When to start dialysis in chronic renal failure
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
graft
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
compress
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
sugar
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
treat
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
dialysis
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
