What is dialysis?

The kidneys are responsible for filtering waste products from the blood. Dialysis is a
procedure that is a substitute for many of the normal duties of the kidneys. The kidneys
are two organs located on either side of the back of the abdominal cavity. Dialysis can
allow individuals to live productive and useful lives, even though their kidneys no longer
work adequately. In the United States, there are over 200,000 people who use dialysis
techniques on an ongoing basis.

Dialysis helps the body by performing the functions of failed kidneys. The kidney has
many roles. An essential job of the kidney is to regulate the body's fluid balance. It does
this by adjusting the amount of urine that is excreted on a daily basis. On hot days, the
body sweats more. Thus, less water needs to be excreted through the kidneys. On cold
days, the body sweats less. Thus, urine output needs to be greater in order to maintain the
proper balance within the body. It is the kidney's job to regulate fluid balance by
adjusting urine output.

Another major duty of the kidney is to remove the waste products that the body produces
throughout the day. As the body functions, the cells use energy. The operation of the cells
produces waste products that must be removed from the body. When these waste
products are not removed adequately, they build up in the body. An elevation of waste
products, as measured in the blood, is called "azotemia." When waste products
accumulate they, cause a sick feeling throughout the body called "uremia."

When do patients require dialysis?

Patients usually require dialysis when the waste products in their body become so high
that they start to become sick from them. The level of the waste products usually builds
up slowly. Doctors measure several blood chemical levels to help decide when dialysis is
necessary. The two major blood chemical levels that are measured are the "creatinine
level" and the "blood urea nitrogen" (BUN) level. As these two levels rise, they are
indicators of the decreasing ability of the kidneys to cleanse the body of waste products.

Doctors use a urine test, the "creatinine clearance," to measure the level of kidney
function. The patient saves urine in a special container for one full day. The waste
products in the urine and in the blood are estimated by measuring the creatinine. By
comparing the blood and urine level of this substance, the doctor has an accurate idea of
how well the kidneys are working. This result is called the creatinine clearance. Usually,
when the creatinine clearance falls to 10-12 cc/minute, the patient needs 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.

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.

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.

What does the patient do during dialysis?

Hemodialysis

Treatment for hemodialysis takes place in a hemodialysis unit. This is a special building
that is equipped with machines that perform the dialysis treatment. Special equipment
adds the proper materials to purified water for the dialysis machines. The dialysis unit is
also the place where patients can receive dietary counseling and help with social needs.

Patients generally go to the dialysis unit three times a week for treatment. For example,
the schedule is either Monday, Wednesday, and Friday or Tuesday, Thursday, and
Saturday. Before treatment, patients weigh themselves so that excess fluid accumulated
since the last dialysis session can be measured. Patients then go to assigned chairs that are
like lounge chairs. The area of the graft or fistula (the connection between the artery and
vein), is cleaned thoroughly. Two needles are then inserted into the graft or fistula. One
takes the blood to the machine where it is cleaned. The other needle allows blood that is
returning to the patient to go back into the patient's body.

Treatments last from 2 ½ to 4 ½ hours. During this time, the dialysis staff checks the
patient's blood pressure frequently and adjusts the dialysis machine to ensure that the
proper amount of fluid is being removed from the patients body. Patients can read, watch
television, sleep, or do other work during treatment.

Peritoneal Dialysis

Peritoneal dialysis requires the patient to play a more active role in their dialysis
treatment. Of primary importance is the patient's responsibility for maintaining a clean
surface on the abdomen, where treatment is administered, in order to prevent infection.

In this process, the patient weighs herself/himself to determine the fluid to be used. The
patient then puts on a mask and cleans the peritoneal catheter site. Fluid that has been
allowed to stay in the peritoneal cavity is drained back into the plastic bag that originally
contained the fluid. The patient then disconnects this bag and connects a new bag of
solution that is allowed to drain into the peritoneal cavity. Once the fluid is in the body,
the new bag is rolled up and placed in the patient's underwear until the next treatment.
This procedure usually takes 30 minutes to accomplish and must be done four to five
times a day.

As an alternative to this treatment, some patients on peritoneal dialysis use a machine

called a "cycler." This cycler is used every night. Five to six bags of dialysis fluid is used
on the cycler and the machine automatically changes the fluid while the patient sleeps.

What are the advantages of the different types of dialysis?

Each of the two types of dialysis, hemodialysis and peritoneal dialysis, has advantages
and disadvantages. It is up to the patient to decide which of these procedures is best by
considering her/his life style, other medical conditions, support systems, and how much
responsibility and participation in the treatment program he/she desires. Each patient
must view the two types of dialysis procedures from her/his own perspective.

Regardless of which type of dialysis is chosen , patients have certain responsibilities such
as following a diet program, watching their fluid intake and taking special vitamins and
other medicines to control blood pressure and calcium and phosphorus balance.

For many patients, the major advantage of hemodialysis is minimal participation in the
treatment. However, patients are required to adhere to a specific schedule and travel to
the dialysis unit. Hemodialysis also requires stricter diet control and fluid control than
peritoneal dialysis.

For those patients preferring more independence, peritoneal dialysis allows for more
flexible scheduling and can be performed at home. The patient still must undergo a
certain amount of dialysis each day, but can alter the exact timing of the dialysis
procedure. On the other hand, peritoneal dialysis must be done every day of the week.

The major problem with peritoneal dialysis is infection. The patient has a plastic tube that
goes from the peritoneal cavity to the outside of the body and this is a potential site for
the entry of bacteria into the body. Great emphasis is placed on cleanliness and technique
during the training sessions.

How can patients learn more about dialysis?

As a patient approaches dialysis, there are numerous sources of information. The doctor
often has access to training videos that explain the dialysis techniques and their
respective advantages and disadvantages.

Dialysis At A Glance

• Dialysis is a procedure that is a substitute for many of the normal duties of the
kidneys.
• Dialysis allows patients with kidney failure a chance to live productive lives.
• There are two types of dialysis: hemodialysis and peritoneal dialysis.
• Each type of dialysis has advantages and disadvantages. Patients can often choose
the type of long term dialysis that best matches their needs.