Hemodialysis is the most common method used to treat advanced and
permanent kidney failure. Since the 1960s, when hemodialysis first
became a practical treatment for kidney failure, we've learned much
about how to make hemodialysis treatments more effective and minimize
side effects. In recent years, more compact and simpler dialysis
machines have made home dialysis increasingly attractive. But even with
better procedures and equipment, hemodialysis is still a complicated and
inconvenient therapy that requires
a coordinated effort from your whole health care team, including
your nephrologist, dialysis nurse, dialysis technician, dietitian, and
social worker. The most important members of your health care team are
you and your family. By learning about your treatment, you can work with
your health care team to give yourself the best possible results, and
you can lead a full, active life.
When Your Kidneys Fail
Healthy kidneys clean your blood by removing excess fluid,
minerals, and wastes. They also make hormones that keep your bones
strong and your blood healthy. When your kidneys fail, harmful wastes
build up in your body, your blood pressure may rise, and your body may
retain excess fluid and not make enough red blood cells. When this
happens, you need treatment to replace the work of your failed kidneys.
How Hemodialysis Works
In hemodialysis, your blood is allowed to flow, a few ounces at
a time, through a special filter that removes wastes and extra fluids.
The clean blood is then returned to your body. Removing the harmful
wastes and extra salt and fluids helps control your blood pressure and
keep the proper balance of chemicals like potassium and sodium in your
body.
One of the biggest adjustments you must make when you start
hemodialysis treatments is following a strict schedule. Most patients go
to a clinic—a dialysis center—three times a week for 3 to 5 or more
hours each visit. For example, you may be on a Monday-Wednesday-Friday
schedule or a Tuesday-Thursday-Saturday schedule. You may be asked to
choose a morning, afternoon, or evening shift, depending on availability
and capacity at the dialysis unit. Your dialysis center will explain
your options for scheduling regular treatments.
Researchers are exploring whether shorter daily sessions, or
longer sessions performed overnight while the patient sleeps, are more
effective in removing wastes. Newer dialysis machines make these
alternatives more practical with home dialysis. But the Federal
Government has not yet established a policy to pay
for more than three hemodialysis sessions a week.
Hemodialysis.
Several centers around the country teach people how to perform
their own hemodialysis treatments at home. A family member or friend who
will be your helper must also take the training, which usually takes at
least 4 to 6 weeks. Home dialysis gives you more flexibility in your
dialysis schedule. With home hemodialysis, the time for each session and
the number of sessions per week may vary, but you must maintain
a regular schedule by giving yourself dialysis treatments as often
as you would receive them in a dialysis unit.
Adjusting to Changes
Even in the best situations, adjusting to the effects of kidney
failure and the time you spend on dialysis can be difficult. Aside from
the "lost time," you may have less energy. You may need to make changes
in your work or home life, giving up some activities and
responsibilities. Keeping the same
schedule you kept when your kidneys were working can be very
difficult now that your kidneys have failed. Accepting this new reality
can be very hard on you and your family. A counselor or social worker
can answer your questions and help you cope.
Many patients feel depressed when starting dialysis, or after
several months of treatment. If you feel depressed, you should talk with
your social worker, nurse, or doctor because this is a common problem
that can often be treated effectively.
Getting Your Vascular Access Ready
Arteriovenous fistula.
One important step before starting hemodialysis is preparing a
vascular access, a site on your body from which your blood is removed
and returned. A vascular access should be prepared weeks or months
before you start dialysis. It will allow easier and more efficient
removal and replacement of your blood with fewer complications. For more
information about the different kinds of vascular accesses and how to
care for them, see the National Institute of Diabetes and Digestive and
Kidney Diseases (NIDDK) fact sheet
Vascular Access for Hemodialysis.
Equipment and Procedures
When you first visit a hemodialysis center, it may seem like a
complicated mix of machines and people. But once you learn how the
procedure works and become familiar with the equipment, you'll be more
comfortable.
Graft.
Dialysis Machine
The dialysis machine is about the size of a dishwasher. This machine has three main jobs:
- pump blood and watch flow for safety
- clean wastes from blood
- watch your blood pressure and the rate of fluid removal from your body
Dialyzer
Structure of a typical hollow fiber dialyzer.
The dialyzer is a large canister containing thousands of small
fibers through which your blood is passed. Dialysis solution, the
cleansing fluid, is pumped around these fibers. The fibers allow wastes
and extra fluids to pass from your blood into the solution, which
carries them away. The dialyzer is sometimes called an artificial
kidney.
- Reuse. Your dialysis center may use
the same dialyzer more than once for your treatments. Reuse is
considered safe as long as the dialyzer is cleaned before each use. The
dialyzer is tested each time to make sure it's still working, and it
should never be used for anyone but you. Before each session, you should
be sure that the dialyzer is labeled with your name and check to see
that
it has been cleaned, disinfected, and tested.
Dialysis Solution
Dialysis solution, also known as dialysate, is the fluid in the
dialyzer that helps remove wastes and extra fluid from your blood. It
contains chemicals that make it act like a sponge. Your doctor will give
you a specific dialysis solution for your treatments. This formula can
be adjusted based on how well
you handle the treatments and on your blood tests.
Needles
Many people find the needle sticks to be one of the hardest
parts of hemodialysis treatments. Most people, however, report getting
used to them after a few sessions. If you find the needle insertion
painful, an anesthetic cream or spray can be applied to the skin. The
cream or spray will numb your
skin briefly so you won't feel the needle.
Most dialysis centers use two needles—one to carry blood to the
dialyzer and one to return the cleaned blood to your body. Some
specialized needles are designed with two openings for two-way flow of
blood, but these needles are less efficient and require longer sessions.
Needles for high-flux or high-efficiency dialysis need to be a little
larger than those used with regular dialyzers.
Arterial and venous needles.
Some people prefer to insert their own needles. You'll need
training on inserting needles properly to prevent infection and protect
your vascular access. You may also learn a "ladder"
strategy for needle placement in which you "climb" up the entire
length of the access session by session so that you don't weaken an area
with a grouping of needle sticks. A different approach is the
"buttonhole" strategy in which you use a limited number of sites but
insert the needle back into the same hole made by the previous needle
stick. Whether you insert your own needles or not, you should know these
techniques to better care for your access.
Tests to See How Well Your Dialysis Is Working
About once a month, your dialysis care team will test your
blood by using one of two formulas—URR or Kt/V—to see whether your
treatments are removing enough wastes. Both tests look at one specific
waste product, called blood urea nitrogen (BUN), as an indicator for the
overall level of waste products in your system. For more information
about these measurements, see the NIDDK fact sheet
Hemodialysis Dose and Adequacy.
Your kidneys do much more than remove wastes and extra fluid.
They also make hormones and balance chemicals in your system. When your
kidneys stop working, you may have problems with anemia and conditions
that affect your bones, nerves, and skin. Some of the more common
conditions caused by kidney failure are extreme tiredness, bone
problems, joint problems, itching, and "restless legs." Restless legs
will keep you awake as you feel them twitching and jumping.
Anemia and Erythropoietin (EPO)
Anemia is a condition in which the volume of red blood cells is
low. Red blood cells carry oxygen to cells throughout the body. Without
oxygen, cells can't use the energy from food, so someone with anemia
may tire easily and look pale. Anemia can also contribute to heart
problems.
Anemia is common in people with kidney disease because the
kidneys produce the hormone erythropoietin, or EPO, which stimulates the
bone marrow to produce red blood cells. Diseased kidneys often don't
make enough EPO, and so the bone marrow makes fewer red blood cells. EPO
is available commercially and is commonly given to patients on
dialysis.
For more information about the causes of and treatments for anemia in kidney failure, see the NIDDK fact sheet
Anemia in Kidney Disease and Dialysis.
Renal Osteodystrophy
The term "renal" describes things related to the kidneys. Renal
osteodystrophy, or bone disease of kidney failure, affects 90 percent
of dialysis patients. It causes bones to become thin and weak or formed
incorrectly and affects both children and adults. Symptoms can be seen
in growing children with kidney disease even before they start dialysis.
Older patients and women who have gone through menopause are at greater
risk for this disease.
For more information about the causes of this bone disease and its treatment in dialysis patients, see the NIDDK fact sheet
Renal Osteodystrophy.
Itching (Pruritus)
Many people treated with hemodialysis complain of itchy skin,
which is often worse during or just after treatment. Itching is common
even in people who don't have kidney disease; in kidney failure,
however, itching can be made worse by wastes in the bloodstream that
current dialyzer membranes can't remove from the blood.
The problem can also be related to high levels of parathyroid
hormone (PTH). Some people have found dramatic relief after having their
parathyroid glands removed. The four parathyroid glands sit on the
outer surface of the thyroid gland, which is located on the windpipe in
the base of your neck, just above the collarbone. The parathyroid glands
help control the levels of calcium and phosphorus in the blood.
But a cure for itching that works for everyone has not been
found. Phosphate binders seem to help some people; these medications act
like sponges to soak up, or bind, phosphorus while it is in the
stomach. Others find relief after exposure to ultraviolet light. Still
others improve with EPO shots. A few
antihistamines (Benadryl, Atarax, Vistaril) have been found to
help; also, capsaicin cream applied to the skin may relieve itching by
deadening nerve impulses. In any case, taking care of dry skin is
important. Applying creams with lanolin or camphor may help.
Sleep Disorders
Patients on dialysis often have insomnia, and some people have a
specific problem called the sleep apnea syndrome, which is often
signaled by snoring and breaks in snoring. Episodes of apnea are
actually breaks in breathing during sleep. Over time, these sleep
disturbances can lead to "day-night reversal" (insomnia at night,
sleepiness during the day), headache, depression, and decreased
alertness. The apnea may be related to the effects of advanced kidney
failure on the control of breathing. Treatments that work with people
who have sleep apnea, whether they have kidney failure or not, include
losing weight, changing sleeping position, and wearing a mask that
gently pumps air continuously into the nose (nasal continuous positive
airway pressure, or CPAP).
Many people on dialysis have trouble sleeping at night because
of aching, uncomfortable, jittery, or "restless" legs. You may feel a
strong impulse to kick or thrash your legs. Kicking may occur during
sleep and disturb a bed partner throughout the night. The causes of
restless legs may include
nerve damage or chemical imbalances.
Moderate exercise during the day may help, but exercising a few
hours before bedtime can make it worse. People with restless leg
syndrome should reduce or avoid caffeine, alcohol, and tobacco; some
people also find relief with massages or warm baths. A class of drugs
called benzodiazepines, often used to treat insomnia or anxiety, may
help as well. These prescription drugs include Klonopin, Librium,
Valium, and
Halcion. A newer and sometimes more effective therapy is levodopa
(Sinemet), a drug used to treat Parkinson's disease.
Sleep disorders may seem unimportant, but they can impair your
quality of life. Don't hesitate to raise these problems with your nurse,
doctor, or social worker.
Amyloidosis
Dialysis-related amyloidosis (DRA) is common in people who have
been on dialysis for more than 5 years. DRA develops when proteins in
the blood deposit on joints and tendons, causing pain, stiffness, and
fluid in the joints, as is the case with arthritis. Working kidneys
filter out these proteins, but dialysis filters are not as effective.
For more information, see the NIDDK fact sheet
Amyloidosis and Kidney Disease.
How Diet Can Help
Eating the right foods can help improve your dialysis and your
health. Your clinic has a dietitian to help you plan meals. Follow the
dietitian's advice closely to get the most from your hemodialysis
treatments. Here are a few general guidelines.
- Fluids. Your dietitian will help you
determine how much fluid to drink each day. Extra fluid can raise your
blood pressure, make your heart work harder, and increase the stress of
dialysis treatments. Remember that many foods—such as soup, ice cream,
and fruits—contain plenty of water. Ask your dietitian for tips on
controlling your thirst.
- Potassium. The mineral potassium is
found in many foods, especially fruits and vegetables. Potassium affects
how steadily your heart beats, so eating foods with too much of it can
be very dangerous to your heart. To control potassium levels in your
blood, avoid foods like oranges, bananas, tomatoes, potatoes, and dried
fruits. You can remove some of the potassium from potatoes and other
vegetables by peeling and soaking them in a large container of water for
several hours, then cooking
them in fresh water.
You can remove some potassium from potatoes by soaking them in water.
- Phosphorus. The mineral phosphorus can
weaken your bones and make your skin itch if you consume too much.
Control of phosphorus may be even more important than calcium itself in
preventing bone disease and related complications. Foods like milk and
cheese, dried beans, peas, colas, nuts, and peanut butter are high in
phosphorus and should be avoided. You'll probably need to take a
phosphate binder with your food to control the phosphorus in your blood
between dialysis sessions.
- Salt (sodium chloride). Most canned
foods and frozen dinners contain high amounts of sodium. Too much of it
makes you thirsty, and when you drink more fluid, your heart has to work
harder to pump the fluid through your body. Over time, this can cause
high blood pressure and congestive heart failure. Try to eat fresh foods
that are naturally low in sodium, and look for products labeled "low
sodium."
- Protein. Before you were on dialysis,
your doctor may have told you to follow a low-protein diet to preserve
kidney function. But now you have different nutritional priorities. Most
people on dialysis are encouraged to eat as much high-quality protein
as they can. Protein helps you keep muscle and repair tissue, but
protein breaks down into urea (blood urea nitrogen, or BUN) in your
body. Some sources of protein, called high-quality proteins,
produce less waste than others. High-quality
proteins come from meat, fish, poultry, and eggs. Getting most of
your protein from these sources can
reduce the amount of urea in your blood.
- Calories. Calories provide your body
with energy. Some people on dialysis need to gain weight. You may need
to find ways to add calories to your diet. Vegetable oils—like olive,
canola, and safflower oils—are good sources of calories and do not
contribute to problems controlling your cholesterol. Hard candy, sugar,
honey, jam, and jelly also provide calories and energy. If you have
diabetes, however, be very careful about eating sweets. A dietitian's
guidance is especially important for people with diabetes.
- Supplements. Vitamins and minerals may
be missing from your diet because you have to avoid so many foods.
Dialysis also removes some vitamins from your body. Your doctor may
prescribe a vitamin and mineral supplement designed specifically for
people with kidney failure. Take your prescribed supplement after
treatment on the days you have hemodialysis. Never take vitamins that you can buy off the store shelf, since they may contain vitamins or minerals that are harmful to you.
You can also ask your dietitian for recipes and titles of
cookbooks for patients with kidney disease. Following the restrictions
of a diet for kidney disease might be hard at first, but with a little
creativity, you can make tasty and satisfying meals. For more
information, see the NIDDK booklet
Eat Right to Feel Right on Hemodialysis.
Financial Issues
Treatment for kidney failure is expensive, but Federal health
insurance plans pay much of the cost, usually up to 80 percent. Often,
private insurance or State programs pay the rest. Your social worker can
help you locate resources for financial assistance. For more
information, see the NIDDK fact sheet
Financial Help for Treatment of Kidney Failure.
Hope through Research
The NIDDK, through its Division of Kidney, Urologic, and
Hematologic Diseases, supports several programs and studies devoted to
improving treatment for patients with progressive kidney disease and
permanent kidney failure, including patients on hemodialysis.
- The End-Stage Renal Disease Program
promotes research to reduce medical problems from bone, blood, nervous
system, metabolic, gastrointestinal, cardiovascular, and endocrine
abnormalities in kidney failure and to improve the effectiveness of
dialysis and transplantation. The research focuses on evaluating
different hemodialysis schedules and on finding the most useful
information for measuring dialysis adequacy. The program also seeks to
increase kidney graft and patient survival and to maximize quality of
life.
- The HEMO Study, completed in 2002,
tested the theory that a higher dialysis dose and/or high-flux membranes
would reduce patient mortality (death) and morbidity (medical
problems). Doctors at 15 medical centers recruited more than 1,800
hemodialysis patients and randomly assigned them to high or standard
dialysis doses and high- or low-flux filters. The study found no
increase in the health or survival of patients who had a higher dialysis
dose, who dialyzed with high-flux filters, or who did both.
- The U.S. Renal Data System (USRDS)
collects, analyzes, and distributes information about the use of
dialysis and transplantation to treat kidney failure in the United
States. The USRDS is funded directly by the NIDDK in conjunction with
the Centers for Medicare & Medicaid Services. The USRDS publishes an
Annual Data Report
,
which identifies the total population of people being treated for
kidney failure; reports on incidence, prevalence, death rates, and
trends over time; and develops data on the effects of various treatment
approaches. The report also helps identify problems and opportunities
for more focused special studies of renal research issues.
- The Hemodialysis Vascular Access Clinical Trials Consortium
is conducting a series of multicenter, clinical trials of drug
therapies to reduce the failure and complication rate of arteriovenous
(AV) grafts and fistulas in hemodialysis. These studies are randomized
and placebo ontrolled, which means the studies meet the highest
standard for scientific accuracy. AV grafts and fistulas prepare the
arteries and veins for regular dialysis. See the NIDDK fact sheet Vascular Access for Hemodialysis for more information. Recently developed drugs to prevent blood clots may be evaluated in these large clinical trials.
Resources
Organizations That Can Help
American Association of Kidney Patients
3505 East Frontage Road
Suite 315
Tampa, FL 33607
Phone:
1–800–749–2257
Email:
info@aakp.org
Internet:
www.aakp.org
American Kidney Fund
6110 Executive Boulevard
Suite 1010
Rockville, MD 20852
Phone:
1–800–638–8299 or
301–881–3052
Email:
helpline@kidneyfund.org
Internet:
www.kidneyfund.org
Life Options Rehabilitation Program
c/o Medical Education Institute, Inc.
414 D'Onofrio Drive
Suite 200
Madison, WI 53719
Phone:
1–800–468–7777 or
608–232–2333
Email:
lifeoptions@MEIresearch.org
Internet:
www.lifeoptions.org
www.kidneyschool.org
National Kidney Foundation, Inc.
30 East 33rd Street
New York, NY 10016
Phone:
1–800–622–9010 or
212–889–2210
Internet:
www.kidney.org
Additional Reading
If you would like to learn more about kidney failure and its treatment, you may be interested in reading
AAKP Patient Plan
A series of booklets and newsletters that cover the different
phases of learning about kidney failure, choosing a treatment, and
adjusting to changes.
American Association of Kidney Patients
3505 East Frontage Road
Suite 315
Tampa, FL 33607
Phone:
1–800–749–2257
Email:
info@aakp.org
Internet:
www.aakp.org
Getting the Most From Your Treatment series
A series of brochures based on the National Kidney Foundation's
Dialysis Outcomes Quality Initiative (NKF-DOQI). Titles include
What
You Need to Know About Peritoneal Dialysis, What You Need to Know
Before Starting Dialysis, and What You Need to Know About Anemia.
Additional patient education brochures include information on diet, work, and exercise.
National Kidney Foundation, Inc.
30 East 33rd Street
New York, NY 10016
Phone:
1–800–622–9010 or
212–889–2210
Internet:
www.kidney.org
Medicare Coverage of Kidney Dialysis and Kidney Transplant Services
Publication Number CMS-10128
U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244–1850
Phone:
1–800–MEDICARE (
1–800–633–4227)
TDD:
1–877–486–2048
Internet:
www.medicare.gov/publications/pubs/pdf/10128.pdf PDF Version (717 KB)
*
Newsletters and Magazines
Family Focus Newsletter (published quarterly)
National Kidney Foundation, Inc.
30 East 33rd Street
New York, NY 10016
Phone:
1–800–622–9010 or
212–889–2210
Internet:
www.kidney.org
For Patients Only (published six times a year)
ATTN: Subscription Department
18 East 41st Street
20th Floor
New York, NY 10017–6222
Renalife (published quarterly)
American Association of Kidney Patients
3505 East Frontage Road
Suite 315
Tampa, FL 33607
Phone:
1–800–749–2257
Email:
info@aakp.org
Internet:
www.aakp.org
The U.S. Government does not endorse or favor any specific commercial product or company. Trade,
proprietary, or company names appearing in this document are used only because they are considered
necessary in the context of the information provided. If a product is not mentioned, the omission does not
mean or imply that the product is unsatisfactory.
Acknowledgments
The NIDDK thanks these dedicated health professionals for their careful review of the original version of this publication.
Richard A. Sherman, M.D.
Robert Wood Johnson Medical School
Richard D. Swartz, M.D.
University of Michigan Health System
Charlie Thomas, A.C.S.W., C.I.S.W.
Samaritan Transplant Services, Phoenix, AZ
The individuals listed here facilitated field testing for this publication. The NIDDK thanks them for their contribution.
Kim Bayer, M.A., R.D., L.D.
BMA Dialysis
Bethesda, MD
Cora Benedicto, R.N.
Clinic Director
Gambro Health Care
N Street Clinic
Washington, DC
