PATIENT EDUCATION - DIALYSIS

What is Dialysis?

Dialysis is the major treatment for kidney failure. It is the medical word for filtering waste products and removing fluid from your body that your kidneys are no longer able to remove.
 
There are two forms of dialysis: Haemodialysis andPeritoneal Dialysis There are two forms of dialysis: Haemodialysis andPeritoneal Dialysis 

Haemodialysis

Haemodialysis is a process by which excess waste products and water are removed from the blood by using a dialyser, also known as an artificial kidney.     This form of treatment means the blood is transported outside the body through the dialyser via a specially created vein in the forearm known as arterio-venous fistula. This process requires the use of a machine.
 
In haemodialysis, the blood channels through tubing to the dialyser. The dialyser is a bundle of hollow fibres made up from a semi-permeable membrane. The membrane is thin film with thousands of microscopically small holes. The holes allow water and small dissolved substances to pass through but retain the proteins and blood cells, which are too large.
 
During the dialysis treatment the blood is allowed to flow on one side of the membrane and dialysate solution on the other, and exchange (diffusion) takes place from the blood to the dialysate solution and visa-versa. The dialysate solution has a salt composition similar to blood but without the waste products.  Usually one session takes about 4 hours.
 
The actual dialysis treatment is controlled and monitored by a dialysis machine. This consists of a blood unit and fluid unit.   The pump in the blood unit pumps blood from the patient through the dialyser and back to the patient via the blood tubes.   The fluid unit controls the mixture of the dialysate solution.

Access

In order to have chronic haemodialysis, you need to have surgery to create access, a way to carry the blood to the dialyser. The most common type of chronic access used nowadays is: Arterio-venous (A.V) fistula and the Arterio-venous (AN) graft.
 
The fistula is created internally and is used for a prolonged length of time.  Your surgeon makes a fistula under the skin by joining an artery and vein, allowing arterial blood to flow directly into the vein.  Due to arterial pressure, the vein will increase in size and thicken; it takes about 4-8 weeks for the fistula to mature.
 
A fistula makes it easy to put a needle into the vein to allow blood flow through the dialyser using the blood pump.  The graft is an artificial blood vessel used to join an artery and vein. It is used when patients own blood vessels are too small for fistula construction.
 
The graft may be either straight or looped and is close to the surface of the skin.  The graft may be of artificial material or can be obtained from the patients own body e.g. vein in the thigh.
 
Temporary access can be created in cases that need urgent dialysis and cannot wait for a few weeks for the fistula to mature.  These include the subclavian catheter, internal jugular catheter and arterio-venous shunt.
 
The subclavian catheter is a set of tubing which is inserted into the subclavian vein near the neck.  The internal jugular catheter is placed into the veins at the side of the neck.
 
The sublclavian and internal jugular catheter cannot be used beyond a few weeks as it tends to get blocked or the site of insertion may become infected.
 
The shunt is surgically created with an artificial material, and has a short life span i.e. 6 months.

Care of the Fistula/Graft

• Keep area clean and dry. 
• Feel for thrill sensation at both ends of fistula/graft at least twice weekly.
• Inspect fistula for redness, swelling, tenderness, or warmth to touch to detect infection.
• Avoid constrictive clothing, jewellery etc. that may block the fistula.
• No blood pressure, blood taking, or intravenous administration should be done on the

    fistula arm.
• Avoid excessive pressure on puncture sites after dialysis.
• Rotate needling sites to prevent aneurysm.
• If injury occurs at site, apply pressure over bleeding and seek immediate medical help.

Haemodialysis Advantages and Disadvantages

Advantages
 
Staff performs treatment
No equipment at home
Treatment 3 times/week
No external access
Regular contact with staff and other patients
 
Disadvantages
 
Travel to centre
Fixed dialysis times
Two needles inserted each treatment
Wastes build up between treatments
Diet and fluid restrictions

Peritoneal Dialysis

Peritoneal dialysis is performed by introducing dialysate solution into the peritoneal (abdominal) cavity through a silastic catheter.   The natural membrane lining of the peritoneal cavity acts as a filter where waste products and excess fluid from the body pass through the membrane into the dialysate solution.  The dialysate solution used is sterile and contains salts and a high content of glucose (sugar). The glucose will cause water from the blood stream to be drawn into the peritoneal cavity.
 
A peritoneal dialysis procedure is called an exchange because used solution is removed and replaced with fresh solution.  You connect long tubing set to the short tubing you are wearing (attached to catheter). The lower bag is for draining used solution from the peritoneal cavity and when empty, you are ready to fill with fresh dialysate solution from the upper bag.   The fluid surrounds the internal organs; it does not go into the stomach or other organs. The dialysate solution is left in the peritoneal cavity for several hours to collect waste products and excess fluid from the blood.
 
The most common forms of peritoneal dialysis used today are C.A.PD. and A.PD.
 
Continuous ambulatory peritoneal dialysis (C.A.PD.) functions much like the kidneys do. Constantly cleaning the blood as long as there is dialysate solution in the cavity.   Typically you do exchanges four times a day i.e. when awaking, lunch time, late afternoon, and bedtime (every 5-6hours).
 
C.A.PD. gives you constant dialysis, 24 hours a day seven days a week.
 
Automated Peritoneal Dialysis (A.PD.) is dialysis at home with a cycler machine.
 
Each night before you go to sleep, you connect your set to a long tubing set, attached to dialysate bags on the cycler. The machine does the exchanges while you sleep. The machine is quiet and does not wake you. The tubing is long enough for you to sleep comfortably and walk several feet.
 
The peritoneal catheter called a tenckhoff is a small soft tube; it is placed into the peritoneal cavity surgically. You will typically stay overnight in hospital. Just a few inches of the catheter is outside your body. Most is inside you body. The catheter is left in place so dialysis can be done. It provides a small opening in which dialysate solution can be placed.
 
Training for Peritoneal Dialysis is provided on a national basis at all National Renal Care units and is normally done as an out-patient.
 
Patients on Peritoneal Dialysis lead very normal lives; many patients continue to work, go to school or are active in the community and can even travel.
 
Disposables are delivered to your home or your travel destination free of charge.

Advantages and Disadvantages

Advantages
 
Self-care
No needles
Greater independence
Flexible diet
Flexible schedule
Blood pressure control
Blood sugar control
Less stress on body
Disadvantages
 
Daily exchanges
No off days
Permanent catheter
Some risk of infection
Some possible weight gain

Living with Dialysis

The dependence on artificial life support devices, adherence to strict medical regimes and increase in financial obligations and a decrease in physical and social functioning, frequently result in feelings of depression, anxiety, worthlessness and hostility.   All members of your family unit are affected by your renal disease. Family members may need to assume new roles.  For the person who is ill, losing former roles either temporary or permanently, can be frightening and depressing.   These include unemployment or being too ill to do family chores, to name a few. There are changes in roles or lifestyles that may occur in your own family.
 
Family members may need to be responsible for you at first but continuing to treat you as if you are too sick to care for you can place a huge burden on the family. Due to your illness you may need to depend on your family at first, this may be hard to accept, especially if you are a very independent person.
 
Sex may be a difficult topic to many, but it is important to discuss it in order to understand the physical and emotional changes that occur with renal failure. A chronic illness such as renal failure will change one's desire for sexual intimacy.  For men impotence or the inability to maintain an erection may occur and women may experience difficulty with arousal.  Men and women may just show a lack of interest, which can strain a sexual relationship. It is important to talk these concerns over with your doctor or nurse.  Being a kidney patient doesn't mean you can't have a satisfying relationship.
 
Kidney failure and the treatment may be difficult to accept at first however with time, support and education you can adjust.  You must learn to live with dialysis as part of your life. Learn is the key word for you as a dialysis patient if you are going to make the most of life.  You will need to learn to understand and accept your illness and learn what it means to be a kidney patient. You will need to learn to eat and drink the right things, to take medication and exercise appropriately.
 
Communication is vital, talk about your feelings and experiences with someone you trust. Talking and sharing about what is happening to you will decrease your feelings of loneliness and increase your feelings of being supported and loved. Share your thoughts and feelings with family, friends and your medical treatment team. Talking to other patients is helpful.   Once you are feeling better it will be important to return to as many of your past activities as possible. With your doctors permission you may return to work, your hobbies, clubs etc. Getting back into old routines will help you feel that sense of normality again.
 
In conclusion your overall physical and mental adjustment depends upon you.