ABCs of Kidney Disease | Treatment Options for End-Stage Renal Disease

hi I'm sue thaw viraja this is a

presentation of the ABCs of kidney

disease treatment options for end-stage

renal disease this is a video in the

series of the Johns Hopkins nephrology

patient education programs made possible

through the funding of the Edward Krause

endowment fund and the Shaw foundation

so this section is going to focus on

treatment of end-stage kidney disease

when the kidneys fail we either call it

end stage renal disease or in stage

kidney disease and then we have two

options for being able to replace that

kidney function either we can filter the

blood be a something called dialysis or

we can transplant a new kidney now in

this presentation we're not going to

focus on transplant that will be a

different presentation so dialysis is a

term for us having a way of artificially

removing the waste and extra fluid from

the blood and what this happens when our

kidneys can no longer do this there are

two major types of dialysis hemodialysis

and peritoneal dialysis and we're going

to talk about both of these different

types of dialysis and further depth but

basics is the hemodialysis is another

way of cleaning the blood the peritoneal

dialysis we're not using a machine but

more using the inner lining of our

abdomen to clean the blood both types of

dialysis though require surgery for a

dialysis access so they do require some

planning before we can get started with

that now neither type of dialysis is

better than the other so it's really a

matter of getting that information about

the different types of dialysis and

having that discussion with your

healthcare team to figure out what's the

best option for you and what you'll be

most comfortable with this is a picture

that demonstrates the basic setup of

hemodialysis and the principle is there

is some way of getting blood from the

individual because remember our kidneys

were cleaning our blood during the

course of the day their overall cleaning

about 180 to 200 liters worth of blood

during a dialysis treatment we have to

have another way of getting the blood

from an individual and when we run it

through a machine and through what we

call an artificial kidney or a dialyzer

the cleaned blood then is returned back

to the patients so we have to have a way

of being able to get that blood out of

the individual into the machine and so

we focus on the starting point the

hemodialysis access

there are three major types and we're

going to talk about the three types

first before we show you any of the

models of them

there's the fistula which is a shunt

that is created between your own artery

in your own vein there's no artificial

material in it this procedure is

performed by a vascular surgeon it takes

about six to twelve weeks before it's

ready to be used and the procedure

itself is a same-day outpatient

procedure and a lot of times it doesn't

even need to be done under general

anesthesia the process starts by you

being referred to the vascular surgeon

having an evaluation they might do an

ultrasound of the veins in your arm to

figure out if you're a candidate for a

fistula sometimes people have veins that

are either too small or have been

damaged over the years from different

other medical treatments and they don't

have veins that could be used for a

fistula in those cases we use synthetic

material which we refer to as a graft

that would be the way of connecting that

artery in the vein now the shunt because

it's already the right size and it's

already pre designed for this purpose

only takes a couple of days two weeks

before you need to use it so a little

less planning before you need to get

started on dialysis the third category

is the catheter and this is typically

the one that we try to minimize the use

of because it's the highest risk of

infection but it is the way we can start

dialysis on an urgent basis if we need

to start at the same day this is a

special IV line that's all the larger

size to be able to carry enough blood

for the dialysis treatments and it's

done in radiology or in the operating

room and it can be used right away so

now we're gonna take a look at the

models of the hemodialysis access

reviewing the three different types that

we just looked at on the slide the first

one is the fistula and the second one is

the hemodialysis graft both of these are

in this model here one of the key things

to look at is that there's nothing

outside of the body and this is why it's

really the lower risk of infection when

you have a hemodialysis fistula or a


once you get past the original surgery

when you have the sutures you won't be

needing any bandages you won't have any

restrictions in terms of bathing

showering swimming or any issues like

that we do ask you not to be having any

blood draws or have a blood pressure

measured on that

because then you could damage the access

what would happen during the diocese

treatment is a nurse would put a

tourniquet just like when they're

drawing blood that would cause the vein

of the fistula to pop up and then they

would put a needle in during the

treatment those needles would then stay

in during the course of the treatment

and then be removed at the end of the

session at the end of the session they

would put some pressure on there for

about 10 to 15 minutes and then you'd be

having a bandage on there for about

three to four hours after that you could

remove the bandage and then just not

need to have anything on there now this

lower part of the arm is what we call a

hemodialysis graft unlike when our veins

in our arm might be too small we

sometimes put a piece of synthetic

material tubing called a graft in to

connect that artery in the vein and this

is a nice representation of this because

it's in the lower part of the arm same

type of principle for the fistula the

Diocese nurses would put two needles in

it during the course of the dialysis

session they would remove those needles

put some pressure on those points at the

end of the treatment and then you would

have a bandage on there for about three

to four hours the benefits of this of

course are the reduced risk of infection

and the fact that you don't really have

anything outside of your body during the

dialysis session so the third type of

dialysis axis is the hemodialysis

catheter and this is the one that we can

use right away now a key part of this is

this catheter has to be a larger size

than any of the typical IVs that you get

in the hospital or the emergency room

and it needs to be a big enough size to

have enough blood flow for the dialysis

treatment because of that it's going to

always go into one of the bigger blood

vessels and the tip is typically going

all the way to the level of the heart

another challenge with these catheters

are there's a large portion of it that's

outside of the body so that's where that

increased risk of infection is and so

when we look at the catheter model from

this little blue piece here that portion

is always outside of the body just under

the skin surface now when we have these

catheters placed they're typically put

in or tucked in underneath the

collarbone so you can't see it from your

when you're wearing your shirts or

anything like that but it is a large

portion of it that

is that Ken got caught on things and can

get infected now because so much is

outside of the body there is the risk of

infection so we are really careful about

not getting these wet so when you're

showering and or bathing you really

can't get this catheter wet you really

cannot be swimming and the dressings are

changed by the nurses whenever you come

for in for your dialysis treatment now

these catheters have two ports to them

during the treatment the nurses would

remove the caps and hook them up to the

lines for the dialysis treatment itself

at the end of the treatment they would

unhook the lines and then just put new

caps on them and that's how the catheter

would stay until your next dialysis

session when we talk about hemodialysis

there are two different types in Center

hemodialysis and home hemodialysis so in

Center it's performed in a dialysis unit

by medical staff it's happening three

days a week and often for about three to

four hours so when it's three days a

week you're either going on a Monday

Wednesday Friday schedule or a Tuesday

Thursday Saturday schedule there's no

training involved because this the

treatment is taken care of by the staff

there now when you come in for treatment

you'd be weighed before and at the end

of the each treatment that's how the

staff figures out how much fluid to take

off with each session they're checking

the blood pressure the heart rate and

the temperature before the treatment and

then every fifteen to thirty minutes

during the course of the session blood

work is often checked during those

treatments so you're not having to be

going to the lab on a separate basis

also certain medications that you had

been taking beforehand are either gonna

be replaced by the actual dialysis

treatment or they're gonna be given

during the dialysis session so a lot of

times your medication list is changing

once you get started on dialysis now

because you're going to the dialysis

unit three times a week you're gonna be

seeing your kidney doctor there at the

dialysis unit instead of going to their

office so what are the downsides the

fact that you have a set schedule you're

gonna have an appointment time on a

Monday Wednesday Friday so you have to

plan ahead if you need to be

rescheduling for another doctor's

appointment or from going out of town

and it's a little more of a restricted

diet remember when your kidneys were

doing the work they were doing the work

seven days a week now we're gonna try to


in two treatments that are happening

just three times a week now home

hemodialysis we're using the same type

of dialysis access that we are using for

in Center it's just it's a different

machine this treatment is going to be

performed at home by you and a partner

the sessions are happening about four to

six days a week and each sessions about

two to three hours training typically

takes about four to eight weeks but if

you need a little bit longer time no one

is going to be releasing that machine to

you or expecting you to do that earlier

than you're ready to during the training

you'd learn about weighing yourself

checking your blood pressure your heart

rate how to access your hemodialysis

catheter or fistula and how to draw your

labs and how to set up and take down the

machine now your partner we learn about

the more the emergency techniques and we

require that the partner would be there

while you're doing your treatments you

will still be coming to the clinic to

follow up with the dialysis nurse and

the doctor about one to two times a

month the downsides of the home

hemodialysis treatments are that you do

need to have a partner at home so this

might be a limiting factor for some

people being able to choose this as an

option additionally you knew need a lot

of space at home for all of the supplies

there's shipped out on a monthly basis

so if you're not in a stable stable home

situation this may not be the best

option for you and we're gonna take a

look at the home hemodialysis machine so

this is a model of our home hemodialysis

machine so as you can see it's pretty

self-contained the front of it is a

pretty user friendly touch screen button

so it's easy to be able to monitor the

different steps and be able to pull off

the information that you need this is a

considered medical life-saving equipment

and so when you're traveling they have

to make accommodations these do not get

checked these are not in baggage claim

these are taken with you and all of your

other supplies can be shipped to your

destination there isn't any specialized

changes that you're gonna need to make

in your house we do make some checks for

our home safety check to make sure that

you it will be appropriate for the

electrical outlet and things along that

line this equipment is not owned by you

it is owned by the dialysis company and

so therefore you don't have to worry

about the maintenance

if there are issues with the machine the

company will switch out the machine for

you but the key parts of it that it is

very user-friendly and just simple

things of being able to pull a lever pop

in a cartridge and a very easy

user-friendly touchscreen the other type

of home dialysis is peritoneal dialysis

and this one takes advantage of the fact

that we all have a thin layer or

membrane on the inside of our abdomen

which can work as a filter to clean our

blood and we use a fluid that gets piped

into the abdomen and sits in there and

pulls out all of the waste products this

treatment only takes place at home and

also requires training now there are two

different types of peritoneal dialysis

and an individual when they're trained

is trained on both options there's the

manual exchanges which don't require any

specialized equipment or electricity and

a cycler which about 90 percent of those

individuals who are on peritoneal

dialysis are using now we start out with

a peritoneal dialysis catheter and when

we talked about a hemodialysis access

that required a lot more planning the

peritoneal dialysis catheters only need

to be placed about one month before you

need to start the treatments it takes

about two to four weeks to heal before

the nurses can start flushing the

catheter and doing some of the exchanges

and then about four weeks after the

placement of the PD catheter you can

fully use the catheter and we can start

doing some of the training and this

picture is a image of uh someone with a

peritoneal catheter and we have the

model that we will be showing you as

well so this is our model of a

peritoneal dialysis catheter as you can

see it's in the lower abdomen I'm about

90% of our catheters are in the lower

abdomen sometimes they are put in the

chest because of different

considerations but most of the time they

are in the lower abdomen as you can see

if there's a portion of tubing that's

outside of the body now this is the

portion that will always be outside

usually people have this coiled up

underneath a gauze or a belt so it's not

getting in the way or getting caught on

their clothing the catheter itself is

anchored just underneath the skin

surface in two different places and the

rest of the catheter is coiled freely

floating in the abdomen now when you are

doing your exchanges you

would be unrolling this and hooking it

up to the different ports you take the

cap off and hook it up to the tubing

here now because this catheter is in the

lower abdomen and you can see where it

is on the body you have to be careful if

you're soaking you can really can't be

soaking in a tub you really can't be

taking tub baths or hot tub saltwater is

okay but not swimming in a general pool

so these are all considerations in your

lifestyle when you're making a decision

about doing peritoneal dialysis so how

does peritoneal dialysis work it starts

off with a special fluid called

dialysate that fluid is put into the

abdomen through that catheter it sits in

the abdomen for a certain amount of time

it either will be sitting there from

about four to six hours depending on

someone's body size and the nature of

their hair Tennille membrane it's

pulling all the waste products out it's

pulling all that extra fluid that all

gets drained out after about four to six

hours and new fluid is instilled in so

while the fluid is sitting in the

abdomen it's pulling out all of those

waste products that's pulling out extra

water and all of the chemicals and this

dialysate because it doesn't contain any

blood will then be able to be poured

down the drain or in the toilet and

discarded so peritoneal dialysis is

performed only at home there's not a

requirement for a partner because

there's no direct access to blood so

there's less risk of any emergency

procedures the training itself takes

about two to six weeks during the

training you're learning how to check

your weight your blood pressure and how

to determine which of those dialysate

fluids to be using you're doing the

exchanges either doing manual exchanges

about three to four times a day

depending on your body size or you're

doing something where you're using a

machine called a cycler where that's

gonna do the exchanges during the course

of the night sometimes people will be

doing a combination of both

it's really going to be individualized

based on what your body needs there are

some downsides to the peritoneal

dialysis you do need space at home

you're getting those shipment of

materials about once a month so if

you're not in a stable home situation

it's harder to be able to do this

treatment the other thing is that the

dial safe fluid has a high amount of


in it and so sometimes it can be more

difficult to control your diabetes now

in this picture it's starting to

demonstrate how someone is connecting

between the different dialysate bags and

doing the connections and we're going to

show you the model that will show the

manual exchange and the cycler so for

peritoneal dialysis it's done in two

different ways there's the manual

exchanges and the cycler now during the

training you're going to be trained on

both types of both the manual and use of

the cycler most people will tend to be

using the cycler and doing all of their

exchanges at nighttime but the manual

gives you that opportunity if you're

travelling for one night or if there's a

power outage you still have a way of

doing these treatments sometimes people

might need to do both now the manual

exchanges all work basically with

gravity so if you have this peritoneal

fluid in there already the dialysate

fluent in when you're time to do your

exchange you would take your catheter

remove the cap hook up to the line here

and then this bag would you want to

admit this bag would be on the floor

because the bag is gonna be draining to

gravity the fluid that's sitting in your

abdomen would then drain into this bag

fill the bag and then once that bag had

finished training you would open up the

next larger the new fluid bag and then

drain that fluid in and then leave that

in for about four to six hours you would

go through that process the actual

process itself between draining the old

fluid and then putting the new fluid in

should take about 30 minutes if it takes

a little bit longer than we might do

some troubleshooting for many people

they are using the cycler and the cycler

is a machine that at nighttime they

would be hooking up to about 10:00 p.m.

at night and stopping the treatments

maybe about 6:00 in the morning

the cycler is designed to have all of

the connections already made with all

the bags of fluid so that the machine

would be doing all of those exchanges it

also has a touch screen to it and then

it would allow you to know what it's

draining how much it's drained and then

the next bag of fluid that it's

instilling the lines for this cycler are

a little bit longer so you do have the

ability to get out of bed you don't

necessarily have to disconnect from the

machine now typically if somebody is

using the cycler they're running their


through the course of the night at the

end of the night they would disconnect

from the machine depending on their body

size and what their prescription is they

might do a manual exchange and carry

that on through the day or they might

not have any fluid and not have to do

anything until later that evening when

they would hook up to the cycler again

so who's not a candidate for peritoneal


you know if somebody has had a lot of

abdominal surgeries they may have

developed a lot of scar tissue in their

abdominal wall and that would prevent

them from being able to filter the blood

appropriately if they've had an issue

where they have a VP shunt where they've

built up fluid on the brain and they

have a VP shunt that could get infected

if they're on peritoneal dialysis if

they've had an abdominal cancer there's

always a risk that they could be

spreading some of those cancer cells so

we don't typically allow individuals to

do peritoneal dialysis in those settings

and then the last category is somebody

has liver disease where they already are

building up a lot of fluid called

ascites they may not tolerate having

more fluid in their abdomen for the

peritoneal dialysis so how do you choose

which type of dialysis is the best one

for you you pick which one suits your

lifestyle you can transition from one

type of dialysis to the other neither

type of dialysis is better than the

other both types have good outcomes it's

more important to find the one that

you're more comfortable with and that's

gonna fit your lifestyle because then

you're gonna have better results and if

you want to learn more information about

treatment options for end-stage kidney

disease or end-stage renal disease

please refer to the following resources