Dialysis treatment replaces the function of the kidneys, which normally serve as the body's natural filtration system. Through the use of a blood filter and a chemical solution known as dialysate, the treatment removes waste products and excess fluids from the bloodstream, while maintaining the proper chemical balance of the blood. There are two types of dialysis treatment: hemodialysis and peritoneal dialysis.
Dialysis can be used in the treatment of patients suffering from poisoning
or overdose, in order to quickly remove drugs from the bloodstream. Its most prevalent application, however, is for patients with temporary or permanent kidney failure. For patients with end-stage renal disease (ESRD), whose kidneys are no longer capable of adequately removing fluids and wastes from their body or of maintaining the proper level of certain kidney-regulated chemicals in the bloodstream, dialysis is the only treatment option available outside of kidney transplantation
. In 1996 in the United States, over 200,000 people underwent regular dialysis treatments to manage their ESRD.
Blood pressure changes associated with hemodialysis may pose a risk for patients with heart problems. Peritoneal dialysis may be the preferred treatment option in these cases.
Peritoneal dialysis is not recommended for patients with abdominal adhesions
or other abdominal defects, such as a hernia
, that might compromise the efficiency of the treatment. It is also not recommended for patients who suffer frequent bouts of diverticulitis, an inflammation of small pouches in the intestinal tract.
There are two types of dialysis treatment: hemodialysis and peritoneal dialysis:
Hemodialysis is the most frequently prescribed type of dialysis treatment in the United States. The treatment involves circulating the patient's blood outside of the body through an extracorporeal circuit (ECC), or dialysis circuit. Two needles are inserted into the patient's vein, or access site, and are attached to the ECC, which consists of plastic blood tubing, a filter known as a dialyzer (artificial kidney), and a dialysis machine that monitors and maintains blood flow and administers dialysate. Dialysate is a chemical bath that is used to draw waste products out of the blood.
Since the 1980s, the majority of hemodialysis treatments in the United States have been performed with hollow fiber dialyzers. A hollow fiber dialyzer is composed of thousands of tube-like hollow fiber strands encased in a clear plastic cylinder several inches in diameter. There are two compartments within the dialyzer (the blood compartment and the dialysate compartment). The membrane that separates these two compartments is semipermeable. This means that it allows the passage of certain sized molecules across it, but prevents the passage of other, larger molecules. As blood is pushed through the blood compartment in one direction, suction or vacuum pressure pulls the dialysate through the dialysate compartment in a countercurrent, or opposite direction. These opposing pressures work to drain excess fluids out of the bloodstream and into the dialysate, a process called ultrafiltration.
A second process called diffusion moves waste products in the blood across the membrane into the dialysate compartment, where they are carried out of the body. At the same time, electrolytes and other chemicals in the dialysate solution cross the membrane into the blood compartment. The purified, chemically balanced blood is then returned to the body.
Most hemodialysis patients require treatment three times a week, for an average of three-four hours per dialysis "run." Specific treatment schedules depend on the type of dialyzer used and the patient's current physical condition. While the treatment prescription and regimen is usually overseen by a nephrologist (a doctor that specializes in the kidney), dialysis treatments are typically administered by a nurse or patient care technician in outpatient clinics known as dialysis centers, or in hospital-based dialysis units. In-home hemodialysis treatment is also an option for some patients, although access to this type of treatment may be limited by financial and lifestyle factors. An investment in equipment is required and another person in the household should be available for support and assistance with treatments.
In peritoneal dialysis, the patient's peritoneum, or lining of the abdomen, acts as a blood filter. A catheter is surgically inserted into the patient's abdomen. During treatment, the catheter is used to fill the abdominal cavity with dialysate. Waste products and excess fluids move from the patient's bloodstream into the dialysate solution. After a waiting period of six to 24 hours, depending on the treatment method used, the waste-filled dialysate is drained from the abdomen, and replaced with clean dialysate.
There are three types of peritoneal dialysis:
- Continuous ambulatory peritoneal dialysis (CAPD). A continuous treatment that is self-administered and requires no machine. The patient inserts fresh dialysate solution into the abdominal cavity, waits four to six hours, and removes the used solution. The solution is immediately replaced with fresh dialysate. A bag attached to the catheter is worn under clothing.
- Continuous cyclic peritoneal dialysis (CCPD). An overnight treatment that uses a machine to drain and refill the abdominal cavity, CCPD takes 10-12 hours per session.
- Intermittent peritoneal dialysis (IPD). This hospital-based treatment is performed several times a week. A machine administers and drains the dialysate solution, and sessions can take up to 24 hours.
Peritoneal dialysis is often the treatment option of choice in infants and children, whose small size can make vascular (through a vein) access difficult to maintain. Peritoneal dialysis can also be done outside of a clinical setting, which is more conducive to regular school attendance.
Patients are weighed immediately before and after each hemodialysis treatment to assess their fluid retention. Blood pressure and temperature are taken and the patient is assessed for physical changes since their last dialysis run. Regular blood tests monitor chemical and waste levels in the blood. Prior to treatment, patients are typically administered a dose of heparin, an anticoagulant that prevents blood clotting, to ensure the free flow of blood through the dialyzer and an uninterrupted dialysis run for the patient.
Both hemodialysis and peritoneal dialysis patients need to be vigilant about keeping their access sites and catheters clean and infection-free during and between dialysis runs.
Dialysis is just one facet of a comprehensive treatment approach for ESRD. Although dialysis treatment is very effective in removing toxins and fluids from the body, there are several functions of the kidney it cannot mimic, such as regulating high blood pressure and red blood cell production. Patients with ESRD need to watch their diet and fluid intake carefully and take medications as prescribed to manage their disease.
Many of the risks and side effects associated with dialysis are a combined result of both the treatment and the poor physical condition of the ESRD patient. Dialysis patients should always report side effects to their healthcare provider.
(Hct) levels, a measure of red blood cells, are typically low in ESRD patients. This deficiency is caused by a lack of the hormone erythropoietin, which is normally produced by the kidneys. The problem is elevated in hemodialysis patients, who may incur blood loss during hemodialysis treatments. Epoetin alfa, or EPO (sold under the trade name Epogen), a hormone therapy, and intravenous or
Hemodialysis is the most frequently prescribed type of dialysis treatment in the United States. This treatment involves circulating the patient's blood outside of the body through a dialysis circuit. The blood is filtered and cleansed inside the hemodialyzer and returned to the body.
(Illustration by Electronic Illustrators Group.)
oral iron supplements are used to manage anemia in dialysis patients.
Cramps, nausea, vomiting, and headaches
Some hemodialysis patients experience cramps and flu-like symptoms during treatment. These can be caused by a number of factors, including the type of dialysate used, composition of the dialyzer membrane, water quality in the dialysis unit, and the ultrafiltration rate of the treatment. Adjustment of the dialysis prescription often helps alleviate many symptoms.
Because of the stress
placed on the cardiovascular system with regular hemodialysis treatments, patients are at risk for hypotension
, a sudden drop in blood pressure. This can often be controlled by medication and adjustment of the patient's dialysis prescription.
Both hemodialysis and peritoneal dialysis patients are at risk for infection. Hemodialysis patients should keep their access sites clean and watch for signs of redness and warmth that could indicate infection. Peritoneal dialysis patients must follow the same precautions with their catheter. Peritonitis
, an infection of the peritoneum, causes flu-like symptoms and can disrupt dialysis treatments if not caught early.
Because there is a great deal of blood exposure involved in dialysis treatment, a slight risk of contracting hepatitis B
and hepatitis C exists. The hepatitis B vaccination
is recommended for most hemodialysis patients. As of 1997, there had only been one documented case of HIV being transmitted in a United States dialysis unit to a staff member, and no documented cases of HIV ever being transmitted between dialysis patients in the United States. The strict standards of infection control
practiced in modern hemodialysis units makes the chance of contracting one of these diseases very small.
Puffiness in the patient related to edema
, or fluid retention, may be relieved after dialysis treatment. The patient's overall sense of physical well-being may also be improved. Because dialysis is an ongoing treatment process for many patients, a baseline for normalcy can be difficult to gauge.
American Association of Kidney Patients. 100 S. Ashley Dr., #280, Tampa, FL 33602. (800) 749-2257. http://www.aakp.org.
American Kidney Fund (AKF). Suite 1010, 6110 Executive Boulevard, Rockville, MD 20852. (800) 638-8299. http://220.127.116.11/Default.htm.
National Kidney Foundation. 30 East 33rd St., New York, NY 10016. (800) 622-9010. http://www.kidney.org.
United States Renal Data System (USRDS). The University of Michigan, 315 W. Huron, Suite 240, Ann Arbor, MI 48103. (734) 998-6611. 〈http://www.med.umich.edu/usrds〉.
— The vein tapped for vascular access in hemodialysis treatments. For patients with temporary treatment needs, access to the bloodstream is gained by inserting a catheter into the subclavian vein near the patient's collarbone. Patients in long-term dialysis require stronger, more durable access sites, called fistulas or grafts, that are surgically created.
— A chemical bath used in dialysis to draw fluids and toxins out of the bloodstream and supply electrolytes and other chemicals to the bloodstream.
— The general parameters of dialysis treatment that vary according to each patient's individual needs. Treatment length, type of dialyzer and dialysate used, and rate of ultrafiltration are all part of the dialysis prescription.
— An artificial kidney usually composed of hollow fiber which is used in hemodialysis to eliminate waste products from the blood and remove excess fluids from the bloodstream.
— A hormone produced by the kidneys that stimulates the production of red blood cells by bone marrow.
— End-stage renal disease; chronic or permanent kidney failure.
Extracorporeal circuit (ECC)
— The path the hemodialysis patient's blood takes outside of the body. It typically consists of plastic tubing, a hemodialysis machine, and a dialyzer.
— The abdominal cavity; the peritoneum acts as a blood filter in peritoneal dialysis.