Introduction to Dialysis

[lprutean]

Introduction to DialysisPatient Educationby Lidia Pruteanu

Kidney

The kidneys are very important organs with multiple functions in the human body. People have usually two kidneys with some exceptions, located in the back of the abdominal cavity, above the waistline, on both sides of the spinal column.

They are red dark, and have a bean-shaped , are about the size of a fist, and weigh about five ounces. They are protected by the rib cage and pads of fat.

Kidney Functions

The main function of the kidney is to :

- filter the waist from the blood

-remove excess of fluid from the body

-keep the fluids and electrolytes in balance

- control of Blood Pressure

- maintain acid-base balance

- produce hormones to keep the bones healthy and to help the bone marrow to produce red blood cells.

Types of Kidney disease

1. Acute kidney failure ( AKF) is a sudden loss of kidney function due to different causes: an acute illness , accident, toxins, trauma, formation of kidney stones. Usually this stage reversible.

2. Chronic kidney (CKD) is a slow and progressive decrease of kidney function, usualy irreversible, leading to a permanent loss of function.

CKD has a number of causes :

- diabetes

- high blood pressure

- polycystic kidney

- glomerular disease

- systemic lupus erythematosus

- birth defects

- drugs

- cancer

- kidney infection

- sickle cell disease

- AIDS

When Kidney Fail

Usually when 75-80 % of renal function is lost, kidneys are not longer able to maintain a healthy life .Progressive decreasing of renal function may be managed conservatively with diet, fluid control, and medications till GFR reaches 10-15 % of normal. When kidney fails the patient needs dialysis treatment or renal transplant to sustain life.

Treatments for kidney failure

The dialysis treatment cleans the blood from toxins, removes the waste and excess of water from the body, controls the blood pressure keeps certain blood levels in normal range. Dialysis is a way to replace some of the kidney function, but cannot improve or cure the kidney failure. Dialysis is necessary to maintain health till kidney transplant occurs.

Types of treatment

1. Hemodialysis

2. Peritoneal dialysis

3. Transplantation

1.Hemodialysis can be done is the dialysis centers, at home, ( home dialysis ), nocturnal dialysis( in center about 8 hours 3-7 nights per week) or short daily home dialysis. ( 2-3 hours treatments 5-7 days per week)

In case of Acute Renal Failure a 24 hours slow treatment ( CRRT) is being done in the hospital, in acute units , ICU..

2.PD treatment is done at home by the patient him/herself or a family member who was fully trained by a dialysis nurse , about 2 weeks, to perform the treatment . The dialysis nurse and nephrologist will be available 24/7 for emergencies, and also the Baxter help desk wil assist patient with the PD machine and will provide technical support.

Patient needs a PD catheter which is surgically placed in the peritoneal cavity, a soft, plastic tube through which a special dialysis solution is placed to fill the abdomen. During dwelling time ( 2-3 hours) the the waste products and excess of fluid is being removed from the patient,s blood through the small capillaries and then drained. The three steps of PD treatment are :

- drain

- fill

- dwell

The cycle has to be repeated 4-5 times per day . Peritoneal treatment can be done manually ( Continuous Ambulatory Peritoneal Dialysis ) CAPD, or via a dialysis machine ( automated peritoneal dialysis APD)

3.Kidney transplantation gives patient one healthy kidney from a donor and a lifestyle that is closest to normal.

The kidney donor could be a life donor , blood related , a family member , a non-blood related , a friend, a spouse, or a deceased donor.

A transplant is not a cure for kidney disease ,it is another form of treatment. The transplant may last up to 17-20 years or more or may not work at all from the beginning..

The most common problem after transplantation is rejection of the new kidney by the body, as the body fights against the "foreign " object ( kidney).

The solution to rejection is to put patient on anti rejection medications which will decreased the ability of the immune system to fight. After the transplant, the patient has to be followed on a regular basis by a neurologist, who is constantly going to adjust the medications accordingly to the antibodies level. Also the patient have to be on a special diet ,, but with very few restrictions.

Dialysis Access

In order to have a dialysis treatment , the patient needs a vascular access . They are three types of access, surgically created :

1. tunneled cuffed catheter

2. arteriovenous graft

3. arteriovenous fistula

The tunneled cuffed catheter is a soft plastic tube introduced through the skin into a large vein, usually internal jugular vein, subclavian vein or femoral vein, which leads directly in the heart .

The catheter has two ports : one to bring the blood out of the blood stream into the extracorporeal circuit of the dialysis machine, and the second one to return the clean blood to the patient. Only a small amount of blood is out of the body at any time ( 100-250 ML) The blood goes through a special filter ( dialyser) where it gets cleaned. The treatment usually is 3-4 hours three time a week . The nephrologist determines the time,the blood flow, the type of filter and the dialysis solution according to the patients needs.

2. An arteriovenous graft is a special plastic tube used to connect an artery and a vein , to create an artificial vessel, which will hold a larger amount of blood than a regular vein . A graft is created for patients who are not a good candidate for fistula, due to the anatomy and conditions of their own vessels..

3. An arteriovenous fistula is surgically created from a native artery and vein . Through surgery the patient,s own artery and vein is connected to create a bigger vessel with a strong blood flow.Most common type of fistula links the radial artery and the cephalic vein in the forearm. The fistula can be created using the brachial artery and cephalic vein in the upper arm. The fistula need 1-2 month to mature . When ready the surgeon will give permission to use it for treatment .

The vascular access is the life line of the patient and needs to be protected from infections or clotting. The catheter needs to be kept covered with a dry and clean dressing all the time. No showers or swimming are permitted. Only the qualified personnel, or the dialysis nurse is permitted to change the dressing, to assess the exit site, and to access the catheter. The graft and fistula needs to be assessed by the dialysis nurse or technician before each cannulation , and checked daily for thrill and bruit by the patient. In case the access stopped working the patient needs to notify the dialysis unit and to be referred to a vascular surgeon for evaluation and declotting .

Dialysis team

In the dialysis center a comprehensive dialysis team oversees the patients treatment , manages the disease process, helps provide a quality care, educates the patient and family members regarding treatment goals to maintain a stated of wellness. The members of the dialysis team are:

- the medical director- nephrologist

- clinical manager

- dialysis nurse

- social worker

- renal dietitian

- psychologist

The most important member of the dialysis team are the patients themselves, as they know themselves the best. Good outcome for patients requires a close relationship based on trust,and respect for knowledge , good communication and collaboration , active participation in own care.References:

Larry E. Lancaster, MSN, EdD, RN (1995). Core Curriculum for Nephrology Nursing, ANNA( Third Edition). New Jersey: Pitman