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When Does a Person Need Dialysis?

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Dialysis is the process of removing waste and excess fluid from the blood.  This process is typically handled by the kidney.  Patients who have suffered kidney damage or kidney failure lose some of this functionality.  A patient will typically need dialysis when waste products in the body become too high and they start to cause damage.  These waste products build up slowly and dialysis can help maintain safe levels.  There are several chemical levels in the blood that doctors measure to determine if you need dialysis.  Two of these are the blood urea nitrogen (BUN) level and the creatinine level.  When these levels rise, they indicate decreased functionality of the kidneys to clean waste products from the body.

Creatinine Clearance Test Shows When You Need Dialysis

Some doctors use a urine test called the “creatinine clearance” to measure kidney function.  A patient saves their urine in a container for a full day.  The waste products in the blood and urine are estimated by measuring the creatinine.  They are then compared to see how well the kidney is removing the wastes and depositing them into the urine.  Through this comparison doctors have a good idea of how well the kidneys are working.  The result is called the creatinine clearance.  When creatinine clearance falls below 10-12 cc/minute, the patient is not doing well and may need dialysis.

Calculating creatine clearance to see if patients need dialysis

The doctor uses other indicators of the patient’s status to decide about the need for dialysis. If the patient is experiencing a major inability to rid the body of excess water, or is complaining of problems with the heart, lungs, or stomach, or difficulties with taste or sensation in their legs, dialysis may be indicated even though the creatinine clearance has not fallen to the 10-12 cc/minute level.

What types of dialysis are there?

There are two main types of dialysis: “hemodialysis” and “peritoneal dialysis.” Hemodialysis uses a special type of filter to remove excess waste products and water from the body. Peritoneal dialysis uses a fluid that is placed into the patient’s stomach cavity through a special plastic tube to remove excess waste products and fluid from the body.

In Home Peritoneal Dialysis Treatment

In Home Peritoneal Dialysis Treatment
Photo by BAXTER CZECH

Peritoneal Dialysis

Peritoneal dialysis uses the patients own body tissues inside of the belly (abdominal cavity) to act as the filter. The intestines lie in the abdominal cavity, the space between the abdominal wall and the spine. A plastic tube called a “dialysis catheter” is placed through the abdominal wall into the abdominal cavity. A special fluid is then flushed into the abdominal cavity and washes around the intestines. The intestinal walls act as a filter between this fluid and the blood stream. By using different types of solutions, waste products and excess water can be removed from the body through this process.

Hemodialysis

During hemodialysis, blood passes from the patient’s body through a filter in the dialysis machine, called a “dialysis membrane.” For this procedure, the patient has a specialized plastic tube placed between an artery and a vein in the arm or leg (called a “gortex graft”). Sometimes, a direct connection is made between an artery and a vein in the arm. This procedure is called a “Cimino fistula.” Needles are then placed in the graft or fistula, and blood passes to the dialysis machine, through the filter, and back to the patient. In the dialysis machine, a solution on the other side of the filter receives the waste products from the patient.

Choices for Dialysis Patients at the End of Life

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When kidney dialysis was introduced in the 1940s it was originally intended as a life saving treatment.  It was mainly used for young patients with acute renal failure and helped them until their kidneys could function without the therapy.  Since then the use and frequency of dialysis has changed.  Today the average dialysis patient is 65 years old and is used as a maintenance treatment just as often as it is for acute episodes.

There are some medical professionals that believe dialysis is simply prolonging an inevitable conclusion of this patient population: death.  “Many of these patients don’t realize they are in the final phase of life because no one has talked forthrightly with them,” said Mildred Z. Solomon, EdD, president of The Hastings Center. A 2013 analysis published in the Journal of General Internal Medicine (2013;28:1511-1516) found that patients with end stage renal disease (ESRD) reported they did not know their medical prognosis and couldn’t recall being offered dialysis alternatives.  Another report in Medical Anthropology Quarterly (2005;24:297-324), found that of all the patients researchers spoke with at two Californian dialysis clinics, only 4 confirmed they initiated dialysis treatments by choice.

Give People a Choice, It Might Be Their Last Chance to Make One

There is a growing movement of physicians and bioethics organizations that believe such patients should be given more information about their illness and more choices about how they want to spend their final years alive.  “We haven’t had a grown-up conversation that this is a stage of life patients are in and death may not be that far away,” Dr. Solomon said. “People want to have that sort of conversation and are expecting it from their doctors, but physicians aren’t initiating it.”  Patients are surrounded by medical staff all the time, including nurses and dialysis technicians.  But these staff are not necessarily trained or equipped to have these types of conversations with patients.  It’s important that the primary physicians and specialists step up and take lead.

It’s a difficult job, but somebody has to be straightforward with patients and give them the choice of how they want to end their lives.  “Everything we know about patients suggests that most of them want to have the conversation,” said Lewis Cohen, MD, professor of psychology at Tufts School of Medicine in Boston. “And patients want doctors to be the ones to broach the subject.”  Dr. Cohen recommended the following guidelines for having such a conversation with ESRD patients:

  • Identify patient preferences. What kind of care do they want? Who should speak with them if they are unable to communicate?
  • Ascertain if the patient is even willing to hear about dialysis alternatives.
  • Ascertain what the patient already knows about their medical condition. Many patients want to get the issue of death out in the open and would rather have the discussion with medical professionals than family or friends.
  • Provide as much information to patients as possible.
  • Give the patient a specific estimate of prognosis.
  • Inquire about the patient’s goals and expectations of treatment.

Patients should hear about their options and receive thorough thoughtful recommendations from practitioners.  By exploring their thoughts, beliefs, ideas and expectations, you can help dialysis patients make the best choices for their unique situation.

What is Kidney Dialysis?

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The kidney is an organ in animal and human bodies that provides several regulatory functions. The main role of the kidney is to remove waste from the blood, which is then directed into the urinary system for disposal. When a person has kidney damage or failure, they may require kidney dialysis. Since the kidney can no longer remove the waste from the blood itself, kidney dialysis handles this process manually with the use of medical equipment.

How Does Kidney Dialysis Work?

A kidney dialysis machine is responsible for removing waste (diffusion) and excess water (ultrafiltration) from the blood. Because the kidney can no longer do this, a machine is used to filter the blood. A catheter is connected to the patient via a major vein, usually in the arm. The blood flows out of the patient, into the machine, and back into the patient in a different catheter. While the blood is in the dialysis machine, it is filtered so the waste and toxins do not accumulate in the patient’s body. It is estimated that the human kidney filters about 1,500 liters of blood every day. Without the kidney, the waste produced by the body would accumulate and result in death. Kidney dialysis is a life saving technology and requires the professional operation by a trained and certified dialysis technician.

How Often Do Patients Need Dialysis?

Every patient is different. The frequency a patient needs kidney dialysis is mainly determined by the health of the existing kidney. The more healthy the kidney, the less kidney dialysis is needed. The amount of fluid the patient acquired between dialysis treatments also directly affects how often treatment is required. The average frequency of kidney dialysis is 3-4 hours per week.

The Role of a Dialysis Technician

The kidney dialysis machine may seem simple, but it requires the proper knowledge to operate and maintain. Each body is different and requires that the dialysis machine filters the blood according to the needs of each patient. It is the responsibility of a trained dialysis technician to understand the patient’s needs and prepare the equipment properly. The dialysis technician is also responsible for monitoring the patient, before, during, and after dialysis to ensure no complications arise. This entails monitoring heart rate, blood pressure, respiration, etc.