Dialysis

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Dialysis is the process by which blood is passed through a natural or artificial filter which cleans kidney toxins out of the body.  Two types of dialysis include hemodialysis and peritoneal dialysis.  In hemodialysis the filter is known as a dialyzer and in peritoneal dialysis the natural filter is the outside lining of your intestines.  Please see Treatment Options of Chronic Kidney disease for further information.  If you are on dialysis, you will hear physicians and staff discuss certain indicators on how well dialysis is going.  The definitions and explanations of these indicators are listed below:

Adequacy or KT/VThis is a number used to determine if you are getting adequate kidney toxins removed from your body during dialysis.  K stands for the size of the filter or dialyzer, T stands for Time on dialysis in minutes, and V stands for your body size.  As you can see, to reach an adequate toxin clearance number of at least 1.2, we can increase the size of the filter/dialyzer or increase your time.  It is very difficult to change V, because that is your body size.  Discuss this number with dialysis staff and your doctor to see if you are achieving adequate clearance.

 

Dry Weight/Fluid Consumption:  Before and after dialysis you are asked to weigh yourself on the scale.  1 kilogram(kg) is equal to 1.0 Liters of water which is 2.2 pounds or about a quart of fluid.  If your weight before dialysis is 60kg and after dialysis is 58kg, that means the dialysis machine removed 2.0 Liters of Fluid or about 4.4 pounds.  The definition of dry weight is the weight at which you are at after dialysis  with no evidence of fluid on your legs, lungs, or other parts of your body.  In the strict definition, your blood pressure should be normal as well.  If on Monday after dialysis you weigh 70kg and Wednesday before dialysis you weigh 76kg, that is 6kg of weight gain between dialysis.  This is known as interdialytic weight gain and should be limited to about 2-4kg.  The greater your interdialytic weight gain the more fluid removal  has to be done by the machine during your next dialysis session.   Greater amounts of fluid removal over a shorter period of time lead to cramping on dialysis and low blood pressure during the dialysis treatment.  Please try to limit your fluid consumption to less than 2.0 Liters/day or around 2 quarts.  The treatments for large fluid gains between dialysis sessions are dietary restriction of salt and fluid, or increase the time on dialysis. People who do not achieve the dry weight have increased chance of progressive heart disease, progressive high blood pressure, and recurrent hospitalizations for “fluid on the lungs” or heart failure. It is important to limit fluid consumption to aide in staying healthy.

 

Dialysis Treatment Times:  The National Institutes of Health studied dialysis patients to determine what treatment time was best for patient survival and to limit complications.  This is a very important concept for physicians, nursing staff and patients.  There are two components that determine dialysis time.  As discussed previously,  dialysis adequacy called the KT/V has a time component.  So to improve your toxin clearance you may be asked to increase your time by a short amount.  The next logical question arises when you ask your kidney doctor, “why did you increase my time when my KT/V is good?”  The other component of time is fluid removal.    If the patient has large weight gains and fluid consumption between dialysis treatments, it is very difficult for dialysis to remove the fluid in a standard session.  To increase fluid removal while minimizing cramping, low blood pressure, and other symptoms, you may be asked to increase your time in order to remove the remaining fluid to achieve dry weight.

 

Medications on Dialysis: Prescription medications present a challenge to patients for a multitude of reasons.  Most of these are centered on cost, when to take the medications, and side effects..  General medications rules are to take your medications after dialysis to prevent removal of the medications while you are on dialysis. Dialysis patient’s medications fall into some general categories that are briefly explained below:

                Vitamins:  During dialysis treatment, the process removes not only the toxins but also some water soluble vitamins such as the B complex vitamins.  Dialysis does not remove the fat soluble vitamins such as Vitamin A,D,E, and K. If you are on dialysis, you should be prescribed a Dialysis Multi-Vitamin that is rich in B Vitamins, Folate and deficient in Vitamins A,D,E,and K.  These vitamins help build bones, muscle, prevent anemia and other various functions.  Please take your Vitamins regularly after your dialysis treatment so your vitamins are not immediately removed.  We recommend taking your vitamins at night before bedtime.

                Binders:  These are a class of medications that are taken WITH phosphorus containing meals to aid in phosphorus control.  The names of the medications include, Tums or Calcium Carbonate, Renagel, FosRenol, Phos-Lo, Alterna-Gel, and other less commonly used drugs.  Persistently elevated phosphorus concentrations in the blood increase your risk of heart attack, broken bones, infections, and an extremely serious condition that causes your skin to die.  It is very important that you work with your dietician and doctor to maintain adequate phosphorus control to help prevent complications.  To maintain phosphorus control you must restrict dietary phosphorus intake and take your “binders”.  It is VERY important that binders are taken WITH meals and high phosphorus snack so they will work properly.  If the binders are taken between meals, they will not work effectively and your phosphorus level will not be controlled.

                EPO:  Most patients with Chronic Kidney Disease and on dialysis are anemic.  The kidneys normally produce a hormone called erythropoietin that travels in the blood to the bone marrow to produce blood.  Since this process is halted in patients with kidney disease, we have to prescribe a medication called EPO or Aranesp to help make blood and treat anemia associated with kidney disease.  EPO treatment has been shown to improve  symptoms on dialysis.   Patients have less fatigue, improved heart function, and improved brain function.  This medication will be given to you during  dialysis and in home patients will be given in the office or self injection. We monitor your anemia level very carefully during dialysis and adjust this medication to give you the optimal benefits.  Ask your kidney doctor or dialysis staff about other benefits of these medications

                Vitamin D Analogs:  Early when the kidneys start to fail, the ability of the body to produce the active form of Vitamin D is altered.  Chronic Kidney Disease and Dialysis patients are frequently deficient in Vitamin D because the kidneys cannot help the skin to produce active Vitamin D.  Vitamin D deficiency causes bone disease, fatigue, and fractures.  To  treat the deficiency and reduce complications, we administer medications similar to Vitamin D like, Rocalcitriol, Hectoral, or Zemplar.    These are prescription medications and you should NOT take over the counter Vitamin D unless directed by your kidney doctor.  We monitor hormone levels in your blood on a recurrent basis to adequately dose this drug to the precise level needed for you to minimize complications.

                Blood Pressure Medications:  Sometimes after the start of dialysis you may be asked to stop taking some of your blood pressure medications.  The goals for blood pressure will vary from patient to patient and in general you should take your blood pressure medications after dialysis unless you are on a shift that is late in the day, then you may take your medications early in the morning.

Anemia:  Anemia is a very common disorder among dialysis patients.  The symptoms of anemia are fatigue, tiredness, pale skin, and weakness.  Anemia can lead to these symptoms; however it can seriously affect your heart by making it work harder.  While the heart is working harder because of anemia, high blood pressure, and other conditions, the heart adapts by enlarging.  This adaption is not good for your body and increases your risk for heart disease.   Anemia is diagnosed by symptoms and measuring your blood counts.  The specific test that is ordered is a Hemoglobin and Hematocrit.  When these are low you are diagnosed with anemia.  In dialysis patients there are several reasons to have anemia.  To better understand the reasons, the following is a brief discussion on how red blood cells are made.  Bone marrow has to go through a complex process to produce red blood cells.  The essential ingredient in producing a red blood cell is hemoglobin, which carries oxygen throughout your body.  This process requires Iron, Erythropoietin, Protein, Vitamins and Minerals.  These are the building blocks to provide production of hemoglobin and red blood cells.  During your dialysis you are prescribed intravenous iron, erythropoietin (EPO), vitamins, and encouraged to eat and maintain your protein intake.  Treatment of your anemia improves your heart function, tiredness, general well being, brain function, and lengthens your life on dialysis.  Please ask your doctor for further explanation about the symptoms and the benefits of the treating your anemia.

Dialysis Related Bone Disease and High Phosphorus:  Bone disease in dialysis and Chronic Kidney Diseases are called Renal Osteodystrophy. This is a medical term that means abnormal bone caused by kidney disease.  The signs & symptoms of Renal Osteodystrophy are; bone pain, fatigue, increased risk for fractures, hardening of the arteries, increased risk for heart disease, weakness of the muscles that cause difficulty with stairs, and joint pain.  This disorder is followed by laboratory analysis that is drawn while you are on dialysis.  Blood is drawn to determine your Phosphorus, Calcium, and Parathyroid Hormone level.  We then adjust your Binders, Diet, and Vitamin D Analogs to achieve goals proposed by the National Institutes of Health and the National Kidney foundation.  To help your doctors achieve the best possible outcome for you and your family, it is important to follow a low phosphorus diet and take your binders as prescribed.  We aim to achieve a blood Phosphorus concentration of less than 5.5 to decrease your risk of developing a heart attack and other complications of Renal Osteodystrophy.   

 

Diet: A dietician at the Kidney and Hypertension Institute will specially tailor a diet for you.     The following are some general dietary categories:

                Protein Intake:  It is very important to eat enough protein while on dialysis.  We monitor your protein intake with nutritional markers when we draw your blood.  The buzz word for protein intake is “albumin”.  This is a protein in your body that determines your protein nutritional status.  A low albumin increases your risk for infection and decreases your life span on dialysis.  Protein intake can be attained through supplements, eggs, or other dietary sources of protein.  Please consult our dietician for the specific protein diet that is correct for you.

                Phosphorus Intake:  This is one of the most difficult parts of the diet dialysis patients have to follow.  We recommend a low phosphorus diet.  Phosphorus is in dairy products like milk, yellow cheese, ice creams, dark colored soda pop (except Root Beer), and other dietary groups.  To control phosphorus to the recommend goal phosphours foods must equal the removal of phosphorus by dialysis and phosphorus binders.  If the intake is more than the removal of phosphorus by dialysis and taking your binders, then your blood levels of phosphorus will rise, and increase your risk for heart attacks and bone disease.  If your phosphorus intake is less than or equal to phosphorus removal by dialysis in conjuction with taking you binders, then your levels will be controlled and  your risk for heart disease and bone problems will be lowered.  Please work with your dietician to learn about phosphorus containing foods, and don’t forget to take your Binders WITH food.

                Salt or Sodium:  It is common knowledge that salt causes fluid retention.  While on   dialysis, your native kidneys cannot excrete the fluid like normal functioning kidneys.  Dialysis removes sodium and fluid, although there is limitations on how much fluid that can be removed.  Controlling the intake of excess sodium and fluid between your dialysis sessions will allow the treatments to remove all the sodium and fluid to achieve your dry weight control, blood pressure control, thus reducing your stroke risk and heart disease risk.  Limit your Sodium content to no more than 2,000 mg/day and your fluid to 2.0 Liters per day.  Ask your dietician or physician to aid you in these goals.  We are here to help you!

                Fluid Restriction:  This concept parallels the sodium concept and should be done in conjunction with each other.   The definition of a “fluid” is anything that is liquid or melts at room temperature.  The best way that I have found that patients can monitor and follow their fluid restriction is a procedure that I developed that eliminates the recording of measured amounts.  I call this the “Pop Bottle Method.” Take a 2.0 Liter empty bottle of soda and fill it up each day with water and place in the refrigerator.  If you get thirsty for water then poor a glass out of the chilled water bottle.  If you drink a hot chocolate from a mug, then pour a mug full of water out of the 2.0 L Water Bottle.  If you have a glass of milk, finish the milk and then pour water for the 2.0L Water Bottle into the empty glass of milk and then discard the water in the milk glass down the drain.  When then water bottle is empty for the day you have reached your fluid consumption limit for the day.  There are multiple other ways of doing this, but I have found that this works well.

                Potassium:  It is recommended from NIH and National Kidney foundation that dialysis patients follow a low potassium diet.  The functions of potassium in your body are essential for heart function and muscle function.  The symptoms of high potassium are muscle weakness and manifest frequently as to weak to get out of bed or too weak to stand up from a seated position.  Potassium is essential in your nerve function and the conduction of your heart.  Elevated blood levels of Potassium can cause your heart to beat abnormally known as arrhythmias, and even stop your heart from beating. Potassium containing foods are potatoes, French fries, tomatoes, orange juices and other fruit juices, cantaloupe, watermelon, bilberries, Salt Substitutes, bananas, and other various foods. Consult your dietician and physician for a more detailed list.

Dietary Conclusions:  We are here to help you the patient. Please ask the dietician, staff, or physician if you have any questions about your diet.  It is impossible for anybody to understand all this information in a few conversations.  That is why it is an education process and that is our goal.  If we can successfully educate you the patient, it will give you a better outcome.  Ask questions.

 

Heart Disease/Coronary Heart Disease/Cardiovascular Disease:  Patients with kidney failure and kidney disease are at increased risk for developing Cardiovascular Disease.  Cardiovascular disease includes heart attacks, strokes, aneurysms, and other vascular disease disorders.  Why does this happen?  It is a very complex process related to many factors discuss below.  Heart Disease is the number one cause of death in the United States.  Our philosophy at the Kidney and Hypertension Institute is treating you in a way to decrease your heart disease risk.  To do this education about what increases your risk for heart disease if vital.

                Hypertension/High Blood Pressure:  Elevated blood pressure contributes to the increase risk for cardiovascular disease. To decrease your risk we treat your blood pressure to the recommend goals.  We need your help to do this.  Blood pressure is treated by follow your sodium and fluid restrictions, taking your blood pressure medications, and attaining your Dry Weight.

                Cholesterol:  Dialysis patients have various levels of cholesterol, and it is currently unclear in the literature what level of cholesterol needs to be control to for dialysis patients.

                Diabetes:  Patients who intensively control their blood sugars have a less chance of develop cardiovascular problems then patients who don’t keep their blood sugar control.  Work with your diabetes doctor to achieve this.

                Exercise: Physical exercise will decrease your risk of cardiovascular disease as well as increase you muscle strength and improve arthritis symptoms.  Multiple benefits from exercise, ask your doctor to help you design a program that works best with your physical well being.

                Phosphorus Control: Patients who have a consistently elevate phosphorus for a period of time have higher rates of heart attack then patients with controlled phosphorus concentrations.  This is why it is important to follow your diet and to take your binders with food.

                Kidney Failure:  Uremia in itself increases the risk for heart disease.  Dialysis patients who do not have their blood cleaned adequately (See KT/V) are at risk for developing further cardiovascular disease.  It is important that your KT/V is at the goal set by the National Kidney Foundation.  It is also important to achieve the goal of adequacy that you complete your prescribe treatment time.  Patients who have kidney failure that are treated with dialysis have a lower cardiovascular risk then those who are not treated with dialysis.

 

Infection:  Patients with Chronic Kidney Disease and on Dialysis are increased risk for developing infections.  This is due to a variety of factors including, suppression of your immune system, access your blood stream or peritoneal cavity, and other factors associated with kidney failure.  It is not infrequent that dialysis patient may have recurrent hospitalizations for infections.  Staff and physicians at Kidney and Hypertension Institute of Utah are dedicated to helping reducing the risk of infections.  Staff, physicians, and patients should wash their hands frequently to prevent cross contamination.  While accessing your fistula, catheter, or peritoneal catheter make sure the site is clean and the anti-septic solution is dry.  Please work with the staff and yourself to ensure proper technique to reduce the risk of infection for you and other patients.

Dialysis Access:  A dialysis access is created through an outpatient minor surgical procedure.  The purpose of an access is to create the ability to gain access to your blood or peritoneal cavity.  For patients on hemodialysis a shunt is created, which in its simplest terms is a connection between an artery and vein.  If the surgeon makes this connection by using your natural vein it is called a fistula, if the surgeon uses a foreign piece of material it is called a graft.  Blood then flows through the shunt, and the dialysis nurses use this to meticulously place needles so the dialysis machine can pump your blood through the artificial kidney and return your clean blood back.  The other type of hemodialysis access is known as a catheter.  This is placed in a large vein in your body usually in your neck area.  This is used for patients who start dialysis and don’t have a fistula created before the initiation of dialysis, or when a fistula or graft clots off and there is no blood flowing in the shunt.  This is known as a clotted access.  We proactively monitor the shunt to determine if it is about ready to clot.  If parameters suggest that the shunt is going to clot, we refer you to the radiologist or surgeon for a “clean out” or “angioplasty” so the shunt will not completely clot off.  The difference between a graft and a fistula is that one the fistula is natural.  Fistula’s last longer, have very few infections associated with them, and give a better dialysis.  Patient with grafts have higher infection rates, hospitalizations, and do not last as long.  The preferred access in a hemodialysis patient is a fistula.  The location of your fistula may be in your forearm, upper arm, or leg. The location is determined by the size of your veins.  Catheters should only be used on a temporary basis because of poor dialysis associated with catheters and recurrent infections.

                Care of your Access:  You should keep your access clean and free of tight clothing.  You should not allow anyone to use your access except trained dialysis staff.  You should also monitor for control of bleeding after dialysis, and if you have recurrent bleed call the dialysis center immediately or your physician.  Do not place constrictive devices around your access are, sleep on your access arm, or allow anyone to take blood pressures in your access arm.  All these interventions can make your access clot and thus will have to be opened up by the surgeon or radiologist.  Certain cases a new access will have to be created.  You should also feel your access every day. There should be a “thrill” or a “buzz” when you place your fingers over the access.  If you do not feel this thrill, contact the dialysis center.

                Peritoneal Catheter: This is the access used for Peritoneal Dialysis or “PD”.  This is a piece of plastic like material that the surgeon inserts through your skin to the right or left of your belly button.  The tip of the catheter is  place in the space between your intestines and body wall.  This allows peritoneal fluid to fill your cavity, remove toxins, and then drain.  It is important to keep the “exit site” clean and free of debris.  You cannot swim, use hot tubs, or other certain activities with a peritoneal dialysis catheter.