis

Since dialysis is not only time-consuming, it is also expensive, not every person chooses it, especially if they are facing acute kidney failure.

 In case you decide not to have dialysis, other treatments can help you manage and reduce the symptoms. One of these is anemia management, in which the patient gets injected EPO weekly, to help produce RBCs. Regulating blood pressure and diabetes can further help you control the damage to your kidneys. 

A kidney transplant is another viable option for some people. Since it’s also a long-term commitment, you should always consult your nephrologist and talk to them about whether or not the transplant is the right fit for you. 

Stopping dialysis

 When you start considering stopping dialysis, consult your nephrologist and ask them to check your weight and blood pressure. Analyzing these can help to find out if the dialysis is effective. You must also mention all the concerns you have regarding this before stopping your dialysis. Though you have the right to stop any kind of treatment on you, you must also talk to a mental health professional before putting a halt to this life-saving treatment. 

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