Dialysis A comprehensive Guide

Dialysis – A comprehensive Guide

Reviewed by – Dr.S.Krishnan

Patients suffering from kidney failure either temporary or permanent may require Dialysis when the fluids and impurities build up in their blood. Let’s get to know more details about the Dialysis, types, advantages, precautions and side effects and more.

What are the kidney’s functions in our body?

Our body produces several wastes as a result of bodily activities which are termed scientifically as metabolic activities. The wastes produced in these processes are then released into the bloodstream and from there excreted through various excretory systems. The urinary system is one of the major excretory systems in the human body.

Urinary system or renal excretory system includes –

  • 1 pair kidney
  • 1 pair ureter
  • 1 urinary bladder
  • 1 urethra

In general, the impurities from the body are excreted in various ways. In our body kidneys play a key role in purifying the blood to remove excess fluids and wastes from the body. The entire system of filtering impurities and wastes from the blood through kidneys is called as a renal excretory system or in the simple terms urinary system.

In a healthy individual, the blood is filtered and the impurities are excreted out through urine. This process of filtering wastes happens at the level of tiny parts of the kidneys called nephrons which are termed as functional units of the kidney. Each kidney is composed of nearly a million numbers of nephrons which work as filtering units. The kidneys also play a role in balancing water level in the body.

What is Dialysis?

Dialysis is a treatment method in which the impurities from the blood are filtered using a machine instead of kidneys. The dialysis helps the patients with renal or kidney failure to manage electrolytes balance in their blood to extend life or can help until the patient could find a right donor.

According to the National Kidney Foundation when kidneys work at <15% of their normal function it is considered as end-stage kidney failure. Dialysis is the method used to purify the blood as a substitute when both kidneys fail to do their normal function.

Dialysis treatment is in practice since the 1940s helping the patients suffering kidney failure. Dialysis works as a substitute for the natural kidneys function in the body. This is also called as Renal Replacement Therapy or RRT.

Who needs a Dialysis?

Kidneys help to maintain normal levels of Creatinine in the blood. Creatinine levels are used as a marker. There are several other parameters to gauge the severity of renal failure – viz. Blood pressure, Anemia, Calcium, Phosphorus, electrolytes, and fluid status. If the kidneys are failed for some reason or not working properly then the Creatinine levels are more in the blood.

Patients suffering from kidney failure may require Dialysis when the fluids and impurities build up in their blood. Generally, an individual whose kidneys are failed nearly 85 to 90% would require a Dialysis. They may further face multiple other related issues if not addressed. The main causes behind kidney failure and need for Dialysis are high blood pressure and diabetes.

Related Article

Diabetes means the body does not produce adequate insulin or use it properly. Nowadays in India, the percentage of diabetes cases are increasing day by day. Diabetes may also be one of the major cause of the kidney failure. Read more about tips to manage Diabetes in a natural way.

When the impurities build up in the blood due to failed kidneys, the patient may experience sickness. The doctor specialized in the kidneys are called nephrologist. A nephrologist comes to a decision of suggesting a Dialysis treatment to the patient based on some tests that determine the level of impurities in the blood. The two main chemical levels in the blood that help to diagnose the failed kidneys are –

  • Creatinine level
  • Blood Urea Nitrogen (BUN) level

Creatinine level

The nephrologist estimates the kidney function by Creatinine Clearance to measure the kidney function levels. Creatinine Clearance is the calculation about how much Creatinine is cleared from the body by kidneys. By comparing the Creatinine level in the blood and urine the doctor would come to the judgment about the functioning of kidneys. In general, the patient needs dialysis if the Creatinine levels reach 10.0 mg/dL.

In general, the Creatinine clearance is measured in two methods. One is by using a formula and the second one is by collecting a sample of 24 hours old urine and latest blood sample. Once the Creatinine levels in both samples are obtained, they are compared.

Normal Creatinine levels in the blood are –

  • Adult Male – 0.6 to 1.2 mg/dl
  • Adult Female – 0.5 to 1.1 mg/dl
  • Normal Level in a person with only one kidney functioning – 1.8 to 1.9 mg/dl

Normal Creatinine clearance for healthy men and women are as –

  • Female – 88-128 mL/min
  • Male – 97-137 mL/min

Blood Urea Nitrogen (BUN) level

Blood Urea Nitrogen (BUN) level is used as the next indicator of estimating kidney failure. Urea also gets accumulated in the blood that gets created in the body as a result of metabolic activities in the body. Doctors may use BUN to Creatinine ratio to calculate more precisely.

Symptoms of kidney failure

Symptoms of kidney failure are not at all felt in some individuals, and the may come to know about the elevated creatinine levels in some regular exercise of normal blood checkup. But symptoms may be seen in some individuals depending on the key cause of the problem. Symptoms may be are like –

  • Fatigue
  • Swelling in some body parts (best example is puffed eyes)
  • Breath shortness
  • Dehydration
  • Confusion

Advantages of Dialysis

In patients suffering from kidney failure or non-functioning kidneys at a normal level, the dialysis benefits to –

  • Remove excess salts, water and wastes from the blood to balance the levels of these substances in the body.
  • Maintain the healthy balance of chemicals that are essential for body functions and which if exceeded in quantity may cause harm to the body.
  • Help to control High Blood Pressure.

Does a patient need Dialysis for a lifetime?

It depends on the patient’s condition and the nephrologist would be helpful to arrive at a decision. In general, if the kidneys fail to function due to some acute kidney health issues which could be treated, in such cases the dialysis may be needed for the duration until the kidneys restore their normal functioning.

But if the kidney failure is chronic or at an end stage, the patient may need lifetime treatment of dialysis until he gets a donor for a kidney transplant.

What are the types of Dialysis?

Dialysis treatment is available in two different types based on the availability, patient condition, and cost. They are –

  • Intermittent Hemodialysis (IHD)
  • Peritoneal Dialysis (PD)

Let’s check these two methods in detail.

Intermittent Hemodialysis

This type of Dialysis is the most used one. The word “hemo” means blood. As the name says Hemodialysis means filtering impurities and excess water from the blood. In this method, the blood from the patient’s body is allowed to pass through an external machine that has a special kind of filters that helps to purify the impure blood.

The blood is allowed to come out from the body through a flexible surgical tube called a catheter. Then the blood is allowed to pass into the external filter that works as a substitute for kidneys and the filtered blood is then sent back into the body through another catheter. Before undergoing this treatment method, the patient needs to undergo a small surgical procedure to make the arrangement so that there is a direct access to the bloodstream to aid the treatment. This is done in 3 different options based on the need and choice and condition of the patient.

  • Fistula – Arteriovenous fistula or A-V Fistula
  • Graft – Arteriovenous graft or A-V Graft
  • Catheter – Central Venous Catheter

Fistula or Arteriovenous fistula or A-V fistula

It is an arrangement made for Hemodialysis. The artery and vein in the patient’s arm are joined to form a fistula. This would serve as a point of access for injecting catheters for pulling out the impure blood and passing it again after filtration into the patient’s body. After this minor surgery, the wound heals in around 6 weeks after which the patient can take up Hemodialysis process. In short, it is also called as A-V Fistula.

Graft or Arteriovenous Graft or A-V Graft

Unlike in the A-V fistula, an artery and a vein under the skin in the patient’s arm are joined to form a graft by using a plastic tube. In simple words, it is like joining the two blood vessels with help of an artificial tube. This takes lesser time to heal compared to A-V fistula. It heals in a span of 2 weeks but may not last for long durations like fistula. The patient might need another graft after a few years. Chances of infections are more in graft compared to fistula and need frequent regular visits to the doctor to make sure the graft is healthy to serve the need.

Catheter or Central Venous Catheter

This method is used when the patient has to take the Hemodialysis session as earliest as possible. A temporary plastic tube or catheter is inserted in the vein at the neck region below the collarbone of the patient. It can also be done in the groin region.

Process of Hemodialysis session

The patient would generally lie down or sit back. The medical professional who is handling the treatment would insert two catheters with help of needles at the point of access that is a fistula or a graft. First, the pump in the machine starts to draw out the blood from the patient’s body, next the blood passes through a filter called dialyzer which works as an external artificial kidney where the actual filtering of the impure blood happens. The excess salts, water, and impurities from the blood are filtered and the purified blood is sent back into the patient’s body through the second catheter inserted at the point of access, i.e. the fistula or the graft in the arm.

Hemodialysis is conducted generally 3 times in a week and for a period of 4 to 5 hours every alternate day. Hemodialysis is generally done at a special dialysis center or in a hospital or at home.

Peritoneal Dialysis

Hemodialysis works by removing the impurities directly from the blood but the method of Peritoneal Dialysis works by basic science mechanisms called diffusion and osmosis. In this procedure, a Dialysis solution or Dialysate is used to pull out the impurities from the blood into it by using the method of diffusion. Excess water in the blood is eliminated by using the osmosis method. The pressure required for osmosis is generated as the Dialysate contains pure water added with salts and electrolytes.

Peritoneal dialysis procedure uses the natural filtering ability of the peritoneum to filter waste products from the blood. The peritoneum is the internal lining of the abdomen.

In simple terms, the Dialysis solution is placed in Peritoneum for some period to collect or absorb wastes and then discharged out through a tube. This procedure has to be repeated for several times in a day based on the patient’s condition as directed by the doctor. This method is also done at night times while the patient sleeps using an automated mechanism.

The advantage of Peritoneal Dialysis is that it is more flexible for the patient to use, needs fewer visits to hospitals, and can be done by self-help. But the drawback is that it is not so accurate at filtering compared to the Hemodialysis.

Before going to start this treatment process, the patient has to undergo a minor surgery to get fixed with a catheter into the abdomen which is kept open only while using and at rest of the time been kept closed.

Peritoneal Dialysis may benefit patients who find the regular Hemodialysis method uncomfortable, for example, patients like infants, kids, elders. It can even be done during traveling. Peritoneal Dialysis is further of 2 different types based on the method like automation or manual. They are –

  • CAPD – Continuous ambulatory peritoneal dialysis
  • CCPD – Continuous cyclic peritoneal dialysis

Continuous ambulatory peritoneal dialysis

This method is a manual method which needs no machine. The patient or the attendant or caregiver can do the job manually. The Dialysis solution or the Dialysate is allowed to be there in the abdominal cavity for some time likely around for 8 hours and replaced with a fresh solution manually. This process is carried out 4 to 5 times every day.

Continuous cyclic peritoneal dialysis

Machinery is used in this method to carry out the exchange process of Dialysis solution. Hence also called Automated Peritoneal Dialysis. Automated PD is carried out when the patient is asleep.

CRRT – Continuous renal replacement therapy

While the other methods come under the intermittent type of dialysis, this method is done continuously without breaks, hence termed as continuous renal replacement therapy. This is generally conducted in ICU (intensive care unit) round the clock. Further, these are of different types. Chances of complications are less in this method.

Dialysis can be temporary in some cases like –

  • If the patient is suffering from an acute kidneys problem
  • If the patient consumed any toxic items or drugs overdose
  • In some chronic heart conditions
  • If any trauma or injury happened to the kidneys

This type of Dialysis treatment may be required for the shorter duration until the kidneys restore to normal conditions.

Dialysis in India

It is estimated that every year, nearly 2 lakh new individuals in India are suffered from an advanced stage of kidney failure. But the actual number of patients that are getting the proper dialysis treatment is only 1 lakh. Currently, the demand for the dialysis in India is growing at a rate 31% whereas it is only at a rate of 6% to 8% in developed countries from the rest of the world. The major reason being diabetes and hypertension or high BP are two key factors that trigger the kidney failure.

Dialysis in India is not so much affordable for a common middle-class individual even though the cost of dialysis in India is very low compared to other developed countries. The patient suffering from a kidney failure that needs hemodialysis has to scarify three half-days in a week and 12 sessions in a month.

According to Indian Renal Foundation, each hemodialysis session would cost approximately ranging from 12,000 to 15,000 INR. And for peritoneal dialysis, it would cost around 18,000 to 20,000 INR. If the patient is going for a kidney transplant, that would cost approximately 4 lakhs which would be a huge financial burden for a common man, in addition, it would be emotionally more challenging for the patient’s family members too to pass through such critical stage. Typically such unexpected expenses may make them financially weak if they have to bear all the incurred costs from their pocket.

Fortunately, there are some health insurance policies in India that cover for kidney failure conditions that require a regular dialysis. The types of policies are called critical illness policies that cover several other chronic conditions including kidney failure requiring a dialysis. Some examples of policy providers in India are –

  • TATA AIG – CritiCare
  • Bajaj Allianz – Critical Illness
  • Max Bupa – Critical Insurance
  • Bharti AXA – Critical Illness Insurance
  • HDFC Ergo – Critical Illness

Source: https://www.policybazaar.com/health-insurance/critical-illness-insurance/articles/critical-illness-policies-which-cover-dialysis/

As there are majorly two types of dialysis treatments, most commonly known and people are aware of in India is hemodialysis, the insurance policies are covering currently only for the hemodialysis but not for the other alternative type of dialysis known as peritoneal dialysis.

If the patient has to choose the Peritoneal Dialysis over the Hemodialysis, he has to afford the entire costs incurred in the treatment from his pocket. This may be the major cause behind the fact that patients and doctors also tend to incline more towards the hemodialysis over the peritoneal dialysis.

What are the possible side effects of Dialysis?

The most common possible side effects of the Dialysis are the patient may feel like –

  • Low Blood Pressure
  • Nausea
  • Vomiting
  • Skin irritations
  • Muscle cramps
  • Fatigue
  • Fever with chills
  • Chest pain
  • Back pain
  • Headache

Precautions to take while you are under Dialysis therapy

The Dialysis process should be comfortable enough for the patient. Inform the caregiver or doctor if you suffer any discomfort while taking the therapy. Making changes in the diet could help to reduce the possible side effects. Your doctor would suggest the best balance of water, protein, and salts that you should consume. Stay away from the food item or habits that would be hard for your kidneys such as smoking or alcohol and the drugs that impact the kidneys.

Make sure the graft on your arm stays healthy. Keep it clean and infection free. Consult your doctor if you notice any infection or problem at the graft area on the arm. Maintain the bandage that covers the graft clean and dry. Make sure the caregiver also wash their hands properly to be sterile while treating you at the session.

Dialysis is an alternative to the kidney’s function in patients suffering from kidney failure or any temporary trauma. Patients must be careful in their food habits sometimes along with some medication if needed.

In women the renal failure may impact fertility and conceiving may be difficult compared to the normal individual as the high rate of impurities in the body due to failed kidneys may impact on the fertility. Compared to women, men have less effect on the fertility. If the women who are under Dialysis is pregnant or becomes pregnant, she might need an increased session of dialysis.

Can the patient stop taking the Dialysis therapy?

The Dialysis therapy is expected to maintain or improve the current quality of life. But if the patient or their family wants to discontinue the treatment, should consult the doctor to discuss the advantages and the disadvantages of stopping the treatment in middle and other alternative treatment options available for the patient’s condition. If needed the doctor may suggest a take a medical counseling session to overcome any hesitations or depression as it is quite common in some patients that they may feel depressed to take the long process of Dialysis therapy.

About Dr. S Krishnan: 

Dr. S Krishnan has over 22 years of experience as a Paediatric Nephrologist and Nephrologist/Renal specialist. He is associated with several reputed institutions including the Apollo Hospitals in Secunderabad, Nephroplus and Geetha Multi-Speciality Hospital in West Maredpally. More information about his profile is available here.

Do you have any question about Dialysis or wish to get any information? Drop a message for Dr. S Krishnan below.

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