A Comparison between two Hemodialysis Options for Patients

Staff-Assisted Home Hemodialysis VS In-Center Hemodialysis and In-Hospital Hemodialysis:

What is Staff-Assisted Home Hemodialysis (HHD)?

For over four decades, Home Hemodialysis (HHD) has been the most popular therapeutic option among ESRD patients. It can be a difficult and challenging time if you are diagnosed with kidney failure or ESRD as treatments are an utmost priority to stay alive. It is important to seek advice to your doctor and learn proactively about taking necessary decisions in your treatment care options.

Procedure

n hemodialysis treatment, it excretes by-products and excess fluid in the blood with the use of filter called dialyzer or artificial kidney. Needles are put in place to the accessed sites, connected to the plastic tubing (catheters) that carries your blood to the artificial kidney then the dialysis machine pumps blood through the system which controls pressure, temperature, pressure and time of treatment.

The same process of treatment is carried out in HHD to effectively perform the method, you and your partner should be properly trained and knowledgeable about HHD.

Advantages

According to study, the more involved you are to your course treatment, the better your response is to dialysis. The HHD option allows you to control your treatment timing and arrange an appropriate schedule to fit in your treatment procedure. This also enables you to be fully aware of the nature of the disease, symptoms, side-effects of procedures, medications and dialysis itself.

Types of Home-Hemodialysis

These three types of Home Hemodialysis can be done at home:

1. Conventional HHD – training for this type of hemodialysis can take up to several weeks to a few months. You and your partner or an assistant will be trained on how to safely handle dialysis and measures to be done in case of foreseeable problems that will be encountered. This is performed for three to four hours, three times a week.
2. Short daily HHD – training also may lasts for several weeks for you and your partner. This treatment is usually done five to seven times a week and can last about two hours utilizing a newly designed machine. Because of treatment frequency, less amount of fluid are being removed regularly which minimizes the development of symptoms such as headaches, cramping, nausea and a “washed-out” feeling after treatment.
3. Nocturnal HHD- this type can be done either every other night or six nights a week, depending on your medical case and to what the doctor has prescribed. This is a long, slow method normally done at night while you are asleep. If you take more hours of dialysis the result of waste removal is of great amount.

You can choose whatever HHD treatment is possible for you even combine two of the HHD types depending on your medical condition, health care needs, dialysis machine and advice from your doctor. The most essential part in HHD is know that you are receiving the exact amount of dialysis appropriate for your medical needs. Speak to health care providers or your dialysis team so that tests can be done and for them to monitor if the right amount of dialysis are properly met.

Short daily and nocturnal HHD benefits include:

• Better improvements in nerve damage and less RLS
• More energetic in regular tasks
• Less medication taken to control hypertension and anemia
• Reduced drug prescription for phosphorus intake to prevent bone disease
• Better sleep
• Shorter hospitalization
• Lesser symptoms and “washed out”feeling
• More improved quality of life

What is In-Center Hemodialysis and In-Hospital Hemodialysis (ICHD)?

According to a survey from the Center for Disease Control and Prevention, in-centerhemodialysis is the most commonly performed modality compared to HHD, accounting to 91% of all treatments among American patients with CKD or ERSD.

Some patients with renal disease prefer an in-centerhemodialysis or an in-hospital HHD for a number of reasons:

• Dialysis centers are fully-staffed with kidney health professionals which can competently administer treatments, to whom patients can fully entrust their treatment procedures.
• Treatment is only three times a week, usually lasts three to four hours leaving patients four days of free time to take care of personal interests or do hobbies and spend time with family.
• Patients enjoy social interaction in fellow dialysis patients and staff. Being able to express thoughts and emotions to like-minded individuals who share the same burden of such medical condition lessens their feeling of isolation and depression.
• Kidney health care team makes every visit to the dialysis center a pleasant experience. The staff look after your personal health care needs appropriately and medical attention is given to increase quality of life.

Procedure

Once you are at the dialysis center, a dialysis team from the nurse to a health care administrator will assist youduring the procedure.

Before the treatment will commence, your access area will be washed by the patient care technician (PCT), you will be weighed to monitor your weight and then escorted to the dialysis chair for the machine to be connected. Pre-procedural vital signs are checked by the nurse especially the sitting and standing blood pressure.

The typical daily session for ICHD is until four hours. During that time, you have the freedom to watch television, chat to other patients, play on your mobile phone or go online etc., basically any activity you can do in your dialysis chair. The dialysis nurse will monitor your blood pressure and the device from time to time. When it is finished, you will be disconnected to the machine and vital signs are again documented.

Which is a better option HHD or ICHD?

Home hemodialysis is not suitable for everyone as it needs proper training and you should be knowledgeable and open to learning methods regarding your treatment options. You should be able to independently carry out your own treatment and you and your partner should pass several weeks of training including appropriate placement of needles, correct operation of machine and vital signs taking and recording. An HHD partner can be a family member, friend, or people sometimes employ the services of a dialysis nurse or technician to assist them with the dialysis machine. The chosen partner should be reliable, understands the treatment process and someone who is willing to go with you whenever treatment is needed.

Choosing an option whether home hemodialysis or in centerhemodialysis is the right type of treatment for you needs specific advice from your nephrologist or kidney dialysis team. You should express what kind of treatment you are willing to go for and if you can handle HHD which takes a big responsibility. Your doctor or renal health care provides should be able to determine what treatment option best fits your lifestyle and medical needs.

What is Dialysis?

Dialysis is a treatment procedure using a machine which acts as an artificial replacement for patients with kidney failure to cleanse the blood. The two major functions of dialysis are diffusion (waste removal) and ultrafiltration (fluid elimination).

Our kidneys function as the internal equilibrium of the body. It has a multifaceted role in the process of elimination by emptying metabolic waste products, keeping a balanced level between water and mineral and has a key purpose in the endocrine system that helps in the production of red blood cells.
When the kidney fails and unable to perform normally, this can have debilitating effectswhich can cause the following:

• failure to remove end-products, salt and excess water resulting to build up in the body
• uncontrollable rise of toxic chemical levels in the blood, such as sodium, potassium and bicarbonate
• increase in blood pressure (hypertension)

It was sometime in 1943, that the birth of an artificial machine (dialyzer) has been invented by a renowned Dr. Willem Kopff, a Dutch physician, when he was treating patients in the concentration camps with kidney-related diseases. Because the resources were scarce to build a highly effective one, the results were unsuccessful. However, in recent years, there has been significant modification and modernization being carried out to produce an efficient and technologically advanced dialyzer.

Regular treatments started in 1960 and nowadays is the standard choice of procedure around the globe for patients with chronic and end-stage renal diseases.

When do I need dialysis?

Dialysis is required for patients with end- stage renal disease, usually in cases wherein the kidney loses its function about 85-90% with GFR (glomerular filtration rate) < 15.

How is waste removed in dialysis?

Diffusion takes an essential role in providing you a spoil of enjoying the tantalizing aroma of fresh coffee or whenever you drop a teabag on hot water. The movement of the particles from a high to low concentration is under the influence of heat that allow themselves to move around water thus, responsible for that lovely smell of coffee that has been wafted out. This principle is applicable in dialysis wherein diffusion takes place.

In dialysis, there is a dialysate (special dialysis fluid)which is composed of fluid and solutes that passed through a semi-permeable membrane and the blood flows at the opposite side. With constant movement, it is easier for the tiny solutes and water to pass through the thin layer material with its holes or pores yet for larger contents such as sizeable proteins and red blood cells, these substancesobstructsthe membrane. Until such level of equal concentration of solutes are distributed on both membranes, the diffusion process stops. The dialyzer replicates the filtration process that takes place in the kidneys, sifting out smaller particles from bigger elements in the blood inside the filtering unit of the kidney (glomerulus).

Major components that make up the “dialysate bath” include sodium chloride (NaCl), sodium bicarbonate (NaHCO3), calcium chloride (CaCl2), potassium chloride (KCl) and magnesium chloride (MgCl2). Others include glucose, which aids in ultrafiltration (fluid removal) and minimizes nutritional (caloric) losses during dialysis.

How is excess water eliminated in dialysis?

Extra fluid is being pushed out in one of the two processes:

• Ultrafiltration –water is removed from the exerted pressure of a pump
• Osmosis- water continuously moves waste substances when they are of different levels in the membrane until such time when both sides are equal. In such cases, we add glucose to the dialysate to allow water to be moved out of the blood.

What are the different types of dialysis?

The two types of dialysis are hemodialysis and peritoneal dialysis.

What is Hemodialysis?

Hemodialysis (HD) works by emptying wastes and excess water through a dialyzer, an external filter situated outside of your body. In this process, with the aid of the dialysis machine, it allows the blood to flow through the filter where unwanted substances and extra fluids are withdrawn and then back into your body.

In order to provide access to the blood vessels, a minor surgery is being done in the arm or leg. In some cases, means of entry can also be done by combining an artery to a vein under the skin to create a bigger vessel referred to as fistula. However, a graft is also applicable if the blood vessels are inadequate for a fistulaw herein a tube is used to fuse an artery and a vein. For longer treatments, the doctor can insert a catheter to a large vein in the neck.

In HD processwithin the dialyzer, the two fluids: blood and dialysate have to meet inside even though they are separated by a semi-permeable membrane. Through a vascular access (in either forms, catheter or arteriovenous) the blood leaves and:

• First, there is a drip chamber where it passes through which helps in avoiding air in the tubing.
• Second, is the blood pump which ideally pumps the blood at a rate of 300-500 mL/min.
• Third, it enters through the dialyzer and once it leaves, it goes into another drip chamber and finally the air detector. This can accurately detect large air bubble and can stop the flow of blood if those bubbles exist.

Dialysis machines strive to maintain an air free level in the blood for patients undergoing the treatment as normally it can lasts up to 3-4 hours with no one to continuously watch them. Air embolism should be significantly noted when there is a huge presence of air bubbles. Medications such as heparin, erythropoietin, fluids or blood products can be administered in both pre- and post-dialyzer ports.

What is Peritoneal Dialysis?

Peritoneal (PD)operates by cleansing the blood inside the body using a natural semipermeable membrane which is the peritoneum. An access in the abdomen (belly) to make an access will be surgically done by the doctor and a catheter (plastic tube) will be inserted. During the procedure, a dialysate will slowly fill up the peritoneal cavity via the catheter and the blood remains in the arteries and veins in the peritoneum.Excess water and by-products are then drawn out of the blood and into the dialysate.

How often do I need dialysis?

With HD, standard treatment is done three (3) times a week for three-four hours. On a day-to-day basis, usually two hours and 30 minutes- four hours (2.5 – 4), five or six days a week. For nocturnal treatments, eight (8) hours at night, while you are sleeping and done three to six nights a week.

With PD, there is regular cleansing of your blood which you can do four times a day sometime in between meals and bedtime. While this can take up to 30 minutes, you can keep yourself occupied by doing something else. Other patients also prefer using a cycler machine to perform exchanges at night.

Where is it accessible?

Dialysis can be done in a hospital, a renal facility separate from the hospital, or at home. You can collaborate with the doctor to decide which place is suitable to your medical condition and based on your personal wishes.

For HD, it can be done in a dialysis center or in your residence. If a portable machine is available, it makes it easier to carry whether you are on a plane, car or in a boat. If you utilize a large machine, you may want to contact a clinic for treatments whenever you travel.

For PD treatments, any place is suggested as long as it is clean. Proper clean technique should be observed in order to avoid any infection that can harm your abdominal cavity. Make sure that proper measures are appropriately done in handwashing, wearing facial mask and gloves, closing air ventilation and wiping down surfaces.

Is dialysis painful?

The dialysis itself is painless. You may experience initially a discomfort with the needles when inserted into the fistula or graft, but to most patients it does not cause any problems. You can apply numbing creams for temporary relief on the affected site.

In HD, you may feel sick to your stomach, vomit, or feel dizzy and have sore muscle cramps, common occurrence to patients under this treatment yet it will normally go over time.

In PD, you may experience pain when fluids are being put in your abdomen while others can have “drain pain.” It is recommended to leave a certain amount of fluid in the belly (Tidal PD) or moving the catheter can be helpful. This usually gets better in time.

What is ESRD (end-stage renal disease?)

According to study there are one in 10 American adults (1:10), more than 20 million, have some level of CKD (chronic kidney disease) which almost always can progress to an end-stage renal disease (ESRD).In most cases, dialysis treatment is needed for these life-threatening conditions to replace the normal function of the weakened or malfunctioning kidney. If you are a good candidate for kidney transplant, having a healthy kidney from a donor can reverse the damage.

End-stage renal disease (ESRD) also referred to as end-stage kidney disease is the final stage of chronic kidney disease. For patients with ESRD, the kidney functions below 10% from its normal functioning ability. This could mean that either the kidney is hardly functioning or not at all. For patients with chronic kidney disease, it takes about 10-20 years after diagnosis to reach the end-stage. ESRD progresses slowly.

Causes

In the United States, the two leading causes of ESRD are diabetes and high blood pressure. In patients with high glucose in the blood, the body find it difficult to break down sugar contents which can damage nephrons (tiny functional units responsible for the filtering process) in the kidney. For hypertensive patients, there is forcibly an increased pressure upon the smaller vessels in the kidneys that results to damage, preventing the kidney to perform its blood-filtering role.

At-risk

Patients with the following medical conditions are at risk of developing ESRD, this includes:

• Alport syndrome
• Autoimmune conditions such as lupus
• Interstitial nephritis
• Polycystic kidney disease
• Pyelonephritis

Symptoms

There are a wide range of symptoms including:

Common Symptoms:

• overall fatigue
• nausea and vomiting
• headache
• loss of appetite
• unexplained weight loss
• inability to urinate
• increased urination
• pruritus (itching)
• changes in skin color (abnormally dark or light skin)
• bone pain
• difficulty in concentrating or confusion
• general ill feeling

Other Symptoms:

• bruising easily
• excessive thirst
• frequent hiccups and nosebleeds
• absence of menstrual cycles (amenorrhea)
• low libido or impotence
• sleeping problems such as restless leg syndrome (RLS)
• numbing in hands and feet
• halitosis (bad breath)
• frequent hiccups
• swelling or edema especially in hands and legs

Exams and Tests

The doctor will diagnose ESRD through performing a physical examination and ordering blood tests to check kidney function.

The following tests include:

• Urinalysis –used to check for presence of blood and protein in the urine. These are definitive signs that the kidney’s elimination process of by-products is defective or not processing effectively.
• Serum Creatinine Test- this is an indicator whether the waste product creatinine is building up in the blood.
• Blood Urea Nitrogen (BUN)-detects nitrogen presence in the blood.
• Glomerular Filtration Rate (GFR)- estimates how kidneys are filtering waste, normal results range from 90-120 mL/min. However, for older patients they may have lower GFRs as it decreases with age.

ESRD can produce various results to patients on a dialysis treatment. The following should be properly monitored and taken often:

• Albumin
• Calcium
• Cholesterol
• Complete Blood Count (CBC)
• Magnesium
• Phosphorous
• Potassium
• Sodium
• Electrolytes

Treatments

In ESRD two treatments are involved: Dialysis and Kidney Transplant

In dialysis, there are two options that you and your health care provider can decide on, either Hemodialysis or Peritoneal Dialysis.

During HD, an artificial kidney (hemodialyzer) is used to remove waste substances and excess chemicals and fluid from your blood.

During PD, dialysate (special solution fluid) passes through the abdominal cavity via a catheter tube. The solution remains in the belly for a period of time and then removed.

The goals of dialysis are mainly two fold: one, is to get rid of the toxic substances in the kidney and the other is to remove excess fluid and salt.

Kidney Transplant

In 2014, there are over 17,000 kidney transplants that were done in America according to National Kidney Foundation. Kidney transplant is a surgical procedure to replace a damaged kidney with a healthy one from a living donor. Your doctor will refer you to a transplant center and the team will evaluate your condition to see if you are eligible as a candidate for kidney transplant.

Other Management Measures

To prevent ESRD for patients with diabetes and hypertension, they should take proper controlling measure to evade such complication. Medications like angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) are beneficial drug therapies.

Varying symptoms may indicate specific treatments and these include:

• High phosphorous levels- phosphate binders are administered to control its possibility of becoming too high.
• Anemia- extra iron supplements can be taken, having an iron-rich diet, shots of erythropoietin and in severe cases, blood transfusions may be prescribed by your health care provider.
• Speak to your health care provider for calcium and vitamin D supplements
• Certain vaccinations might be advisable, such as Hepatitis A and B, flu and pneumonia (PPV) vaccines

Complications

ESRD possible complications are the following:

• anemia or iron-deficiency
• abnormal electrolyte levels
• bleeding in intestines or stomach
• bone fragility or weakening due to low calcium levels and high phosphorous
• brain dysfunction and dementia
• changes in blood glucose levels
• edema and swelling
• fluid build-up in the lungs
• fractures
• high-blood pressure, heart attack and heart failure
• high risk to infection
• hyperparathyroidism
• increase potassium levels
• infertility and miscarriages
• liver failure
• malnutrition
• nerve damage to legs and arms
• pain in bone, joints and muscles
• problems in heart and blood vessels
• restless legs syndrome (RLS)
• seizures
• stroke

Long-term Outlook

Advanced treatment procedures allow patients with ESRD and kidney related diseases to live longer than those of the olden days. ESRD is a life threatening condition and without dialysis and kidney transplants, survival rate is low or death can be an immediate outcome. The after-effect of treatments depend on an individual’s condition.

ESRD Prevention

ESRD is a difficult disease to control and in most cases not preventable. Therefore, take responsibility of controlling your sugar level and blood pressure, to avoid progression of ESRD if not properly attended. If you detect symptoms, submit yourself to a health care provider to avoid any complications in the future. Thus, for treatment procedures be done immediately, reversing unlikely development of ESRD.