Friday, November 22, 2013

Kidney Dialysis

When people with diabetes experience kidney failure, they must undergo either dialysis or a kidney transplant. Almost 200,000 people in the United States are living with kidney failure as a result of diabetes.
Kidney dialysis diagram

Dialysis works well in the short run, but, it takes a toll on the person with diabetes -- physically and emotionally. Unfortunately, people with diabetes who receive transplants or dialysis experience higher morbidity and mortality because of coexisting complications of diabetes—such as damage to the heart, eyes, and nerves.

Dialysis is a treatment that removes wastes and excess fluid from your blood. Like healthy kidneys, dialysis keeps your body in balance. You do not need dialysis in the early stages of chronic kidney disease. If your kidneys start to fail, you will need a kidney transplant or dialysis to stay alive.

Your doctor will help you decide when to start dialysis, based on results of lab tests that measure how much kidney function you have left and on your symptoms.

Dialysis is done with a unique liquid called dialysate. This fluid is a combination of pure water and carefully measured chemicals. It removes wastes from your blood without taking out any of the substances you need to stay healthy.

A semi-permeable membrane (having minuscule holes allowing only specific types of particles to pass through) keeps your blood separate from the dialysate. This lets the wastes and fluid in your blood travel into the dialysate. Blood cells and proteins that you need cannot fit through the holes.

In hemodialysis, an artificial kidney (hemodialyzer) is used to remove waste and extra chemicals and fluid from your blood. Your doctor will make an access point into your blood vessels using minor surgery. This access point allows your blood to travel to the hemodialyzer for flushing. Sometimes access is created by joining an artery to a vein under your skin, making a bigger blood vessel or fistula.

If your blood vessels are not the right size for a fistula, the doctor may use a soft plastic tube to join an artery and a vein under your skin. This is called a graft.

Sometimes, access is made using a narrow plastic tube called a catheter, which is inserted into a large vein in your neck. Your blood is then cleaned and returned to your body. This type of treatment needs to be done several times a week and usually lasts about three to four hours.

In peritoneal dialysis, your blood is cleaned right inside your body. Your doctor surgically places a plastic tube called a catheter into your abdomen to create an access point. During your treatment, your abdominal area (or peritoneal cavity) is slowly filled with dialysate through the catheter. Your blood stays in the veins and arteries that line your peritoneal cavity while extra fluid and waste products are drawn out of your blood and into the dialysate. This is a daily form of dialysis, and can sometimes be preformed at your home.

Discussing with your doctor what dialysis option is the best for you will help you manage your chronic kidney disease and keep you feeling as well as possible.

Physical Side Effects of Dialysis and How to Prevent Them
Dialysis is a lifesaving treatment for those with end stage renal disease (ESRD). However, with both peritoneal dialysis (PD) and hemodialysis, there are occasions when a patient may have side effects from the treatment.

These side effects can be mild or severe, depending on the patient’s condition and whether or not they are following their dietary and fluid restrictions. Most of these side effects can be managed if the patient carefully follows their healthcare team’s recommendations regarding diet and fluid intake.

Side Effects of Peritoneal Dialysis (PD)
Infection. PD is a method of home dialysis. All three types of peritoneal dialysis—Continuous Ambulatory Peritoneal Dialysis (CAPD), Continuous Cycler-assisted Peritoneal Dialysis (CCPD) and Nocturnal Intermittent Peritoneal Dialysis (NIPD)—need a small rubber tube called a catheter. The catheter, a soft, straw-like tube is positioned both inside and outside of the body to allow dialysis solution into and out of the abdominal cavity. Exchanges (the process of filling, dwelling and draining dialysis solution) must be done carefully because there is a risk of infection from bacteria on the outside of the body.

The frequent handling of the catheter means greater risk for infection. Specifically, there is a chance of peritonitis, which is an infection of the peritoneum (where the catheter is placed in the abdomen.) This infection is the most common side effect of PD. Peritonitis can cause fever, nausea, vomiting and stomach pain. Patients may notice their dialysis solution looks cloudy. Treating peritonitis quickly is the key to stopping widespread infection. The doctor will likely prescribe antibiotics. 

Skin infections around the catheter insertion site are also common. If the area becomes red or inflamed, a visit to the doctor is recommended.

Preventing infection
To decrease the chance of infection, patients are advised to perform each exchange carefully. Exchange should be performed in a clean area. Keeping the catheter area clean and touching it with washed hands or sterile gloves can minimize the transfer of bacteria. Patients may also be advised to apply an antibiotic preparation at their catheter exit site to prevent infection.

Some patients have problems attaching or detaching the dialysis solution bag, which could put stress on the catheter, causing tiny tears that could allow in germs. If a patient has difficulties handling the bag, a renal nurse can provide tips on how to properly connect the bag to the catheter.

If a patient notices any sign of infection, it’s best to call the doctor immediately.

Hernias. A hernia is another potential side effect of PD. The muscles of the abdominal wall protect the internal organs and keep them in place. The insertion of a catheter can weaken these muscles. When patients do an exchange, the pressure from the dialysis solution in the peritoneum pushes against these already weak muscles. This pressure could cause a tear, and organs from the abdominal cavity could emerge through the opening.

Surgery is the only way to repair a hernia. Patients who have a history of hernias are advised not to exert themselves or participate in activities that could strain the abdominal muscles.

Eating Discomfort. Some PD patients find eating uncomfortable, because of the full feeling from the dialysis solution in their stomach area.  Although eating less feels better, it can lead to malnutrition.

The PD renal diet is designed to meet patients’ nutritional needs. If patients eat less, they may not get enough of the proteins and minerals that are important for good health. Timing exchanges (generally after meals) helps relieve some of the discomfort.

Bloating and weight gain. Bloating and weight gain are common complaints while on PD. Some of the weight gain is fluid bloat from the dialysis solution sitting in the peritoneum. The dialysis solution filters not only the toxins from the bloodstream, but also removes excess fluid. When the dialysis solution is drained, a patient will normally remove more fluid (dialysis solution plus the excess fluid filtered from the blood) than what was originally placed in the peritoneum.

Weight gain not associated with fluid bloat can come from the sugar in the dialysis solution being absorbed by the body. These extra calories could lead to extra pounds. Talking to a renal dietitian and nurse for some insight on how to balance nutritional needs and achieve comfort while on PD is advised.  

Side Effects of Hemodialysis
Low blood pressure. The most common side effect of hemodialysis is low blood pressure (also called hypotension). Low blood pressure occurs when too much fluid is removed from the blood during hemodialysis. This causes pressure to drop, and nausea and dizziness can result. Letting a dialysis team member know about these issue is highly recommended. The dialysis machine can be programmed so that the right amount of fluid is removed.

Medication for high blood pressure should usually not be taken before treatment, unless the doctor prescribes it that way. This could cause further drops in pressure and more discomfort. Watching and limiting fluid intake as recommended by the healthcare team may also prevent low pressure during treatments. Patients who drink more than what is advised usually need to have more fluid removed which can cause nausea and dizziness.

Muscle cramps. Patients sometimes experience muscle cramps while undergoing hemodialysis. These muscle cramps, usually in the legs, can be uncomfortable or sometimes painful. The exact cause of muscle cramps can vary from patient to patient. Sometimes when fluid is taken out of the body at a fast rate during dialysis or too much fluid is removed, the muscles react by cramping. A patient should alert a healthcare team member as soon as a cramp happens to get help in alleviating the discomfort. A doctor may be able to recommend some remedies if muscle cramps are making dialysis treatment uncomfortable.

Infection and clotting. Proper care for the access (either a fistula or a graft) is important in hemodialysis. The access can become infected or inflamed. Pressure on the access (from clothing or from sleeping on the side where the access is located) can cause the site to become irritated. Keeping the area clean can help prevent infection.

An access can become clotted with blood. Clotting prevents blood flow, so that a patient will not be able to get dialysis treatment. Patients are advised to monitor the access daily by checking for the thrill (the pulse feeling in the fistula or graft) to ensure it is working properly.

Itching. Many dialysis patients complain about itchy skin. There may be several causes, but it is commonly thought that high phosphorous levels are responsible for this side effect. Phosphorous is not effectively removed by dialysis. That’s why foods with phosphorus are restricted on the renal diet. Following the dietitian’s guidelines can help prevent this side effect. Remembering to take a phosphorus binder as prescribed (usually before every meal) is another way to help prevent or stop itching.

Dialysis patients are also prone to dry skin, which can be the cause of itching. Using very hot water for showers or baths can dry skin more. Harsh soaps can cause irritation and more itching. Moisturizing creams can alleviate some of the discomfort.

Sexual problems. Dialysis can affect a patient’s sex life. The sexual side effects can include loss of desire, erectile dysfunction and vaginal dryness. Loss of desire can be a psychological side effect. Patients on dialysis may deal with anxiety, depression and a change in self-image. These mental challenges can diminish the sex drive.

Hormone levels while on dialysis can also lead to a loss of desire, as well as physical side effects such as erectile dysfunction and vaginal dryness. Certain blood pressure medications can impair the ability to maintain an erection.

Other Health Problems Associated with Kidney Dialysis
Amyloidosis. Dialysis-related amyloidosis develops when proteins in blood are deposited on joints and tendons, causing pain, stiffness and fluid in the joints. The condition is more common in people who have undergone hemodialysis for more than five years.
Anemia. Not having enough red blood cells in your blood (anemia) is a common complication of kidney failure and hemodialysis. Failing kidneys reduce production of a hormone called erythropoietin, which stimulates formation of red blood cells. Diet restrictions, poor absorption of iron, frequent blood tests, or removal of iron and vitamins by hemodialysis also can contribute to anemia.

Bone diseases. If your damaged kidneys are no longer able to process vitamin D, which helps you absorb calcium, your bones may weaken. In addition, overproduction of parathyroid hormone — a common complication of kidney failure — can release calcium from your bones.
Fluid overload. Since fluid is removed from your body during hemodialysis, drinking more fluids than recommended between hemodialysis treatments may cause life-threatening complications, such as heart failure or fluid accumulation in your lungs (pulmonary edema).
High potassium levels (hyperkalemia). Potassium is a mineral that is normally removed from the body by the kidneys. If you eat more potassium than recommended, your potassium level may become too high. In severe cases, too much potassium can cause your heart to stop.
Inflammation of the membrane surrounding the heart (pericarditis). Insufficient hemodialysis can lead to inflammation of the membrane surrounding the heart, which can interfere with your heart's ability to pump blood to the rest of your body.
Sleep problems. People receiving hemodialysis often have trouble sleeping, sometimes because of breaks in breathing during sleep (sleep apnea) or because of aching, uncomfortable or restless legs.

Patients should talk to their social workers or doctors if they experience any of these problems.

Keep an open communication with the healthcare team. Let them know about any reactions to treatment so adjustments can be made. Side effects should not discourage a patient from continuing dialysis, especially since many of these side effects can be controlled.

Emotional Effects of Kidney Dialysis
Coping with kidney failure isn't just about managing the physical symptoms with treatment. It is a major life change that can cause a great deal of stress and can give rise to a range of emotional reactions:
  • Anxiety
  • Depression
  • Anger or a feeling of frustration about the illness
  • Sexual problems
Taking care of your emotional well-being is just as important as looking after your health. Please do not be afraid of discussing emotional or sexual problems with your healthcare team. They will be familiar with the kind of problems you may encounter and will be supportive. They may also be able to offer practical solutions to some of your difficulties.

Coming to Terms with  the Diagnosis
People who are diagnosed with kidney failure are confronted with a range of emotions. Different people react in different ways. Even so, there is a pattern to the way that most people react.

It may help to know about the emotional stages that patients may go through:
  • Shock: Often, newly diagnosed patients (and sometimes their family members) go into a state of shock. This is the feeling that life is going on around you but you are not really involved.
  • Grief: People may feel overwhelmed by grief and loss, as if they have been bereaved. They may feel helpless and have difficulty thinking clearly or dealing with day to day life.
  • Denial: It's common for people to decide, at this stage, that they "won't think about it." This denial that the disease exists is like a "defense mechanism" that can help patients escape from feeling overwhelmed until they are more able to cope.
  • Acceptance: Gradually, reality of kidney failure is acknowledged, and people begin to be able to think about the implications and the changes that need to be made. At this point of acceptance, they begin to adjust successfully to their condition.
One of the main causes of stress is change. All human beings find change stressful - even change that we are looking forward to, like moving house, raises our stress levels.

As a person with renal failure you will have to deal with more change than most people do. Not just the initial change of lifestyle that comes with the diagnosis, but ongoing change as you deal with alterations to your diet, medication and forms of treatment.

All these changes will mean you have to take in a great deal of new information, make decisions, learn new practical skills. You also have to adjust to new ways of doing things, to doing less than you would like to, and to asking for help... This is all extremely stressful - and it comes in addition to coping with the physical effects of kidney failure.

Different people react differently to stress - some get anxious or feel overwhelmed, others may get irritable or hostile, others may deny there is a problem and keep pushing themselves to "cope."

The best way of coping with stress is to recognize that it can be a problem in its own right and that if you are suffering from it, it is with good reason. Accept that you need to actively take time to "de-stress". There are many ways of doing so and they can all contribute to helping you cope with kidney failure.

There are a number of ways of dealing with stress:
  • Talking to someone who understands
  • Doing an activity that you enjoy
  • Relaxing, perhaps by listening to music
  • Doing some physical activity (within safe limits)
  • Take a short break, a day off or a vacation
This can be a specific "worry" related to something in particular, or a more general sense of "being on edge" or "not feeling safe."

Specific anxieties that renal patients may have include:
  • Worries about how the illness will affect your relationships,
  • Your ability to work,
  • Your finances
  • Your quality of life
  • You may also be anxious about understanding your condition or managing your treatment.
Ways of reducing anxiety include:
  • To see if there is something practical you could do to help you feel better. Make that appointment to see the doctor/dietitian/social worker/counsellor about what is worrying you. Ask a nurse about that part of the procedure you don't understand.There will of course be things that worry you that you can do nothing practical about. Most patients will say, however, that they find it helpful simply to talk about their worries to people who understand. Whether it's another patient, a nurse, a family member or a counselor, don't keep yourself alone with your anxiety.
  • Generalized anxiety is just as difficult to live with as anxiety that has an obvious cause.
  • Feeling generally "unsafe" may have something to do with a sense of "having no control" over your own body and life.
  • Many patients find that they can regain a sense of control by learning as much as they can about kidney failure and its treatment. Becoming an "expert" enables them to participate more actively in making decisions and to feel that they are working with the medical staff to control the condition rather than being passive.
  • Other people find that setting reasonable goals for themselves, such as going out, exercising, or keeping up certain activities - and achieving them - gives them a feeling of control.
Like anyone else, you will have times when you feel a bit down and less able to cope with life in general. You may also feel sad and "need a good cry" sometimes. If, however, the sadness turns into a real sense of despair that goes on for some time, this is depression.

You may feel depressed because you are having difficulty coming to terms with some of the changes their condition is imposing on you.

These changes might include:
  • The loss of your previous lifestyle
  • The loss of independence and self-confidence
  • The changes to your body and appearance
  • Difficulties with sex or with having children
  • Awareness of your own mortality
If you are feeling depressed it may help you feel less isolated if you talk to others who understand. This may be one of the renal unit nurses, the renal social worker, a counselor or even a good friend. Sometimes a short course of anti-depressant medication may be useful to get over these acute problems.

It seems quite appropriate for people who are going through these experiences to feel angry at times. It can even be energizing, sometimes, to feel angry.

Where problems arise, however, is if you get "locked into" your anger in a way which makes you unhappy and you can't seem to move through it into some degree of acceptance.

Anger is also a problem when it is expressed in destructive or self-destructive ways - when the feelings of anger and frustration lead to rebellion against diet and fluid restrictions, for example, or to aggressive behavior towards friends, relatives and staff. When people are angry, they may tend to "push away" the people who want to support them.

Anger expressed in these ways is self-destructive because it puts your health at risk, and - on an emotional level - leaves you feeling even more isolated.

It can feel like the hardest thing in the world to reach out for support when you are feeling angry. Paradoxically, it may be the one thing you can do to regain a real sense of power and control in your life. 

Sexual Problems
Some kidney patients never have sexual problems, but many do.
The reasons for these problems may include:
  • Hormonal problems: The hormones that control sexual urges may be too high or too low.
  • Medication: Some of the medication prescribed to renal patients may inhibit sexual desire.
  • Tiredness: This can be caused by anemia or by not having dialysis sufficiently.
  • Emotional factors: When people feel stressed, depressed or anxious, they often do not feel like having sex.
  • Relationship difficulties: The stress of kidney failure on a relationship may affect the couple's sex life.
Sexual problems in men
Impotence (the inability to get or maintain an erection) may be a problem in male kidney patients.

There are various approaches to treating impotence. Initially, doctors will look at possible causes such as anemia, under-dialysis and medication, and consider the treatments for them. There are physical treatments for impotence that can be considered including physical techniques and drugs.

Sexual problems in women
When women patients experience a lack of sexual desire or inability to have orgasms, causes related to anemia, under-dialysis and medication can be investigated.

There may be changes in the menstrual cycle and there is no doubt that the chances of getting pregnant if the kidneys have failed are much reduced. If kidney function is only mildly impaired and the blood pressure is under control before and during pregnancy, it is likely that pregnancy will progress as normal, but there will be a close liaison between the kidney doctor and the obstetrician. Some drugs particularly ACE inhibitors will need to stop before pregnancy and the blood pressure will be checked very carefully.

If you want to know more about the effects of kidney failure on pregnancy then speak to your doctor. And discuss any changes in your periods so that things can be checked out.

Kidney dialysis

Kidney dialysis

Kidney dialysis diagram

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