Is Dialysis Nursing for you? (Part One)

madwife2002, BSN, RN

When I was doing my finals many years ago I was faced with discussing 2 specialties one was Looking after the renal patient the anatomy and physiology, the other the CVA/Stroke patient or as now we talk about it as the brain attack pt. (In days of old when you took your finals you had to hand write almost an assignment under exam conditions about your chosen subject of which you had no prior knowledge and was a 3 hour paper)

So I opted for what I believed was the easier of the two which was of course the pt who suffered the CVA! I remember saying I wouldn't touch the renal pt with a barge pole because it was too complicated, and I would never pass.

The thought of knowing and understanding the care of a renal patient was horrific to me at the time, now many years later I laugh at the thought of why I was frightened of 'kidney patients'.

I guess what I am trying to portrait is that even if you think renal nursing is not for you it could be something you really enjoy, I doubt many nurses got into the specialty really wanting to nurse the complicated and difficult renal patient as they can be known as.

First of all looking after the renal patient can be a huge learning curve in your education & development as a nursing professional.

The renal system affects all the systems of the body and I do not believe people give the kidneys the respect they deserve.

Diabetes and hypertension are the two biggest causes of chronic renal failure in the USA or Chronic Kidney disease (CKD). Yet a large percentage of the population remain unaware that these two illness can and do go on to cause CKD, and more often than not silently.

In the US, the Centers for Disease Control and Prevention found that CKD affected an estimated 16.8% of adults aged 20 years and older, during 1999 to 2004...

Quote
"Prevalence of chronic kidney disease and associated risk factors--United States, 1999-2004". MMWR Morb. Mortal. Wkly. Rep. 56 (8): 161-5. March 2007. PMID 17332726

Quote
ROCKVILLE, Md.--Results from American Kidney Fund-commissioned research showed that majority of those surveyed who care for their loved ones' health are unaware that diabetes and high blood pressure are the leading causes of kidney disease.
Most survey respondents (85 percent) could not name high blood pressure as a leading cause of kidney disease. In addition, the majority (74 percent) of all respondents have a loved one with high blood pressure.
More than two-thirds (69 percent) of respondents could not name diabetes as a leading cause of kidney disease, despite the fact that 55 percent of respondents have a loved one with diabetes, according to the AKF research.

Many Unaware Diabetes, Hypertension Cause CKD

So our responsibility as nurses and health care professionals is to educate our patients, friends and co-workers on the dangers of not having 'well women and men' check ups to try and catch these diseases before they cause an even more disabling disease of CKD.

As a RN with over 12 years of renal nursing and 10 more years of general nursing and midwifery, I have never found a more interesting and varied specialty than being a nephrology nurse. I have also found that Nephrologists are doctors who are actually more than willing to teach and educate staff. They also play a huge role in working together with RNs to keep the pt as healthy as possible.

So what is on offer when a pt has lost the use of their kidneys?

Transplant, Peritoneal Dialysis, Hemodialysis or Death.

Transplant

Transplant is the optimum option that patients live for, yet it is the most unobtainable in many ways. It is estimated that 84,000 people are waiting for transplants each year in the USA and 4,400 pts will die whilst waiting.

The Ethics of Paying Kidney Donors

A very small percentage of pts eligible for a transplant will actually receive one, although statistics show that we have significantly improved the amount of transplants we perform, which is good news but only the tip of the ice berg as far as what we can do to increase the amount of potential donors.

Number of kidney transplants performed

2008: 17,413
2007: 17,519
2006: 18,059
2005: 17,450
2000: 14,629
1995: 12,165
1990: 10,035
1985: 7,505
1980: 3,786

Kidney and Urologic Diseases Statistics for the United States

383,343 is the approximate figure of patients on dialysis so when you compare that to the the percentage of patients on the waiting list for a kidney 87,820. You can easily see that only a very small percentage of patients are actually suitable to be on the transplant list. (figures accurate Feb 2011)

In the US the major problem in my opinion is the fact that it costs around $100,000 a year in medication/anti rejection drugs to keep the kidney alive once they have had a transplant.

Medicare/Medicaid will cover this for 3 years after this time the patient have to pay for their own medication!

It is expected that following a transplant a pt will be fit and healthy enough to find a job and get insurance.

What happens is after the 3 yrs in reality many pts cannot afford their own medication and the transplant can fail.

Pts will still have the chronic illnesses which caused their kidneys to fail so some are simply unable to work. Some pts will have never quite recovered optimum health so are unable to work. Some pts live in poor economic cities and cannot find work!

Of course you also have the 'non compliant' pts ... Some pts will be none compliant with their medication as they were none compliant before CDK, so the cycle of non compliance continues.

These pts then have the potential to be back on the waiting list and need dialysis again. So what happens for the rest of the CKD patients?

Hemodialysis

Hemodialysis is the most common treatment available for patients with end stage renal disease (ESRD).

A very brief history of hemodialysis:

In the 1960's it became readily available as a treatment-although it was recognized as a potential treatment as early as 1854 by a chemist Thomas Graham.

The first human hemodialysis was performed in a uremic patient by Haas in 1924 at the University of Giessen in Germany.

Willem Kolff from the Netherlands, was one of the first investigators interested in the role of toxic solutes in causing the uremic syndrome. In 1943 he introduced the rotating drum hemodialysis system using cellophane membranes and an immersion bath and the first recovery of an acute renal failure patient treated with hemodialysis was reported.

A new phase in clinical hemodialysis started with the introduction of the Quinton and Scribner AV shunt in 1960.

The AV shunt provided for the first time continuous circulation of the blood when the patient was attached to the machine, effectively eliminating clotting and provided ready access for repeated long-term hemodialysis, opening the door to chronic renal replacement therapy.

The next significant advance in vascular access occurred in the 1960's when Cimino and Brescia first described their native arterio-venous fistula for chronic vascular access. This is known as the GOLD standard for access.

Of course their has been major developments over the past 40 plus years related to improvements in membrane biocompatibility and dialyzer design, volumetric control, sophisticated monitoring systems that provide online clearances, isothermal dialysis, high flux membranes and convective modalities such as hemofiltration and hemodiafiltration.

Hemodialysis is offered for patients at free standing Chronic Dialysis Units through out the US, pts can opt to do home hemodialysis but the percentage who do home hemodialysis is low compared to those who frequent the Chronic Units and have experienced technicians and RNs to do the treatment for them.

The approximate cost of keeping a pts on hemodialysis is around $80,000 a year, this figure does not include medications, transportation or other expenses a CKD pt may occur.

The average patient will be prescribed a treatment of 4 hours, 3 times a week-52 weeks of the year!

Can you imagine going to dialysis 3 times a week for potentially the rest of your life?

No I can't !

To the four hours on dialysis treatment you have to add on the following time factors:

Travel time to the hemodialysis center
Waiting time to get on their chair
Time to prepare the pt for dialysis
Time after dialysis to 'hold' sites
Waiting time for transportation if they don't drive themselves
Travel time home

Potentially a patient can take up 5-6 hours of their day, 3 times a week and sometimes 4 times a week!

So with this in mind what do you think the first kind of potential problems for dialysis patients can be?

Not happy if transportation doesn't collect them at the time they are supposed to
Impatience if they do not get on their Chair on time
Boredom
Annoyance if their dialysis does not go smoothly and they spend longer at the center than '4' hours
Boredom
Ticked off if the technician doesnt get the patient off dialysis in a timely manner
Boredom
Anger if transportation doesn't arrive to collect them from dialysis on time

So what can we do as Renal nurses/Social workers/Dialysis technicians to make them feel better?

Try to make sure they get on their chair on time
Inform pts promptly when their is a delay and keep them updated
Liaise with transportation companies to make sure they bring their pts to the unit in a timely manner and collect them in a timely manner
Art Therapy, television, cable tv, internet access, Bingo for boredom
Be pleasant, polite and cheerful
Know your patient and jump in before they get to the annoyed stage where possible
Have experience staff
The list goes on.

Next time I will talk about problems the pts can experience on hemodialysis which should enhance your experience and understanding of the Dialysis Patient if you are looking after them in hospital.

Other Reading Material

American Kidney Fund

Outpatient Dialysis Services [pdf]

The burden of prescription coverage of kidney failure patients in the United States: is Medicare Part D the answer?

Hemodialysis - wikipedia