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Hemodialysis

You need dialysis if your kidneys no longer remove enough wastes and fluid from your blood to keep you healthy. This usually happens when you have only 10 to 15 percent of your kidney function left. You may have symptoms such as nausea, vomiting, swelling and fatigue. However, even if you don't have these symptoms yet, you can still have a high level of wastes in your blood that may be toxic to your body. Your doctor is the best person to tell you when you should start dialysis.

In hemodialysis, a dialysis machine and a special filter called an artificial kidney, or a dialyzer, are used to clean your blood. To get your blood into the dialyzer, the doctor needs to make an access, or entrance, into your blood vessels. This is done with minor surgery, usually to your arm.

The dialyzer, or filter, has two parts, one for your blood and one for a washing fluid called dialysate. A thin membrane separates these two parts. Blood cells, protein and other important things remain in your blood because they are too big to pass through the membrane. Smaller waste products in the blood, such as urea, creatinine, potassium and extra fluid pass through the membrane and are washed away.

Hemodialysis can be done in a hospital, in a dialysis center that is not part of a hospital or at home. You and your doctor will decide which place is best, based on your medical condition, and your wishes.

In a dialysis center, hemodialysis is usually done 3 times per week for about 4 hours at a time. People who choose to do hemodialysis at home may do dialysis treatment more frequently, 4-7 times per week for shorter hours each time.

Your doctor will give you a prescription that tells you how much treatment you need. Studies have shown that getting the right amount of dialysis improves your overall health, keeps you out of the hospital and enables you to live longer. Your dialysis care team will monitor your treatment with monthly lab tests to ensure you are getting the right amount of dialysis. One of the measures your dialysis care team may use is called urea reduction ratio (URR). Another measure is called Kt/V (pronounced kay tee over vee). Ask your dialysis care team what measure they use and what your number is. To ensure that you are getting enough dialysis:

  • your Kt/V should be at least 1.2 or

  • your URR should be at least 65 percent.

Possibly. Many patients have their hemodialysis treatments at home.

Yes. Generally speaking, patients on dialysis are advised to increase their protein intake and limit the amount of potassium, phosphorus, sodium, and fluid in their diet. Patients with diabetes or other health conditions may have additional diet restrictions. It's important to talk with you dietitian about your individual diet needs.

Your dialysis care team will monitor your treatment with monthly lab tests to ensure you get the right amount of dialysis and that you are meeting your dietary goals.

In some cases of sudden or acute kidney failure, dialysis may only be needed for a short time until the kidneys get better. However, when chronic kidney disease progresses to kidney failure over time, your kidneys do not get better and you will need dialysis for the rest of your life unless you are able to receive a kidney transplant.

When you begin hemodialysis, the needles put in your fistula or graft may be uncomfortable. Most patients get used to this in time. Your dialysis care team will make sure you are as comfortable as possible during your treatment. Symptoms like cramps, headaches, nausea or dizziness are not common, but if you do have any of them, ask your dialysis care team if any of the following steps could help you:

  • Slow down your fluid removal, which could increase your dialysis time.

  • Increase the amount of sodium in your dialysate.

  • Check your high blood pressure medications.

  • Adjust your dry weight, or target weight.

  • Cool the dialysate a little.

  • Use a special medication to help prevent low blood pressure during dialysis.

You can help yourself by following your diet and fluid allowances. The need to remove too much fluid during dialysis is one of the things that may make you feel uncomfortable during your treatment.

Dialysis is expensive. However, the federal government's Medicare program pays 80 percent of all dialysis costs for most patients. Private health insurance or state medical aid may also help with the costs.

Before you reuse your dialyzer, your dialysis center cleans it according to careful guidelines. If done properly, reuse is generally safe. Before each treatment, your dialyzer must be tested to make sure it is still working well. If your dialyzer no longer works well, it should be discarded and you should be given a new one. Ask your dialysis care team if they have tested your dialyzer and if it still works well.

If you do not wish to reuse your dialyzer, your center may be willing to provide you with a new dialyzer for each treatment. Ask about the center's policy on reuse.

Yes. Dialysis centers are located in every part of the United States and in many foreign countries.

Before you travel, you must make an appointment for dialysis treatments at another center. The staff at your center may be able to help you arrange this appointment.

Yes. Many dialysis patients continue to work or return to work after they have gotten used to dialysis. If your job has a lot of physical labor (heavy lifting, digging, etc.), you may need to change your duties.

The catheter used for hemodialysis is a tunneled catheter because it is placed under the skin. There are two types of tunneled catheters: cuffed or non-cuffed. Non-cuffed tunneled catheters are used for emergencies and for short periods (up to 3 weeks). Tunneled cuffed catheters, a type recommended by the NKF for temporary access, can be used for longer than 3 weeks when:

  • An AV fistula or graft has been placed but is not yet ready for use.

  • There are no other options for permanent access. For example, when a patient’s blood vessels are not strong enough for a fistula or graft.

Catheters have two openings inside; one is a red (arterial) opening to draw blood from your vein and out of your body into the dialysis pathway and the other is a blue (venous) opening that allows cleaned blood to return to your body.

By taking good care of your access, it will last longer and you will prevent problems such as infection and clotting. Here are some important steps to take:

  • Keep the catheter dressing clean and dry.

  • Make sure the area of the insertion site is clean and your care team changes the dressing at each dialysis session.

  • Keep an emergency dressing kit at home, in case you need to change your dressing in between treatments. Ask your dialysis care team to teach you how to change dressings in an emergency.

  • Never remove the cap on the end of your catheter. Air must not enter the catheter.

  • You can shower or bathe if you have a clear dressing that sticks to your catheter site and the skin around it. This type of dressing is recommended because it’s water proof, which helps prevent infection. And because it’s clear, you can see signs of infection. You should avoid letting the catheter or catheter site go under water during a bath. This would increase the chance of moisture getting near the catheter site, which can cause infection.

  • Wear a mask over your nose and mouth anytime the catheter is opened to prevent bacteria from entering the catheter and your bloodstream. Professionals changing the dressing should wear a mask and gloves as well.

  • The caps and the clamps of your catheter should be kept tightly closed when not being used for dialysis. Only your care team should use your dialysis catheter to draw blood or to give medications or fluids.

  • If the area around your catheter feels sore or looks red, call your dialysis care team at once. Ask your dialysis team about signs and symptoms that require immediate attention.

  • Know your Kt/V and URR (urea reduction ratio). Kt/V and URR are numbers that tell you how much dialysis you are getting. The NKF recommends using Kt/V. If you are receiving enough dialysis, your Kt/V should be at least 1.2. If URR is used, it should be 65 % or more. If your numbers are too low, one possible cause may be that your access is not working well. Ask your dialysis team to check your access.

Sometimes, even when you are very careful, your access may clot or become infected.

Clots can form inside the opening of the catheter or form on the outside of the catheter and block the opening. This can cause blood to flow at a slower rate than the rate your doctor ordered. If the blood flow rate remains low for more than one dialysis treatment, the catheter should be checked and treated the same day. Early treatment may prevent the clot from totally blocking the catheter. It is important to restore the recommended blood flow rate and treat clots that are forming so that your catheter continues to work well and you get the amount of dialysis you need.

Infection can also occur even with a good blood flow rate. It is important to follow your catheter care instructions, exactly as you were taught, in order to avoid infection. You should know the following signs and symptoms of a catheter infection and report them to your doctor or dialysis team right away, so you can get the proper treatment as quickly as possible. The signs and symptoms of a catheter infection include:

  • Fever

  • Chills

  • Drainage from the catheter exit site

  • Redness or tenderness around the catheter exit site

  • General feeling of weakness and illness

Treatment depends on the type of infection but may include:

  1. An ointment applied directly to the infected area if it is an exit site infection.
  2. Antibiotic medication if there is drainage from the exit site.
  3. An intravenous IV antibiotic (a solution containing an antibiotic that is administered directly into a vein) if the infection has spread to the blood.

A decrease in the blood flow rate ordered by your doctor is a sign the catheter is not working as it should. If this occurs for more than one treatment in a week, the catheter should be checked. The lower blood flow rate will cause you to receive less dialysis. You will then need a longer than usual hemodialysis treatment to get the proper amount of dialysis.

Another sign that your catheter is not working well may be the pre-pump arterial pressure alarms. These sounds notify the care team that your catheter (or other vascular access) is not allowing a free draw of blood. This can be a sign that a clot is forming in the catheter blocking the flow of blood.

Treatment is the administration of a “clot busting” medication called tissue plasminogen activator (tPA). Most dialysis centers can give the medication while you are in your dialysis chair, thus preventing a hospital visit. If you are at the end of your treatment, tPA can be given just before your next dialysis appointment. Ask your doctor how you can arrange to be given this medication before your next treatment session.

If the clot is not treated when signs and symptoms of an early clot are found, the catheter can progress to be fully clotted. You may then be required to visit the hospital or vascular lab to have the catheter checked and possibly exchanged for a completely new catheter.

Your healthcare provider injects the medication directly into the catheter opening. It needs to remain inside the catheter for 30 minutes to break down the clot. After 30 minutes if enough blood flow is not restored, the doctor can repeat the process.

  • By restoring your blood flow, hemodialysis can work as it should to remove the toxins and excess fluids from your body.

  • Taking care of the clot early results in fewer treatment interruptions and improved quality of life on dialysis.

  • Other benefits are the prevention of additional health problems and the chance to live longer on dialysis.

1. Learn as much as possible about your prescribed treatment plan: your blood flow rate, how often and how long you need treatments.

2. Follow the treatment plan

  • Stay for your full treatment time

  • Keep your dialysis appointments

  • Arrive on time for your hemodialysis treatments

3. Ask your doctor how much dialysis you should be getting. Keep a record of your Kt/V and URR numbers. Talk to your dialysis team if your numbers are not as good as they should be.

4. Share your concerns with your doctor and dialysis team. You may want to ask them the following questions:

  • How can I tell if my catheter is not working?

  • What is the flow rate my doctor ordered for me?

  • Why does the flow rate for my catheter need to be at this level?

  • If my flow rate should go down, when will I be given clot-dissolving medication?

  • Will the clot-dissolving medication interrupt my dialysis treatment? If so, what will happen to the rest of my treatment?

  • How will you put the clot dissolving medication in my catheter? How long do I have to wait for it to work?

  • What are the signs and symptoms of infection?

Because your kidneys are not able to get rid of enough waste products and fluids from your blood and your body now has special needs, you will need to limit fluids and change your intake of certain foods in your diet. How well you feel will depend on:

  • eating the right kind and amounts of food from your diet

  • having the hemodialysis treatments your doctor orders for you

  • taking the medications your doctor orders for you.

Your diet is very important to your care. It is important that you have the right amount of protein, calories, fluids, vitamins and minerals each day. Your dietitian will help you plan your meals to make sure you get the proper balance. Some general guidelines to follow can be found in our free brochure, "Nutrition and Hemodialysis." You can obtain a copy by calling 800 622-9010.

Because you are on dialysis, you have some very special needs. Eating well helps you stay healthy. Eating poorly can increase your risk of illness. Your dietitian will talk with you about how well you are eating.

Some questions you might be asked:

  • Have you noticed a change in the kind or amount of food you eat each day?

  • Have you had any problems eating your usual or recommended diet?

  • Have you lost weight without trying?

  • Have you noticed any changes in your strength or ability to take care of yourself?

Your dietitian or nurse might look at the fat and muscle stores in your face, hands, arms, shoulders, and legs. Your dialysis care team will look for changes in your blood level of proteins, and especially one called albumin. A change in this protein can mean that you are losing body protein.

Some special blood tests that are done each month are called Kt/V (pronounced kay tee over vee) or urea reduction ratio (URR). These tests help your doctor decide if you are getting enough dialysis. Getting the right amount of dialysis is important to help you feel your best.

A change in your fat and muscle stores or any of these blood tests could be a sign that you are not getting enough dialysis. Along with the Kt/V, these tests provide information about your intake of protein or your protein equivalent of nitrogen appearance (PNA). Using the PNA, your albumin and any changes in your appetite, your dietitian will determine if you are eating enough of the right foods. The right amount of dialysis is needed to make sure you are able to enjoy your food while keeping you healthy.

Changing your diet may help lower the cholesterol level in your blood. Your dietitian will talk with you about the kinds of fat and animal foods you eat. Also, your doctor may decide you need a special medication to reduce the cholesterol in your blood.

In some cases, you may need to make only a few changes in your diet to fit your needs as a kidney patient. For example, some of the free foods you have been using may need to be limited on your kidney diet. Your dietitian will help develop a meal plan especially for you.

The following important tips can be helpful with your diet:

  • Fresh or plain frozen vegetables contain no added salt. Drain all the cooking fluid before serving.

  • Canned fruits usually contain less potassium than fresh fruits. Drain all the fluid before serving.

  • Non-dairy creamers are low in phosphorus and can be used in place of milk.

  • Labels on food packages will give you information about some of the ingredients that may not be allowed in your diet. Learn to read these labels.

  • To help you avoid salt, many herbs and spices can be used to make your diet more interesting. Check with your dietitian for a list of these.