Starting Dialysis: What You Need to KnowBy Charlotte Szromba, MSN, CNN, APRN-BC
When to start kidney replacement therapy (KRT)
Currently chronic kidney disease (CKD) is classified into five stages based on a common measure of kidney function which is the estimated glomerular filtration rate (eGFR). It is the rate kidneys are able to filter out waste from the blood and is based on the creatinine value in the blood, age, race and gender (NKF, 2002). Normal eGFR is 125 mL/min and a lower GFR means a loss of kidney function. We will concentrate on stages 4 and 5.
Stage 4 CKD – eGFR less than 30 mL/min
This stage of CKD is considered fairly severe and it is important to meet with a nephrologist and a healthcare team on a regular basis for monitoring and treatment of complications of CKD, such as anemia, bone disease, malnutrition, acidosis and decreased sense of well-being (NKF, 2002).
The National Kidney Foundation K/DOQI clinical practice guidelines for CKD recommend individuals who reach stage 4 CKD (eGFR less than 30 mL/min/1.73 m2) should start getting ready for kidney replacement therapy (KRT) by learning about treatment options such as hemodialysis, peritoneal dialysis and kidney transplant (NKF, 2006). A referral to a surgeon to create an access for hemodialysis or peritoneal dialysis may be needed at this stage to allow time for the incision to heal and the access to develop.
It is also important during this stage of CKD to protect the kidneys from additional damage by following the advice of the healthcare team regarding diet, medications, blood pressure control and lifestyle changes. Individuals can sometimes remain in stage 4 CKD for several months to years without progressing to stage 5.
Stage 5 CKD – eGFR less than 15 mL/min
This stage generally means kidney failure and the need to start KRT to replace lost kidney function. Some common symptoms include poor appetite, nausea or vomiting, worsening fatigue, increased edema in legs and feet, increased shortness of breath and more difficulty controlling blood pressure. These are all symptoms that indicate KRT is needed.
Types of Kidney Replacement Therapy
• Hemodialysis can take place in an outpatient dialysis center or at home
• Peritoneal dialysis takes place in the home setting and may involve a cycler machine
• Kidney transplant involves the surgical placement of a kidney from a donor in the abdomen
• Non–treatment involves a decision by the individual and the healthcare team to decline any type of KRT.
Decision for type of kidney replacement therapy
It is important to learn about the available therapies by talking with the healthcare team, reading information, attending classes and using the Internet to understand all the options. The physician and healthcare team can provide guidance, but the ultimate decision is up to the individual. It is important to consider lifestyle, personal capabilities, support system and personal preference when making the decision for the type of KRT.
Hemodialysis
Types of Hemodialysis
• In-center hemodialysis lasts three to four hours and is done in an outpatient dialysis unit three times a week. A typical schedule is every Monday, Wednesday and Friday or every Tuesday, Thursday and Saturday.
• Home hemodialysis lasts two to three hours each time, usually five to six times a week. This option has many variations.
• Nocturnal hemodialysis is done at night for six to eight hours, three times a week. This is done in the home setting, however, some dialysis centers are beginning to offer this option.
Preparation for hemodialysis
Vascular access surgery is done to create a path for the blood to be cleaned during dialysis then returned to the body. The surgery is done ahead of time so the incision can heal and the access can develop so it can be used for dialysis.
There are three types of vascular access.
• Fistula surgically links an artery and vein together and is placed in the upper or lower arm and is considered the best type of vascular access. It lasts a long time and has few complications, but often takes several weeks to months for the fistula to be ready to be used for dialysis.
• Graft is a type of hollow tubing surgically placed under the skin linking an artery to a vein, providing a permanent access for dialysis. This option is often used if there is a problem with the size of the patient’s blood vessels.
• Central venous catheter is a small hollow soft tube placed into a large vein in the neck or shoulder that allows access to the blood stream. This type of vascular access is usually temporary and can be used immediately after placement. However it is associated with many complications such as infection or clotting (Breiterman-White, 2006).
In-center Hemodialysis
Advantages
Three treatments per week, four days off.
Treatments are done by trained nurses and technicians.
Meet and spend time with other hemodialysis patients.
No equipment or supplies stored at home.
Disadvantages
Travel to dialysis center on a fixed schedule in all kinds of weather.
Limited fluid intake and diet restrictions to follow.
Permanent access in the arm where needles are inserted for hemodialysis treatment.
Possible discomfort such as headache, nausea, cramps and “washed out’ feeling.
Trips must be planned in advance so arrangement for hemodialysis treatment at destination can be made.
Home hemodialysis
Advantages
Treatments are done in your home on your schedule.
No traveling to dialysis center, only monthly check up in clinic. Treatment is done in the comfort of your home.
Same person helping you and placing needles in your arm each time.
More frequent dialysis avoids large shifts of fluid as in three times a week and allows fewer restrictions on diet and fluids.
You learn enough for you to be in charge of your care with advice from healthcare team.
Disadvantages
You are responsible to do the treatments as prescribed five to six times a week.
You and your partner must be trained to handle equipment and do the treatment. Partner must be available for each treatment.
Storage space must be available in the home for equipment and supplies.
Some plumbing and wiring changes may be necessary in your home, newer machines require less changes.
Peritoneal dialysis (PD)
Types of Peritoneal Dialysis
CAPD – continuous ambulatory peritoneal dialysis is done manually usually three to four times a day, each exchange of fluid takes 20 to 30 minutes.
CCPD – continuous cycling peritoneal dialysis is done at night, using a small machine at the bedside.
Preparation for PD
A hollow tube called a catheter is surgically placed through the wall of the abdomen and this is the permanent access for PD. It is generally placed about one to two inches below the navel and to one side. The catheter remains in the body all the time and about two to four inches of the catheter extends out of the abdomen. The surgery is usually done three to six weeks ahead of time so the incision can heal.
Peritoneal Dialysis
Advantages
No need to travel to center three times a week. Schedule is more flexible. Treatment is done in the comfort of home.
Fewer food and fluid restrictions than incenter hemodialysis.
No need for needle insertion.
Easy to do PD when you travel.
Can dialyze when you sleep with CCPD.
Blood pressure control may be better since it is a continuous therapy.
Disadvantages
Need to schedule exchanges/cycler into your routine seven days a week.
Catheter is permanent and external.
Storage space is needed in the home for equipment and supplies.
Some risk of infection.
May gain weight due to glucose content in the dialysate solution.
Kidney Transplant
Types of Kidney Transplant
• Living related or living non-related transplant - the kidney is donated by an individual who is a close tissue match to the recipient.
• Deceased/cadaver transplant – the kidney is donated by an individual who decided to donate his/her organs when he/she die. The waiting time for this type of transplant can be one to five years depending on blood and tissue type.
Advantages
No dialysis treatments needed with a working kidney transplant.
Fewer diet and fluid restrictions.
Closest thing to having own kidneys, may feel healthier with more energy.
Allows for a normal schedule with less clinic visits.
Disadvantages
Risk of major surgery and stress of waiting for a kidney match.
Need to take anti-rejection medications every day, some side effects may be noted.
Risk of rejection, donated kidneys can fail and dialysis may be needed.
Possible changes in appearance due to medication side effects.
Non-treatment
Individuals who are severely ill or have many health problems may consider this option. Anyone with a chronic illness may struggle with a sense of hopelessness at times and feel any type of dialysis will not add to the quality of their life. There may be a fear of the unknown and what the future may hold. Often the healthcare team can suggest a trial of dialysis for a short time. If a person over time continues to believe treatment for kidney failure will not bring a better quality of life, then talking with the family and healthcare team about preparing for a peaceful passing is important. Symptoms can be managed as they occur and the person is kept as comfortable as possible through palliative or hospice care.
Selecting the treatment that is right for YOU
Learn the facts about the types of kidney replacement therapies and talk to your healthcare team about the choices. Talk to your family and friends to help decide which option fits your lifestyle and future goals. Think about your own skills, general health, abilities and family support and select a treatment that best fits with you.
References
1. Breiterman-White, R. (2006) Vascular access for hemodialysis. In Molzahn & Butera (Eds) Contemporary Nephrology Nursing: principles and Practice (pp 559-577) Pitman, NJ: Anthony J. Jannetti Inc.
2. National Kidney Foundation (NKF). (2002). NKF K/DOQI Clinical practice guidelines for chronic kidney diseases: Evaluation, classification and stratification. American Journal of Kidney Diseases, 39(2) (Suppl. 1), S1-S266.
3. National Kidney Foundation. (2006). NKF K/DOQI Clinical practice guidelines and clinical practice
recommendations, 2006 updates, hemodialysis adequacy, peritoneal dialysis adequacy, vascular access.
Retrieved on Jan 25, 2008 from
http://www.kidney.org/professionals/KDOQI/guidelines_upHD_PD_V.
4. National Kidney Foundation (2007). NKF K/DOQI Clinical practice recommendations for diabetes and chronic kidney disease. American Journal of Kidney Diseases, 49(2)(Suppl.) S10-S11.
5. National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) (2008). Kidney Failure: Choosing a treatment that’s right for you. Retrieved on January 3, 2008 from
http://kidney.nih.gov/kudiseases/pubs/choosingtreatment/index/htm.
Charlotte Szromba MSN, CNN, APRN-BC is a nurse practitioner and a consultant for Nephrology Clinical Solutions.
AAKP has several resources for you and your loved ones regarding treatment options, including the Understanding Your Hemodialysis Options brochure and the Understanding Your Peritoneal Dialysis Options brochure. These brochures provide a description of hemodialysis and peritoneal dialysis as well as an in-depth explanation of the available hemodialysis treatments and peritoneal dialysis treatments. These brochures also offer a detailed explanation of the various physical, emotional and social aspects associated with each treatment. In addition, they include the benefits and drawbacks for the various treatment options.
Visit
www.aakp.org to download electronic copies of the brochures. You can also call 800-749-AAKP to request free copies be mailed to you. These brochures are available in English and Spanish.
This article originally appeared in the May 2008 issue of Kidney Beginnings: The Magazine.
http://www.aakp.org/newsletters/KB-The-Magazine/Feature-Story/Starting-Dialysis/index.cfm
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