Dialysis Unzipped

Hemodialysis (HD)

What it is: Dialysis machine filters the blood and excess fluid for about 4hrs typically three days a week

What you should ask: What kind of port are they dialyzing through? Is it a catheter usually located around the collar bones or do they have an AV fistula?  What is their schedule for dialysis, since hemodialysis is 3 days a week, which days (MWF or TTHSat). Do you still make urine?

Pros/Cons: requires trained staff & site visit to complete, lots of fluid & diet restrictions, lots of heart strain, lower life expectancy, harder to travel

Peritoneal Dialysis (PD)

What it is: do this two ways, filtration nightly thru the patient’s own peritoneum, pt flushes dialysate fluid into their abdomen, lets it sit overnight and osmotically absorb the excess toxins, then pump out the fluid in the morning OR you can do it 5 times a day while awake without machine

What you should ask: What did your dialysate fluid look like? (Cloudy is bad, clear yellow serous fluid= okay), Did you bring your machine with you?

Pro/Con: not for morbidly obese, complex abd surgeries or noncompliant pt, longer life expectancy, more frequent sessions, better for travel, more patient responsibility

Expected Labs:

• Elevated BUN & Cr
• Hyperkalemia
• Hypoalbuminemia
• Elevated slight trop
• Anemia
• Hypocalcemia 
• Hyperphosphatemia
• HTN, sometimes hard to control – neprhology article

What dialysis sequelae do we need to know? 

• Fluid overload
• Hyperkalemia
• Thrombosed fistula
• Bleeding fistula
• SBP
• Chest Pain during or right after
• Hypotension after – esp if took lots of fluid off quickly
• Bleeding – with uremia

How bad is it when a patient misses dialysis?

All depends on how many toxins the patient has floating around in the blood. The three we are most likely to notice: 

• excess fluid, which can build up especially in third spaces and the lungs
• Potassium, which can build up and cause cardiac arrhythmias
• BUN, also known as “uremia” this can cause salty skin and AMS

A build up of any of these usually means admission and emergent dialysis. In most patients this takes 2-3 weeks without dialysis to build up to any symptomatic level. 

When does a patient get put on dialysis? 

• No hard and fast rule
• Typical guidelines-  GFR less 15-12, significant symptoms which can be earlier than 12 if have other comorbidities, repeated need for emergent dialysis

Indications for emergent dialysis

• -A  acidosis ph<7.1
• -E  electrolytes  K>6.5
• -I   Intoxication or Ingestion  (alcohols & toxic drugs like lithium)
• -O  overload, fluid   think extreme pulm edema
• -U  uremia (encephalopathy or pericarditis, etc)

What are new onset kidney failure symptoms?:

• Weakness/fatigue
• Muscle cramping
• XS or minimal urine output
• Foamy urine
• Leg or orbital edema
• N/V
• Chest pain
• Itching

About kidney transplants:

• lasts about 15 years 
• Average wait time for a transplant is 5 years
• Cellcept & tacrolimus r immune suppressing drugs to prevent rejection
• transplant surgeons don’t see their patients after the first year or two

CKD & Dialysis Statistics if you are interested.