reatment Choice: Hemodialysis
Purpose
Hemodialysis cleans and filters your blood using a machine to temporarily rid your body of harmful wastes, extra salt, and extra water. Hemodialysis helps control blood pressure and helps your body keep the proper balance of important chemicals such as potassium, sodium, calcium, and bicarbonate.
Dialysis can replace part of the function of your kidneys. Diet, medications, and fluid limits are often needed as well. Your diet, fluids, and the number of medications you need will depend on which treatment you choose.
How Hemodialysis Works
Hemodialysis uses a special filter called a dialyzer that functions as an artificial kidney to clean your blood. The dialyzer is a canister connected to the hemodialysis machine.
Hemodialysis
During treatment, your blood travels through tubes into the dialyzer, which filters out wastes, extra salt, and extra water. Then the cleaned blood flows through another set of tubes back into your body. The hemodialysis machine monitors blood flow and removes wastes from the dialyzer.
Hemodialysis is usually done three times a week. Each treatment lasts from 3 to 5 or more hours. During treatment, you can read, write, sleep, talk, or watch TV.
Getting Ready
Arteriovenous fistula.Several months before your first hemodialysis treatment, an access to your bloodstream will need to be created. You may need to stay overnight in the hospital, but many patients have their access created on an outpatient basis. This access provides an efficient way for blood to be carried from your body to the dialyzer and back without causing discomfort. The two main types of access are a fistula and a graft.
A surgeon makes a fistula by using your own blood vessels; an artery is connected directly to a vein, usually in your forearm. The increased blood flow makes the vein grow larger and stronger so it can be used for repeated needle insertions. This kind of access is the preferred type. It may take several weeks to be ready for use.
A graft connects an artery to a vein by using a synthetic tube. It doesn’t need to develop as a fistula does, so it can be used sooner after placement. But a graft is more likely to have problems with infection and clotting.
Graft.
Catheter for temporary access.Before dialysis, needles are placed into the access to draw out the blood.
If your kidney disease has progressed quickly, you may not have time to get a permanent vascular access before you start hemodialysis treatments. You may need to use a catheter—a small, soft tube inserted into a vein in your neck, chest, or leg near the groin—as a temporary access. Some people use a catheter for long-term access as well. Catheters that will be needed for more than about 3 weeks are designed to be placed under the skin to increase comfort and reduce complications.
For more information about vascular access, see the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) fact sheet Vascular Access for Hemodialysis.
Who Performs Hemodialysis
Hemodialysis is most often done in a dialysis center by patient care technicians who are supervised by nurses. Medicare pays for three hemodialysis treatments each week. If you choose in-center treatment, you will have a fixed time slot three times per week on Monday-Wednesday-Friday or Tuesday-Thursday-Saturday. If you do not get the time slot you want at first, you can ask to be put on a waiting list for the time slot you prefer. For a special event, you may be able to trade times with someone else. You will want to think about the dialysis schedule if you work or have children to care for. Some centers offer in-center nocturnal dialysis. This treatment is done for a longer period at night, while you sleep at the center. Getting more dialysis means fewer diet and fluid limits, and this treatment leaves your days free for work, child care, hobbies, or other tasks.
You can choose to learn how to do your own hemodialysis treatments at home. When you are the only patient, it is possible to do longer or more frequent dialysis, which comes closer to replacing the steady work healthy kidneys do. Daily home hemodialysis (DHHD) is done 5 to 7 days per week for 2 to 3 hours at a time, and you set the schedule. If your health plan will pay for more than three treatments, you might do the short treatments in the mornings or in the evenings. Nocturnal home hemodialysis (NHHD) is done 3 to 6 nights per week while you sleep. Either DHHD or NHHD will allow a more normal diet and fluids, with fewer blood pressure and other medications. Most programs want people doing hemodialysis at home to have a trained partner in the home while they do treatments. Learning to do home hemodialysis is like learning to drive a car—it takes a few weeks and is scary at first, but then it becomes routine. The dialysis center provides the machine and training, plus 24-hour support if you have a question or problem. New machines for home dialysis are smaller and easier to use than in-center ones.
You have a choice of dialysis centers, and most towns have more than one center to choose from. You can visit a center to see if it has the treatments you want or the time slot you need. Some centers will let you use a laptop or cell phone or have visitors, and others will not. Medicare has a list of all U.S. centers on its Dialysis Facility Compare website (www.medicare.gov/dialysis) with quality ratings for each. Your health plan may have a list of centers you can use. If you choose in-center treatment, you may want the center to be close to your home to reduce your travel time. If you do a home treatment, once you are trained you only need to visit the center once a month. So, the center can be as far away as you are willing to travel once a month.
Possible Complications
Vascular access problems are the most common reason for hospitalization among people on hemodialysis. 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 in order 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—a sudden drop in blood pressure—are two common side effects. Hypotension can make you feel weak, dizzy, or sick to your stomach.
You’ll probably need a few months to adjust to hemodialysis. 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.
Diet for Hemodialysis
Hemodialysis and a proper diet help reduce the wastes that build up in your blood. A dietitian is available at all dialysis centers to help you plan meals according to your doctor’s orders. When choosing foods, 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, such as bananas and oranges; vegetables; chocolate; and nuts. Too much potassium can be dangerous to your heart.
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, and 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 colas. 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.
For more information about choosing the right foods, see the NIDDK booklet Eat Right to Feel Right on Hemodialysis.
Pros and Cons
Each person responds differently to similar situations. What may be a negative factor for one person may be a positive one for another. See a list of the general advantages and disadvantages of in-center and home hemodialysis below.
In-Center Hemodialysis
Pros
+ Facilities are widely available.
+ Trained professionals are with you at all times.
+ You can get to know other patients.
+ You don’t have to have a partner or keep equipment in your home.
Cons
- Treatments are scheduled by the center and are relatively fixed.
- You must travel to the center for treatment.
- This treatment has the strictest diet and fluid limits of all.
- You will need to take—and pay for—more medications.
- You may have more frequent ups and downs in how you feel from day to day.
- It may take a few hours to feel better after a treatment.
Home Hemodialysis
Pros
+ You can do it at the times you choose—but you still must do it as often as your doctor orders.
+ You don’t have to travel to a center.
+ You gain a sense of independence and control over your treatment.
+ Newer machines require less space.
+ You will have fewer ups and downs in how you feel from day to day.
+ Home hemodialysis is more work-friendly than in-center treatment.
+ Your diet and fluids will be much closer to normal
+ You can take along new, portable machines on car trips, in campers, or on airplanes.
+ You can spend more time with your loved ones.
Cons
- You must have a partner.
- Helping with treatments may be stressful to your family.
- You and your partner need training.
- You need space for storing the machine and supplies at home.
- You may need to take a leave of absence from work to complete training.
- You will need to learn to put in the dialysis needles.
- Daily and nocturnal home hemodialysis are not yet offered in all locations.
Working With Your Health Care Team
Questions you may want to ask:
Is hemodialysis the best treatment choice for me? Why?
If I’m treated at a center, can I go to the center of my choice?
What should I look for in a dialysis center?
Will my kidney doctor see me at dialysis?
What does hemodialysis feel like?
What is self-care dialysis?
Is home hemodialysis available in my area? How long does it take to learn? Who will train my partner and me?
What kind of blood access is best for me?
As a hemodialysis patient, will I be able to keep working? Can I have treatments at night?
How much should I exercise?
Who will be on my health care team? How can these people help me?
With whom can I talk about finances, sexuality, or family concerns?
How/where can I talk with other people who have faced this decision?
For more information about hemodialysis, see the NIDDK booklet Treatment Methods for Kidney Failure: Hemodialysis. Or see the chart that summarizes three treatment options.
Treatment Choice: Peritoneal Dialysis
Purpose
Peritoneal dialysis is another procedure that removes wastes, chemicals, and extra water from your body. This type of dialysis uses the lining of your abdomen, or belly, to filter your blood. This lining is called the peritoneal membrane and acts as the artificial kidney.
How Peritoneal Dialysis Works
A mixture of minerals and sugar dissolved in water, called dialysis solution, travels through a catheter into your belly. The sugar—called dextrose—draws wastes, chemicals, and extra water from the tiny blood vessels in your peritoneal membrane into the dialysis solution. After several hours, the used solution is drained from your abdomen through the tube, taking the wastes from your blood with it. Then your abdomen is refilled with fresh dialysis solution, and the cycle is repeated. The process of draining and refilling is called an exchange.
Peritoneal dialysis.
Getting Ready
Before your first treatment, a surgeon places a catheter into your abdomen or chest. The catheter tends to work better if there is adequate time—usually from 10 days to 2 or 3 weeks—for the insertion site to heal. Planning your dialysis access can improve treatment success. This catheter stays there permanently to help transport the dialysis solution to and from your abdomen.
Types of Peritoneal Dialysis
Three types of peritoneal dialysis are available.
Continuous Ambulatory Peritoneal Dialysis (CAPD)
CAPD requires no machine and can be done in any clean, well-lit place. With CAPD, your blood is always being cleaned. The dialysis solution passes from a plastic bag through the catheter and into your abdomen, where it stays for several hours with the catheter sealed. The time period that dialysis solution is in your abdomen is called the dwell time. Next, you drain the dialysis solution into an empty bag for disposal. You then refill your abdomen with fresh dialysis solution so the cleaning process can begin again. With CAPD, the dialysis solution stays in your abdomen for a dwell time of 4 to 6 hours, or more. The process of draining the used dialysis solution and replacing it with fresh solution takes about 30 to 40 minutes. Most people change the dialysis solution at least four times a day and sleep with solution in their abdomens at night. With CAPD, it’s not necessary to wake up and perform dialysis tasks during the night.
Continuous Cycler-assisted Peritoneal Dialysis (CCPD)
CCPD uses a machine called a cycler to fill and empty your abdomen three to five times during the night while you sleep. In the morning, you begin one exchange with a dwell time that lasts the entire day. You may do an additional exchange in the middle of the afternoon without the cycler to increase the amount of waste removed and to reduce the amount of fluid left behind in your body.
Combination of CAPD and CCPD
If you weigh more than 175 pounds or if your peritoneum filters wastes slowly, you may need a combination of CAPD and CCPD to get the right dialysis dose. For example, some people use a cycler at night but also perform one exchange during the day. Others do four exchanges during the day and use a minicycler to perform one or more exchanges during the night. You’ll work with your health care team to determine the best schedule for you.
Who Performs Peritoneal Dialysis
Both types of peritoneal dialysis are usually performed by the patient without help from a partner. CAPD is a form of self-treatment that needs no machine. However, with CCPD, you need a machine to drain and refill your abdomen.
Possible Complications
The most common problem with peritoneal dialysis is peritonitis, a serious abdominal infection. This infection can occur if the opening where the catheter enters your body becomes infected or if contamination occurs as the catheter is connected or disconnected from the bags. Infection is less common in presternal catheters, which are placed in the chest. Peritonitis requires antibiotic treatment by your doctor.
To avoid peritonitis, you must be careful to follow procedures exactly and learn to recognize the early signs of peritonitis, which include fever, unusual color or cloudiness of the used fluid, and redness or pain around the catheter. Report these signs to your doctor or nurse immediately so that peritonitis can be treated quickly to avoid additional problems.
Diet for Peritoneal Dialysis
A peritoneal dialysis diet is slightly different from an in-center hemodialysis diet.
You’ll still need to limit salt and liquids, but you may be able to have more of each, compared with in-center hemodialysis.
You must eat more protein.
You may have different restrictions on potassium. You may even need to eat high-potassium foods.
You may need to cut back on the number of calories you eat because there are calories in the dialysis fluid that may cause you to gain weight.
Your doctor and a dietitian who specializes in helping people with kidney failure will be able to help you plan your meals.
Pros and Cons
Each type of peritoneal dialysis has advantages and disadvantages.
Peritoneal Dialysis
CAPD
Pros
+ You can do it alone.
+ You can do it at times you choose as long as you perform the required number of exchanges each day.
+ You can do it in many locations.
+ You don’t need a machine.
+ You won’t have the ups and downs that many patients on hemodialysis feel.
+ You don’t need to travel to a center three times a week.
Cons
- It can disrupt your daily schedule.
- It is a continuous treatment, and all exchanges must be performed 7 days a week.
CCPD
Pros
+ You can do it at night, mainly while you sleep.
+ You are free from performing exchanges during the day.
Cons
- You need a machine.
- Your movement at night is limited by your connection to the cycler.
Working With Your Health Care Team
Questions you may want to ask:
Is peritoneal dialysis the best treatment choice for me? Why? If yes, which type is best?
How long will it take me to learn how to do peritoneal dialysis?
What does peritoneal dialysis feel like?
How will peritoneal dialysis affect my blood pressure?
How will I know if I have peritonitis? How is it treated?
As a peritoneal dialysis patient, will I be able to continue working?
How much should I exercise?
Where do I store supplies?
How often do I see my doctor?
Who will be on my health care team? How can these people help me?
Whom do I contact with problems?
With whom can I talk about finances, sexuality, or family concerns?
How/where can I talk with other people who have faced this decision?
For more information about peritoneal dialysis, see the NIDDK booklet Treatment Methods for Kidney Failure: Peritoneal Dialysis. Or see the chart that summarizes three treatment options.
Dialysis Is Not a Cure
Hemodialysis and peritoneal dialysis are treatments that help replace the work your kidneys did. These treatments help you feel better and live longer, but they don’t cure kidney failure. Although patients with kidney failure are now living longer than ever, over the years kidney disease can cause problems such as heart disease, bone disease, arthritis, nerve damage, infertility, and malnutrition. These problems won’t go away with dialysis, but doctors now have new and better ways to prevent or treat them. You should discuss these complications and their treatments with your doctor.
