Hemodialysis: Navigation Search

Hemodialysis
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Hemodialysis in progress
Hemodialysis machine
In medicine, hemodialysis (also haemodialysis) is a method for removing waste

products such as creatinine and urea, as well as free water from the blood when the
kidneys are in renal failure. Hemodialysis is one of three renal replacement therapies (the
other two being renal transplant; peritoneal dialysis).
Hemodialysis can be an outpatient or inpatient therapy. Routine hemodialysis is

conducted in a dialysis outpatient facility, either a purpose built room in a hospital or a
dedicated, stand alone clinic. Less frequently hemodialysis is done at home. Dialysis
treatments in a clinic are initiated and managed by specialized staff made up of nurses
and technicians; dialysis treatments at home can be self initiated and managed or done
jointly with the assistance of a trained helper who is usually a family member.[1]
Contents
[hide]
1 Principle
2 History
3 Prescription
4 Side effects and complications
5 Access
o 5.1 Catheter
o 5.2 AV fistula
o 5.3 AV graft
o 5.4 Fistula First project
6 Types
o 6.1 Conventional hemodialysis
o 6.2 Daily hemodialysis
o 6.3 Nocturnal hemodialysis
7 Advantages and disadvantages
o 7.1 Advantages
o 7.2 Disadvantages
8 Equipment
o 8.1 Water system
o 8.2 Dialyzer
9 Membrane and flux
o 9.1 Membrane flux and outcome
o 9.2 Membrane flux and beta-2-microglobulin amyloidosis
o 9.3 Dialyzer size and efficiency
o 9.4 Reuse of dialyzers
10 Nursing cares for hemodialysis patient
11 See also
12 References
13 External links
[edit] Principle
Semipermeable membrane
The principle of hemodialysis is the same as other methods of dialysis; it involves
diffusion of solutes across a semipermeable membrane. Hemodialysis utilizes counter
current flow, where the dialysate is flowing in the opposite direction to blood flow in the
extracorporeal circuit. Counter-current flow maintains the concentration gradient across
the membrane at a maximum and increases the efficiency of the dialysis.
Fluid removal (ultrafiltration) is achieved by altering the hydrostatic pressure of the

dialysate compartment, causing free water and some dissolved solutes to move across the
membrane along a created pressure gradient.
The dialysis solution that is used is a sterilized solution of mineral ions. Urea and other
waste products, potassium, and phosphate diffuse into the dialysis solution. However,
concentrations of sodium and chloride are similar to those of normal plasma to prevent
loss. Sodium bicarbonate is added in a higher concentration than plasma to correct blood
acidity. A small amount of glucose is also commonly used.
Note that this is a different process to the related technique of hemofiltration.
[edit] History
Many have played a role in developing dialysis as a practical treatment for renal failure,
starting with Thomas Graham of Glasgow, who first presented the principles of solute
transport across a semipermeable membrane in 1854.[2] The artificial kidney was first
developed by Abel, Rountree and Turner in 1913,[3], the first hemodialysis in a human
being was by Hass (February 28, 1924)[4] and the artificial kidney was developed into a
clinically useful apparatus by Kolff in 1943 - 1945.[5] This research showed that life could
be prolonged in patients dying of renal failure.
Dr. Willem Kolff was the first to construct a working dialyzer in 1943. The first
successfully treated patient was a 67-year-old woman in uremic coma who regained
consciousness after 11 hours of hemodialysis with Kolffs dialyzer in 1945. At the time of
its creation, Kolffs goal was to provide life support during recovery from acute renal
failure. After World War II ended, Kolff donated the five dialyzers he had made to
hospitals around the world, including Mount Sinai Hospital, New York. Kolff gave a set
of blueprints for his hemodialysis machine to George Thorn at the Peter Bent Brigham
Hospital in Boston. This led to the manufacture of the next generation of Kolffs dialyzer,
a stainless steel Kolff-Brigham dialysis machine.
By the 1950s, Willem Kolffs invention of the dialyzer was used for acute renal failure,
but it was not seen as a viable treatment for patients with stage 5 chronic kidney disease
(CKD). At the time, doctors believed it was impossible for patients to have dialysis
indefinitely for two reasons. First, they thought no man-made device could replace the
function of kidneys over the long term. In addition, a patient undergoing dialysis suffered
from damaged veins and arteries, so that after several treatments, it became difficult to
find a vessel to access the patients blood.
Dr. Nils Alwall: The original Kolff kidney was not very useful clinically, because it did
not allow for removal of excess fluid. Dr. Nils Alwall [6] encased a modified version of
this kidney inside a stainless steel canister, to which a negative pressure could be applied,
in this way effecting the first truly practical application of hemodialysis, which was done
in 1946 at the University of Lund. Alwall also was arguably the inventor of the
arteriovenous shunt for dialysis. He reported this first in 1948 where he used such an
arteriovenous shunt in rabbits. Subsequently he used such shunts, made of glass, as well
as his canister-enclosed dialyzer, to treat 1500 patients in renal failure between 1946 and
1960, as reported to the First International Congress of Nephrology held in Evian in
September 1960. Alwall was appointed to a newly-created Chair of Nephrology at the
University of Lund in 1957. Subsequently, he collaborated with Swedish businessman
Holger Crafoord to found one of the key companies that would manufacture dialysis
equipment in the past 50 years, Gambro. The early history of dialysis has been reviewed
by Stanley Shaldon [7].
Dr. Belding H. Scribner working with a surgeon, Dr. Wayne Quinton, modified the glass
shunts used by Alwall by making them from Teflon. Another key improvement was to
connect them to a short piece of silicone elastomer tubing. This formed the basis of the
so-called Scribner shunt, perhaps more properly called the Quinton-Scribner shunt. After
treatment, the circulatory access would be kept open by connecting the two tubes outside
the body using a small U-shaped Teflon tube, which would shunt the blood from the tube
in the artery back to the tube in the vein [8].
In 1962, Scribner started the worlds first outpatient dialysis facility, the Seattle Artificial
Kidney Center, later renamed the Northwest Kidney Centers. Immediately the problem
arose of who should be given dialysis, since demand far exceeded the capacity of the six
dialysis machines at the center. Scribner decided that the decision about who would
receive dialysis and who wouldnt, would not be made by him. Instead, the choices would
be made by an anonymous committee, which could be viewed as one of the first bioethics
committees.
For a detailed history of successful and unsuccessful attempts at dialysis, including

pioneers such as Abel and Roundtree, Haas, and Necheles, see this review by Kjellstrand
[9]
.
[edit] Prescription
A prescription for dialysis by a nephrologist (a medical kidney specialist) will specify
various parameters for a dialysis treatment. These include frequency (how many
treatments per week), length of each treatment, and the blood and dialysis solution flow
rates, as well as the size of the dialyzer. The composition of the dialysis solution is also
sometimes adjusted in terms of its sodium and potassium and bicarbonate levels. In
general, the larger the body size of an individual, the more dialysis he/she will need. In
the North America and UK, 3-4 hour treatments (sometimes up to 5 hours for larger
patients) given 3 times a week are typical. Twice-a-week sessions are limited to patients
who have a substantial residual kidney function. Four sessions per week are often
prescribed for larger patients, as well as patients who have trouble with fluid overload.
Finally, there is growing interest in short daily home hemodialysis, which is 1.5 - 4 hr
sessions given 5-7 times per week, usually at home. There also is interest in nocturnal
dialysis, which involves dialyzing a patient, usually at home, for 810 hours per night, 3-
6 nights per week. Nocturnal in-center dialysis, 3-4 times per week is also offered at a
handful of dialysis units in the United States.
[edit] Side effects and complications

Hemodialysis often involves fluid removal (through ultrafiltration), because most patients
with renal failure pass little or no urine. Side effects caused by removing too much fluid
and/or removing fluid too rapidly include low blood pressure, fatigue, chest pains, leg-
cramps, nausea and headaches. These symptoms can occur during the treatment and can
persist post treatment; they are sometimes collectively referred to as the dialysis hangover
or dialysis washout. The severity of these symptoms is usually proportionate to the
amount and speed of fluid removal. However, the impact of a given amount or rate of
fluid removal can vary greatly from person to person and day to day. These side effects
can be avoided and/or their severity lessened by limiting fluid intake between treatments
or increasing the dose of dialysis e.g. dialyzing more often or longer per treatment than
the standard three times a week, 34 hours per treatment schedule.
Since hemodialysis requires access to the circulatory system, patients undergoing

hemodialysis may expose their circulatory system to microbes, which can lead to sepsis,
an infection affecting the heart valves (endocarditis) or an infection affecting the bones
(osteomyelitis). The risk of infection varies depending on the type of access used (see
below). Bleeding may also occur, again the risk varies depending on the type of access
used. Infections can be minimized by strictly adhering to infection control best practices.
Heparin is the most commonly used anticoagulant in hemodialysis, as it is generally well

tolerated and can be quickly reversed with protamine sulfate. Heparin allergy can
infrequently be a problem and can cause a low platelet count. In such patients, alternative
anticoagulants can be used. In patients at high risk of bleeding, dialysis can be done
without anticoagulation.
First Use Syndrome is a rare but severe anaphylactic reaction to the artificial kidney. Its
symptoms include sneezing, wheezing, shortness of breath, back pain, chest pain, or
sudden death. It can be caused by residual sterilant in the artificial kidney or the material
of the membrane itself. In recent years, the incidence of First Use Syndrome has
decreased, due to an increased use of gamma irradiation, steam sterilization, or electron-
beam radiation instead of chemical sterilants, and the development of new semipermeable
membranes of higher biocompatibility. New methods of processing previously acceptable
components of dialysis must always been considered. For example, in 2008, a series of
first-use type or reactions, including deaths occurred due to heparin contaminated during
the manufacturing process with oversulfated chondroitin sulfate. [10]
Longterm complications of hemodialysis include amyloidosis, neuropathy and various
forms of heart disease. Increasing the frequency and length of treatments have been
shown to improve fluid overload and enlargement of the heart that is commonly seen in
such patients.[11][12]
Listed below are specific complications associated with different types of hemodialysis
access.
[edit] Access
In hemodialysis, three primary methods are used to gain access to the blood: an
intravenous catheter, an arteriovenous (AV) fistula and a synthetic graft. The type of
access is influenced by factors such as the expected time course of a patient's renal failure
and the condition of his or her vasculature. Patients may have multiple accesses, usually
because an AV fistula or graft is maturing and a catheter is still being used. The creation
of All these three major types of vascular accesses requires surgery.[13]
[edit] Catheter
Catheter access, sometimes called a CVC (Central Venous Catheter), consists of a plastic
catheter with two lumens (or occasionally two separate catheters) which is inserted into a
large vein (usually the vena cava, via the internal jugular vein or the femoral vein) to
allow large flows of blood to be withdrawn from one lumen, to enter the dialysis circuit,
and to be returned via the other lumen. However, blood flow is almost always less than
that of a well functioning fistula or graft.
Catheters are usually found in two general varieties, tunnelled and non-tunnelled.
Non-tunnelled catheter access is for short-term access (up to about 10 days, but often for
one dialysis session only), and the catheter emerges from the skin at the site of entry into
the vein.
Tunnelled catheter access involves a longer catheter, which is tunnelled under the skin
from the point of insertion in the vein to an exit site some distance away. It is usually
placed in the internal jugular vein in the neck and the exit site is usually on the chest wall.
The tunnel acts as a barrier to invading microbes, and as such, tunnelled catheters are
designed for short- to medium-term access (weeks to months only), because infection is
still a frequent problem.
Aside from infection, venous stenosis is another serious problem with catheter access.
The catheter is a foreign body in the vein and often provokes an inflammatory reaction in
the vein wall. This results in scarring and narrowing of the vein, often to the point of
occlusion. This can cause problems with severe venous congestion in the area drained by
the vein and may also render the vein, and the veins drained by it, useless for creating a
fistula or graft at a later date. Patients on long-term hemodialysis can literally 'run out' of
access, so this can be a fatal problem.
Catheter access is usually used for rapid access for immediate dialysis, for tunnelled
access in patients who are deemed likely to recover from acute renal failure, and for
patients with end-stage renal failure who are either waiting for alternative access to
mature or who are unable to have alternative access.
Catheter access is often popular with patients, because attachment to the dialysis machine
doesn't require needles. However, the serious risks of catheter access noted above mean
that such access should be contemplated only as a long-term solution in the most
desperate access situation.
[edit] AV fistula
A radiocephalic fistula.
AV (arteriovenous) fistulas are recognized as the preferred access method. To create a

fistula, a vascular surgeon joins an artery and a vein together through anastomosis. Since
this bypasses the capillaries, blood flows rapidly through the fistula. One can feel this by
placing one's finger over a mature fistula. This is called feeling for "thrill" and produces a
distinct 'buzzing' feeling over the fistula. One can also listen through a stethoscope for the
sound of the blood "whooshing" through the fistula, a sound called bruit.
Fistulas are usually created in the nondominant arm and may be situated on the hand (the
'snuffbox' fistula'), the forearm (usually a radiocephalic fistula, or so-called Brescia-
Cimino fistula, in which the radial artery is anastomosed to the cephalic vein), or the
elbow (usually a brachiocephalic fistula, where the brachial artery is anastomosed to the
cephalic vein). A fistula will take a number of weeks to mature, on average perhaps 46
weeks. During treatment, two needles are inserted into the fistula, one to draw blood and
one to return it.
The advantages of the AV fistula use are lower infection rates, because no foreign
material is involved in their formation, higher blood flow rates (which translates to more
effective dialysis), and a lower incidence of thrombosis. The complications are few, but if
a fistula has a very high blood flow and the vasculature that supplies the rest of the limb
is poor, a steal syndrome can occur, where blood entering the limb is drawn into the
fistula and returned to the general circulation without entering the limb's capillaries. This
results in cold extremities of that limb, cramping pains, and, if severe, tissue damage.
One long-term complication of an AV fistula can be the development of an aneurysm, a
bulging in the wall of the vein where it is weakened by the repeated insertion of needles
over time. To a large extent the risk of developing an aneurysm can be reduced by careful
needling technique. Aneurysms may necessitate corrective surgery and may shorten the
useful life of a fistula. To prevent damage to the fistula and aneurysm or pseudoaneurysm
formation, it is recommended that the needle be inserted at different points in a rotating
fashion. Another approach is to cannulate the fistula with a blunted needle, in exactly the
same place. This is called a 'buttonhole' approach. Often two or three buttonhole places
are available on a given fistula. This also can prolong fistula life and help prevent damage
to the fistula.
[edit] AV graft
An arteriovenous graft.
AV (arteriovenous) grafts are much like fistulas in most respects, except that an artificial
vessel is used to join the artery and vein. The graft usually is made of a synthetic
material, often PTFE, but sometimes chemically treated, sterilized veins from animals are
used. Grafts are inserted when the patient's native vasculature does not permit a fistula.
They mature faster than fistulas, and may be ready for use several weeks after formation
(some newer grafts may be used even sooner). However, AV grafts are at high risk to
develop narrowing, especially in the vein just downstream from where the graft has been
sewn to the vein. Narrowing often leads to clotting or thrombosis. As foreign material,
they are at greater risk for becoming infected. More options for sites to place a graft are
available, because the graft can be made quite long. Thus a graft can be placed in the
thigh or even the neck (the 'necklace graft').
[edit] Fistula First project
AV fistulas have a much better access patency and survival than do venous catheters or
grafts. They also produce better patient survival and have far fewer complications
compared to grafts or venous catheters. For this reason, the Centers for Medicare &
Medicaid (CMS) has set up a Fistula First Initiative [14], whose goal is to increase the use
of AV fistulas in dialysis patients.
[edit] Types
There are three types of hemodialysis: conventional hemodialysis, daily hemodialysis,
and nocturnal hemodialysis. Below is the adaption and summary from a brochure of The
Ottawa Hospital.
[edit] Conventional hemodialysis
The procedure of conventional hemodialysis are: patients attached to a dialysis machine;

the function of a dialysis machine is to push blood to circulate through the patients body
and machine, at the same time, monitor temperature, blood pressure and time of the
procedure; if patient is using fistula or graft, two huge-gate needles on patients side: one
brings wastes- full blood from patients body to the dialyzer, while another needle carries
clean blood back to the body; it is offered three times a week and 3 or 4 hours per
session. Patients are required to follow their rigid schedule.
[edit] Daily hemodialysis
The procedure of daily hemodialysis is similar to the conventional hemodialysis except it

is performed six days a week and about 2 hours per session.
[edit] Nocturnal hemodialysis
the procedure of nocturnal hemodialysis is similar to conventional hemodialysis except it

is performed six nights a week and six-ten hours per session while the patient sleeps.[15]
[edit] Advantages and disadvantages

[edit] Advantages
Low mortality rate

Better control of blood pressure and abdominal cramps
Less diet restriction
Better solute clearance effect for the daily hemodialysis: better tolerance and
fewer complications with more frequent dialysis [16]
[edit] Disadvantages
Restricts independence, as people undergoing this procedure cannot travel around

because of supplies availability
Requires reliable technology such as high water quality and electricity
Requires more supplies like dialysis machines
The procedure is complicated and requires that care givers have more knowledge
Requires time to set up and clean dialysis machines, and expense with machines
and associated staff[17]
[edit] Equipment
Schematic of a hemodialysis circuit
The hemodialysis machine pumps the patient's blood and the dialysate through the
dialyzer. The newest dialysis machines on the market are highly computerized and
continuously monitor an array of safety-critical parameters, including blood and dialysate
flow rates; dialysis solution conductivity, temperature, and pH; and analysis of the
dialysate for evidence of blood leakage or presence of air. Any reading that is out of
normal range triggers an audible alarm to alert the patient-care technician who is
monitoring the patient. Manufacturers of dialysis machines include companies such as
Fresenius, Gambro, Baxter, B. Braun, NxStage and Bellco.
[edit] Water system
A hemodialysis unit's dialysate solution tanks
An extensive water purification system is absolutely critical for hemodialysis. Since

dialysis patients are exposed to vast quantities of water, which is mixed with dialysate
concentrate to form the dialysate, even trace mineral contaminants or bacterial endotoxins
can filter into the patient's blood. Because the damaged kidneys cannot perform their
intended function of removing impurities, ions introduced into the bloodstream via water
can build up to hazardous levels, causing numerous symptoms or death. Aluminum,
chloramine, fluoride, copper, and zinc, as well as bacterial fragments and endotoxins,
have all caused problems in this regard.
For this reason, water used in hemodialysis is carefully purified before use. Initially it is
filtered and temperature-adjusted and its pH is corrected by adding an acid or base. Then
it is softened. Next the water is run through a tank containing activated charcoal to adsorb
organic contaminants. Primary purification is then done by forcing water through a
membrane with very tiny pores, a so-called reverse osmosis membrane. This lets the
water pass, but holds back even very small solutes such as electrolytes. Final removal of
leftover electrolytes is done by passing the water through a tank with ion-exchange
resins, which remove any leftover anions or cations and replace them with hydroxyl and
hydrogen molecules, respectively, leaving ultrapure water.
Even this degree of water purification may be insufficient. The trend lately is to pass this
final purified water (after mixing with dialysate concentrate) through a dialyzer
membrane. This provides another layer of protection by removing impurities, especially
those of bacterial origin, that may have accumulated in the water after its passage through
the original water purification system.
Once purified water is mixed with dialysate concentrate, its conductivity increases, since
water that contains charged ions conducts electricity. During dialysis, the conductivity of
dialysis solution is continuously monitored to ensure that the water and dialysate
concentrate are being mixed in the proper proportions. Both excessively concentrated
dialysis solution and excessively dilute solution can cause severe clinical problems.
[edit] Dialyzer
The dialyzer is the piece of equipment that actually filters the blood. Almost all dialyzers
in use today are of the hollow-fiber variety. A cylindrical bundle of hollow fibers, whose
walls are composed of semi-permeable membrane, is anchored at each end into potting
compound (a sort of glue). This assembly is then put into a clear plastic cylindrical shell
with four openings. One opening or blood port at each end of the cylinder communicates
with each end of the bundle of hollow fibers. This forms the "blood compartment" of the
dialyzer. Two other ports are cut into the side of the cylinder. These communicate with
the space around the hollow fibers, the "dialysate compartment." Blood is pumped via the
blood ports through this bundle of very thin capillary-like tubes, and the dialysate is
pumped through the space surrounding the fibers. Pressure gradients are applied when
necessary to move fluid from the blood to the dialysate compartment.
[edit] Membrane and flux

Dialyzer membranes come with different pore sizes. Those with smaller pore size are
called "low-flux" and those with larger pore sizes are called "high-flux." Some larger
molecules, such as beta-2-microglobulin, are not removed at all with low-flux dialyzers;
lately, the trend has been to use high-flux dialyzers. However, such dialyzers require
newer dialysis machines and high-quality dialysis solution to control the rate of fluid
removal properly and to prevent backflow of dialysis solution impurities into the patient
through the membrane.
Dialyzer membranes used to be made primarily of cellulose (derived from cotton linter).
The surface of such membranes was not very biocompatible, because exposed hydroxyl
groups would activate complement in the blood passing by the membrane. Therefore, the
basic, "unsubstituted" cellulose membrane was modified. One change was to cover these
hydroxyl groups with acetate groups (cellulose acetate); another was to mix in some
compounds that would inhibit complement activation at the membrane surface (modified
cellulose). The original "unsubstituted cellulose" membranes are no longer in wide use,
whereas cellulose acetate and modified cellulose dialyzers are still used. Cellulosic
membranes can be made in either low-flux or high-flux configuration, depending on their
pore size.
Another group of membranes is made from synthetic materials, using polymers such as
polyarylethersulfone, polyamide, polyvinylpyrrolidone, polycarbonate, and
polyacrylonitrile. These synthetic membranes activate complement to a lesser degree than
unsubstituted cellulose membranes. Synthetic membranes can be made in either low- or
high-flux configuration, but most are high-flux.
Nanotechnology is being used in some of the most recent high-flux membranes to create
a uniform pore size. The goal of high-flux membranes is to pass relatively large
molecules such as beta-2-microglobulin (MW 11,600 daltons), but not to pass albumin
(MW ~66,400 daltons). Every membrane has pores in a range of sizes. As pore size
increases, some high-flux dialyzers begin to let albumin pass out of the blood into the
dialysate. This is thought to be undesirable, although one school of thought holds that
removing some albumin may be beneficial in terms of removing protein-bound uremic
toxins.
[edit] Membrane flux and outcome
Whether using a high-flux dialyzer improves patient outcomes is somewhat controversial,

but several important studies have suggested that it has clinical benefits. The NIH-funded
HEMO trial compared survival and hospitalizations in patients randomized to dialysis
with either low-flux or high-flux membranes. Although the primary outcome (all-cause
mortality) did not reach statistical significance in the group randomized to use high-flux
membranes, several secondary outcomes were better in the high-flux group [18][19]. A
recent Cochrane analysis concluded that benefit of membrane choice on outcomes has not
yet been demonstrated [20]. A collaborative randomized trial from Europe, the MPO
(Membrane Permeabilities Outcomes) study, [21] comparing mortality in patients just
starting dialysis using either high-flux or low-flux membranes, found a nonsignificant
trend to improved survival in those using high-flux membranes, and a survival benefit in
patients with lower serum albumin levels or in diabetics.
[edit] Membrane flux and beta-2-microglobulin amyloidosis
High-flux dialysis membranes and/or intermittent on-line hemodiafiltration (IHDF) may

also be beneficial in reducing complications of beta-2-microglobulin accumulation.
Because beta-2-microglobulin is a large molecule, with a molecular weight of about
11,600 daltons, it does not pass at all through low-flux dialysis membranes. Beta-2-M is
removed with high-flux dialysis, but is removed even more efficiently with IHDF. After
several years (usually at least 5-7), patients on hemodialysis begin to develop
complications from beta-2-M accumulation, including carpal tunnel syndrome, bone
cysts, and deposits of this amyloid in joints and other tissues. Beta-2-M amyloidosis can
cause very serious complications, including a spondylarthropathy, and often is associated
with shoulder joint problems. Observational studies from Europe and Japan have
suggested that using high-flux membranes in dialysis mode, or IHDF, reduces beta-2-M
complications in comparison to regular dialysis using a low-flux membrane. [22][23][24][25][26]
[edit] Dialyzer size and efficiency
Dialyzers come in many different sizes. A larger dialyzer with a larger membrane area
(A) will usually remove more solutes than a smaller dialyzer, especially at high blood
flow rates. This also depends on the membrane permeability coefficient K0 for the solute
in question. So dialyzer efficiency is usually expressed as the K0A - the product of
permeability coefficient and area. Most dialyzers have membrane surface areas of 0.8 to
2.2 square meters, and values of K0A ranging from about 500 to 1500 mL/min. K0A,
expressed in mL/min, can be thought of as the maximum clearance of a dialyzer at very
high blood and dialysate flow rates.
[edit] Reuse of dialyzers

The dialyzer may either be discarded after each treatment or be reused. Reuse requires an
extensive procedure of high-level disinfection. Reused dialyzers are not shared between
patients. There was an initial controversy about whether reusing dialyzers worsened
patient outcomes. The consensus today is that reuse of dialyzers, done carefully and
properly, produces similar outcomes to single use of dialyzers [27].
[edit] Nursing cares for hemodialysis patient

Adapt from nephrology nursing practice recommendations developed by Canadian
Association of Nephrology and Technology (CANNT) based on best available evidence
and clinical practice guidelines, a nephrology nurse should perform [28]:
Hemodialysis Vascular Access: Assess the fistula/graft and arm before, after each
dialysis or every shift: the access flow, complications Assess the complication of central
venous catheter: the tip placement, exit site, complications document and notify
appropriate health care provider regarding any concerns. educates the patient with
appropriate cleaning of fistula/graft and exit site; with recognizing and reporting signs
and symptoms of infection and complication.
Hemodialysis adequacy: Assesses patient constantly for signs and symptoms of

inadequate dialysis. Assesses possible causes of inadequate dialysis. Educations patients
the importance of receiving adequate dialysis.
Hemodialysis treatment and complications: Performs head to toe physical assessment

before, during and after hemodialysis regarding complications and accesss security.
Confirm and deliver dialysis prescription after review most update lab results. Address
any concerns of the patient and educate patient when recognizing the learning gap.
Medication management and infection control practice: Collaborate with the patient to
develop a medication regimen. Follow infection control guidelines as per unit protocol.
[edit] See also

Dialysis
Dialysis disequilibrium syndrome
Home hemodialysis
Peritoneal dialysis
Hemofiltration
Extracorporeal therapies
Renal replacement therapy
Step-by-step description of hemodialysis
Treatment Methods for Kidney Failure:
Hemodialysis
On this page:
When Your Kidneys Fail

How Hemodialysis Works
Adjusting to Changes
Getting Your Vascular Access Ready
Equipment and Procedures
Tests to See How Well Your Dialysis Is Working
Conditions Related to Kidney Failure and Their Treatments
How Diet Can Help
Financial Issues
Hope through Research
Resources
Acknowledgments
Hemodialysis is the most common method used to treat advanced and permanent kidney
failure. Since the 1960s, when hemodialysis first became a practical treatment for kidney
failure, weve learned much about how to make hemodialysis treatments more effective
and minimize side effects. In recent years, more compact and simpler dialysis machines
have made home dialysis increasingly attractive. But even with better procedures and
equipment, hemodialysis is still a complicated and inconvenient therapy that requires a
coordinated effort from your whole health care team, including your nephrologist,
dialysis nurse, dialysis technician, dietitian, and social worker. The most important
members of your health care team are you and your family. By learning about your
treatment, you can work with your health care team to give yourself the best possible
results, and you can lead a full, active life.
[Top]
Healthy kidneys clean your blood by removing excess fluid, minerals, and wastes. They
also make hormones that keep your bones strong and your blood healthy. When your
kidneys fail, harmful wastes build up in your body, your blood pressure may rise, and
your body may retain excess fluid and not make enough red blood cells. When this
happens, you need treatment to replace the work of your failed kidneys.
[Top]
In hemodialysis, your blood is allowed to flow, a few ounces at a time, through a special
filter that removes wastes and extra fluids. The clean blood is then returned to your body.
Removing the harmful wastes and extra salt and fluids helps control your blood pressure
and keep the proper balance of chemicals like potassium and sodium in your body.
One of the biggest adjustments you must make when you start hemodialysis treatments is
following a strict schedule. Most patients go to a clinica dialysis centerthree times a
week for 3 to 5 or more hours each visit. For example, you may be on a Monday-
Wednesday-Friday schedule or a Tuesday-Thursday-Saturday schedule. You may be
asked to choose a morning, afternoon, or evening shift, depending on availability and
capacity at the dialysis unit. Your dialysis center will explain your options for scheduling
regular treatments.
Researchers are exploring whether shorter daily sessions, or longer sessions performed
overnight while the patient sleeps, are more effective in removing wastes. Newer dialysis
machines make these alternatives more practical with home dialysis. But the Federal
Government has not yet established a policy to pay for more than three hemodialysis
sessions a week.
Hemodialysis.
Several centers around the country teach people how to perform their own hemodialysis
treatments at home. A family member or friend who will be your helper must also take
the training, which usually takes at least 4 to 6 weeks. Home dialysis gives you more
flexibility in your dialysis schedule. With home hemodialysis, the time for each session
and the number of sessions per week may vary, but you must maintain a regular schedule
by giving yourself dialysis treatments as often as you would receive them in a dialysis
unit.
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Even in the best situations, adjusting to the effects of kidney failure and the time you
spend on dialysis can be difficult. Aside from the lost time, you may have less energy.
You may need to make changes in your work or home life, giving up some activities and
responsibilities. Keeping the same schedule you kept when your kidneys were working
can be very difficult now that your kidneys have failed. Accepting this new reality can be
very hard on you and your family. A counselor or social worker can answer your
questions and help you cope.
Many patients feel depressed when starting dialysis, or after several months of treatment.
If you feel depressed, you should talk with your social worker, nurse, or doctor because
this is a common problem that can often be treated effectively.
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Arteriovenous fistula. One important step before starting hemodialysis is preparing a

vascular access, a site on your body from which your blood is removed and returned. A
vascular access should be prepared weeks or months before you start dialysis. It will
allow easier and more efficient removal and replacement of your blood with fewer
complications. For more information about the different kinds of vascular accesses and
how to care for them, see the National Institute of Diabetes and Digestive and Kidney
Diseases (NIDDK) fact sheet Vascular Access for Hemodialysis.
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When you first visit a hemodialysis center, it may seem like a complicated mix of
machines and people. But once you learn how the procedure works and become familiar
with the equipment, youll be more comfortable.
Graft.
Dialysis Machine
The dialysis machine is about the size of a dishwasher. This machine has three main jobs:
pump blood and watch flow for safety

clean wastes from blood
watch your blood pressure and the rate of fluid removal from your body
Dialyzer
Structure of a typical hollow fiber dialyzer. The dialyzer is a large canister containing
thousands of small fibers through which your blood is passed. Dialysis solution, the
cleansing fluid, is pumped around these fibers. The fibers allow wastes and extra fluids to
pass from your blood into the solution, which carries them away. The dialyzer is
sometimes called an artificial kidney.
Reuse. Your dialysis center may use the same dialyzer more than once for your
treatments. Reuse is considered safe as long as the dialyzer is cleaned before each
use. The dialyzer is tested each time to make sure its still working, and it should
never be used for anyone but you. Before each session, you should be sure that
the dialyzer is labeled with your name and check to see that it has been cleaned,
disinfected, and tested.
Dialysis Solution
Dialysis solution, also known as dialysate, is the fluid in the dialyzer that helps remove
wastes and extra fluid from your blood. It contains chemicals that make it act like a
sponge. Your doctor will give you a specific dialysis solution for your treatments. This
formula can be adjusted based on how well you handle the treatments and on your blood
tests.
Needles
Many people find the needle sticks to be one of the hardest parts of hemodialysis
treatments. Most people, however, report getting used to them after a few sessions. If you
find the needle insertion painful, an anesthetic cream or spray can be applied to the skin.
The cream or spray will numb your skin briefly so you wont feel the needle.
Most dialysis centers use two needlesone to carry blood to the dialyzer and one to
return the cleaned blood to your body. Some specialized needles are designed with two
openings for two-way flow of blood, but these needles are less efficient and require
longer sessions. Needles for high-flux or high-efficiency dialysis need to be a little larger
than those used with regular dialyzers.
Arterial and venous needles.
Some people prefer to insert their own needles. Youll need training on inserting needles
properly to prevent infection and protect your vascular access. You may also learn a
ladder strategy for needle placement in which you climb up the entire length of the
access session by session so that you dont weaken an area with a grouping of needle
sticks. A different approach is the buttonhole strategy in which you use a limited
number of sites but insert the needle back into the same hole made by the previous needle
stick. Whether you insert your own needles or not, you should know these techniques to
better care for your access.
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About once a month, your dialysis care team will test your blood by using one of two
formulasURR or Kt/Vto see whether your treatments are removing enough wastes.
Both tests look at one specific waste product, called blood urea nitrogen (BUN), as an
indicator for the overall level of waste products in your system. For more information
about these measurements, see the NIDDK fact sheet Hemodialysis Dose and Adequacy.
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Your kidneys do much more than remove wastes and extra fluid. They also make
hormones and balance chemicals in your system. When your kidneys stop working, you
may have problems with anemia and conditions that affect your bones, nerves, and skin.
Some of the more common conditions caused by kidney failure are extreme tiredness,
bone problems, joint problems, itching, and restless legs. Restless legs will keep you
awake as you feel them twitching and jumping.
Anemia and Erythropoietin (EPO)
Anemia is a condition in which the volume of red blood cells is low. Red blood cells
carry oxygen to cells throughout the body. Without oxygen, cells cant use the energy
from food, so someone with anemia may tire easily and look pale. Anemia can also
contribute to heart problems.
Anemia is common in people with kidney disease because the kidneys produce the
hormone erythropoietin, or EPO, which stimulates the bone marrow to produce red blood
cells. Diseased kidneys often dont make enough EPO, and so the bone marrow makes
fewer red blood cells. EPO is available commercially and is commonly given to patients
on dialysis.
For more information about the causes of and treatments for anemia in kidney failure, see
the NIDDK fact sheet Anemia in Kidney Disease and Dialysis.
Renal Osteodystrophy
The term renal describes things related to the kidneys. Renal osteodystrophy, or bone
disease of kidney failure, affects 90 percent of dialysis patients. It causes bones to
become thin and weak or formed incorrectly and affects both children and adults.
Symptoms can be seen in growing children with kidney disease even before they start
dialysis. Older patients and women who have gone through menopause are at greater risk
for this disease.
For more information about the causes of this bone disease and its treatment in dialysis
patients, see the NIDDK fact sheet Renal Osteodystrophy.
Itching (Pruritus)
Many people treated with hemodialysis complain of itchy skin, which is often worse
during or just after treatment. Itching is common even in people who dont have kidney
disease; in kidney failure, however, itching can be made worse by wastes in the
bloodstream that current dialyzer membranes cant remove from the blood.
The problem can also be related to high levels of parathyroid hormone (PTH). Some
people have found dramatic relief after having their parathyroid glands removed. The
four parathyroid glands sit on the outer surface of the thyroid gland, which is located on
the windpipe in the base of your neck, just above the collarbone. The parathyroid glands
help control the levels of calcium and phosphorus in the blood.
But a cure for itching that works for everyone has not been found. Phosphate binders
seem to help some people; these medications act like sponges to soak up, or bind,
phosphorus while it is in the stomach. Others find relief after exposure to ultraviolet light.
Still others improve with EPO shots. A few antihistamines (Benadryl, Atarax, Vistaril)
have been found to help; also, capsaicin cream applied to the skin may relieve itching by
deadening nerve impulses. In any case, taking care of dry skin is important. Applying
creams with lanolin or camphor may help.
Sleep Disorders
Patients on dialysis often have insomnia, and some people have a specific problem called
the sleep apnea syndrome, which is often signaled by snoring and breaks in snoring.
Episodes of apnea are actually breaks in breathing during sleep. Over time, these sleep
disturbances can lead to day-night reversal (insomnia at night, sleepiness during the
day), headache, depression, and decreased alertness. The apnea may be related to the
effects of advanced kidney failure on the control of breathing. Treatments that work with
people who have sleep apnea, whether they have kidney failure or not, include losing
weight, changing sleeping position, and wearing a mask that gently pumps air
continuously into the nose (nasal continuous positive airway pressure, or CPAP).
Many people on dialysis have trouble sleeping at night because of aching, uncomfortable,
jittery, or restless legs. You may feel a strong impulse to kick or thrash your legs.
Kicking may occur during sleep and disturb a bed partner throughout the night. The
causes of restless legs may include nerve damage or chemical imbalances.
Moderate exercise during the day may help, but exercising a few hours before bedtime
can make it worse. People with restless leg syndrome should reduce or avoid caffeine,
alcohol, and tobacco; some people also find relief with massages or warm baths. A class
of drugs called benzodiazepines, often used to treat insomnia or anxiety, may help as
well. These prescription drugs include Klonopin, Librium, Valium, and Halcion. A newer
and sometimes more effective therapy is levodopa (Sinemet), a drug used to treat
Parkinsons disease.
Sleep disorders may seem unimportant, but they can impair your quality of life. Dont
hesitate to raise these problems with your nurse, doctor, or social worker.
Amyloidosis
Dialysis-related amyloidosis (DRA) is common in people who have been on dialysis for
more than 5 years. DRA develops when proteins in the blood deposit on joints and
tendons, causing pain, stiffness, and fluid in the joints, as is the case with arthritis.
Working kidneys filter out these proteins, but dialysis filters are not as effective. For
more information, see the NIDDK fact sheet Amyloidosis and Kidney Disease.
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How Diet Can Help
Eating the right foods can help improve your dialysis and your health. Your clinic has a
dietitian to help you plan meals. Follow the dietitians advice closely to get the most from
your hemodialysis treatments. Here are a few general guidelines.
Fluids. Your dietitian will help you determine how much fluid to drink each day.
Extra fluid can raise your blood pressure, make your heart work harder, and
increase the stress of dialysis treatments. Remember that many foodssuch as
soup, ice cream, and fruitscontain plenty of water. Ask your dietitian for tips on
controlling your thirst.
Potassium. The mineral potassium is found in many foods, especially fruits and
vegetables. Potassium affects how steadily your heart beats, so eating foods with
too much of it can be very dangerous to your heart. To control potassium levels in
your blood, avoid foods like oranges, bananas, tomatoes, potatoes, and dried
fruits. You can remove some of the potassium from potatoes and other vegetables
by peeling and soaking them in a large container of water for several hours, then
cooking them in fresh water.
You can remove some potassium from potatoes by soaking them in water.
Phosphorus. The mineral phosphorus can weaken your bones and make your skin
itch if you consume too much. Control of phosphorus may be even more
important than calcium itself in preventing bone disease and related
complications. Foods like milk and cheese, dried beans, peas, colas, nuts, and
peanut butter are high in phosphorus and should be avoided. Youll probably need
to take a phosphate binder with your food to control the phosphorus in your blood
between dialysis sessions.
Salt (sodium chloride). Most canned foods and frozen dinners contain high
amounts of sodium. Too much of it makes you thirsty, and when you drink more
fluid, your heart has to work harder to pump the fluid through your body. Over
time, this can cause high blood pressure and congestive heart failure. Try to eat
fresh foods that are naturally low in sodium, and look for products labeled low
sodium.
Protein. Before you were on dialysis, your doctor may have told you to follow a
low-protein diet to preserve kidney function. But now you have different
nutritional priorities. Most people on dialysis are encouraged to eat as much high-
quality protein as they can. Protein helps you keep muscle and repair tissue, but
protein breaks down into urea (blood urea nitrogen, or BUN) in your body. Some
sources of protein, called high-quality proteins, produce less waste than others.
High-quality proteins come from meat, fish, poultry, and eggs. Getting most of
your protein from these sources can reduce the amount of urea in your blood.
Calories. Calories provide your body with energy. Some people on dialysis need
to gain weight. You may need to find ways to add calories to your diet. Vegetable
oilslike olive, canola, and safflower oilsare good sources of calories and do
not contribute to problems controlling your cholesterol. Hard candy, sugar, honey,
jam, and jelly also provide calories and energy. If you have diabetes, however, be
very careful about eating sweets. A dietitians guidance is especially important for
people with diabetes.
Supplements. Vitamins and minerals may be missing from your diet because you
have to avoid so many foods. Dialysis also removes some vitamins from your
body. Your doctor may prescribe a vitamin and mineral supplement designed
specifically for people with kidney failure. Take your prescribed supplement after
treatment on the days you have hemodialysis. Never take vitamins that you can
buy off the store shelf, since they may contain vitamins or minerals that are
harmful to you.
You can also ask your dietitian for recipes and titles of cookbooks for patients with
kidney disease. Following the restrictions of a diet for kidney disease might be hard at
first, but with a little creativity, you can make tasty and satisfying meals. For more
information, see the NIDDK booklet Eat Right to Feel Right on Hemodialysis.
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Financial Issues
Treatment for kidney failure is expensive, but Federal health insurance plans pay much of
the cost, usually up to 80 percent. Often, private insurance or State programs pay the rest.
Your social worker can help you locate resources for financial assistance. For more
information, see the NIDDK fact sheet Financial Help for Treatment of Kidney Failure.
[Top]
The NIDDK, through its Division of Kidney, Urologic, and Hematologic Diseases,
supports several programs and studies devoted to improving treatment for patients with
progressive kidney disease and permanent kidney failure, including patients on
hemodialysis.
The End-Stage Renal Disease Program promotes research to reduce medical

problems from bone, blood, nervous system, metabolic, gastrointestinal,
cardiovascular, and endocrine abnormalities in kidney failure and to improve the
effectiveness of dialysis and transplantation. The research focuses on evaluating
different hemodialysis schedules and on finding the most useful information for
measuring dialysis adequacy. The program also seeks to increase kidney graft and
patient survival and to maximize quality of life.
The HEMO Study, completed in 2002, tested the theory that a higher dialysis
dose and/or high-flux membranes would reduce patient mortality (death) and
morbidity (medical problems). Doctors at 15 medical centers recruited more than
1,800 hemodialysis patients and randomly assigned them to high or standard
dialysis doses and high- or low-flux filters. The study found no increase in the
health or survival of patients who had a higher dialysis dose, who dialyzed with
high-flux filters, or who did both.
The U.S. Renal Data System (USRDS) collects, analyzes, and distributes
information about the use of dialysis and transplantation to treat kidney failure in
the United States. The USRDS is funded directly by the NIDDK in conjunction
with the Centers for Medicare & Medicaid Services. The USRDS publishes an
Annual Data Report, which identifies the total population of people being treated
for kidney failure; reports on incidence, prevalence, death rates, and trends over
time; and develops data on the effects of various treatment approaches. The report
also helps identify problems and opportunities for more focused special studies of
renal research issues.
The Hemodialysis Vascular Access Clinical Trials Consortium is conducting a

series of multicenter, clinical trials of drug therapies to reduce the failure and
complication rate of arteriovenous (AV) grafts and fistulas in hemodialysis. These
studies are randomized and placebo ontrolled, which means the studies meet the
highest standard for scientific accuracy. AV grafts and fistulas prepare the arteries
and veins for regular dialysis. See the NIDDK fact sheet Vascular Access for
Hemodialysis for more information. Recently developed drugs to prevent blood
clots may be evaluated in these large clinical trials.
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The U.S. Government does not endorse or favor any specific commercial product or
company. Trade, proprietary, or company names appearing in this document are used only
because they are considered necessary in the context of the information provided. If a
product is not mentioned, the omission does not mean or imply that the product is
unsatisfactory.
Resources
Organizations That Can Help
American Association of Kidney Patients

3505 East Frontage Road
Suite 315
Tampa, FL 33607
Phone: 18007492257
Email: info@aakp.org
Internet: www.aakp.org
American Kidney Fund

6110 Executive Boulevard
Suite 1010
Rockville, MD 20852
Phone: 18006388299 or 3018813052
Email: helpline@kidneyfund.org
Internet: www.kidneyfund.org
Life Options Rehabilitation Program

c/o Medical Education Institute, Inc.
414 DOnofrio Drive
Suite 200
Madison, WI 53719
Phone: 18004687777 or 6082322333
Email: lifeoptions@MEIresearch.org
Internet: www.lifeoptions.org
www.kidneyschool.org
National Kidney Foundation, Inc.

30 East 33rd Street
New York, NY 10016
Phone: 18006229010 or 2128892210
Internet: www.kidney.org
Additional Reading
If you would like to learn more about kidney failure and its treatment, you may be
interested in reading
AAKP Patient Plan

A series of booklets and newsletters that cover the different phases of learning about
kidney failure, choosing a treatment, and adjusting to changes.
Suite 315
Tampa, FL 33607
Phone: 18007492257
Getting the Most From Your Treatment series

A series of brochures based on the National Kidney Foundations Dialysis Outcomes
Quality Initiative (NKFDOQI). Titles include What You Need to Know About Peritoneal
Dialysis, What You Need to Know Before Starting Dialysis, and What You Need to Know
About Anemia.
Additional patient education brochures include information on diet, work, and exercise.
30 East 33rd Street
New York, NY 10016
Phone: 18006229010 or 2128892210
Medicare Coverage of Kidney Dialysis and Kidney Transplant Services

Publication Number CMS10128
U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 212441850
Phone: 1800MEDICARE (18006334227)
TDD: 18774862048
Internet: www.medicare.gov/publications/pubs/pdf/10128.pdf (717 KB)
You Can Live: Your Guide for Living with Kidney Failure
Publication Number CMS02119
U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 212441850
Phone: 1800MEDICARE (6334227)
TDD: 18774862048
Internet: www.medicare.gov/publications/pubs/pdf/02119.pdf (871 KB)
Newsletters and Magazines
Family Focus Newsletter (published quarterly)

30 East 33rd Street
New York, NY 10016
Phone: 18006229010 or 2128892210
For Patients Only (published six times a year)

ATTN: Subscription Department
18 East 41st Street
20th Floor
New York, NY 100176222
Renalife (published quarterly)

Suite 315
Tampa, FL 33607
Phone: 18007492257
Acknowledgments
The NIDDK thanks these dedicated health professionals for their careful review of the
original version of this publication.
Richard A. Sherman, M.D.

Robert Wood Johnson Medical School
Richard D. Swartz, M.D.
University of Michigan Health System
Charlie Thomas, A.C.S.W., C.I.S.W.
Samaritan Transplant Services, Phoenix, AZ
The individuals listed here facilitated field testing for this publication. The NIDDK
thanks them for their contribution.
Kim Bayer, M.A., R.D., L.D.
BMA Dialysis
Bethesda, MD
Cora Benedicto, R.N.
Clinic Director
Gambro Health Care
N Street Clinic
Washington, DC
About the Kidney Failure Series
You and your doctor will work together to choose a treatment thats best for you. The
booklets and fact sheets of the NIDDK Kidney Failure Series can help you learn about
the specific issues you will face.
Booklets
Eat Right to Feel Right on Hemodialysis

Kidney Failure: Choosing a Treatment Thats Right for You
Kidney Failure Glossary
Treatment Methods for Kidney Failure: Hemodialysis
Treatment Methods for Kidney Failure: Peritoneal Dialysis
Treatment Methods for Kidney Failure: Transplantation
Fact Sheets
Amyloidosis and Kidney Disease

Anemia in Kidney Disease and Dialysis
Financial Help for Treatment of Kidney Failure
Hemodialysis Dose and Adequacy
Kidney Failure: What to Expect
Peritoneal Dialysis Dose and Adequacy
Chronic Kidney Disease-Mineral and Bone Disorder (formerly Renal
Osteodystrophy)
Vascular Access for Hemodialysis
Learning as much as you can about your treatment will help make you an important
member of your health care team.
The NIDDK will develop additional materials for this series as needed. Please address
any comments about this series and requests for copies to the National Kidney and
Urologic Diseases Information Clearinghouse. Descriptions of the publications in this
series are available on the Internet at
www.kidney.niddk.nih.gov/kudiseases/pubs/kidneyfailure/index.htm.
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National Kidney and Urologic Diseases Information
Clearinghouse
3 Information Way
Bethesda, MD 208923580
Phone: 18008915390
TTY: 18665691162
Fax: 7037384929
Email: nkudic@info.niddk.nih.gov
Internet: www.kidney.niddk.nih.gov
The National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) is a

service of the National Institute of Diabetes and Digestive and Kidney Diseases
(NIDDK). The NIDDK is part of the National Institutes of Health of the U.S. Department
of Health and Human Services. Established in 1987, the Clearinghouse provides
information about diseases of the kidneys and urologic system to people with kidney and
urologic disorders and to their families, health care professionals, and the public. The
NKUDIC answers inquiries, develops and distributes publications, and works closely
with professional and patient organizations and Government agencies to coordinate
resources about kidney and urologic diseases.
Publications produced by the Clearinghouse are carefully reviewed by both NIDDK

scientists and outside experts.
This publication is not copyrighted. The Clearinghouse encourages users of this

publication to duplicate and distribute as many copies as desired.
NIH Publication No. 074666

December 2006
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Vascular Access for Hemodialysis
On this page:
What is an arteriovenous fistula?

What is an arteriovenous graft?
What is a venous catheter for temporary access?
What can I expect during hemodialysis?
What are some possible complications of my vascular access?
How should I take care of my vascular access?
For More Information
If you are starting hemodialysis treatments in the next several months, you need to work
with your health care team to learn how the treatments work and how to get the most
from them. One important step before starting regular hemodialysis sessions is preparing
a vascular access, which is the site on your body where blood is removed and returned
during dialysis. To maximize the amount of blood cleansed during hemodialysis
treatments, the vascular access should allow continuous high volumes of blood flow.
A vascular access should be prepared weeks or months before you start dialysis. The
early preparation of the vascular access will allow easier and more efficient removal and
replacement of your blood with fewer complications.
The three basic kinds of vascular access for hemodialysis are an arteriovenous (AV)
fistula, an AV graft, and a venous catheter. A fistula is an opening or connection between
any two parts of the body that are usually separatefor example, a hole in the tissue that
normally separates the bladder from the bowel. While most kinds of fistula are a problem,
an AV fistula is useful because it causes the vein to grow larger and stronger for easy
access to the blood system. The AV fistula is considered the best long-term vascular
access for hemodialysis because it provides adequate blood flow, lasts a long time, and
has a lower complication rate than other types of access. If an AV fistula cannot be
created, an AV graft or venous catheter may be needed.
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What is an arteriovenous fistula?
An AV fistula requires advance planning because a fistula takes a while after surgery to
developin rare cases, as long as 24 months. But a properly formed fistula is less likely
than other kinds of vascular access to form clots or become infected. Also, properly
formed fistulas tend to last many yearslonger than any other kind of vascular access.
A surgeon creates an AV fistula by connecting an artery directly to a vein, frequently in
the forearm. Connecting the artery to the vein causes more blood to flow into the vein. As
a result, the vein grows larger and stronger, making repeated needle insertions for
hemodialysis treatments easier. For the surgery, youll be given a local anesthetic. In most
cases, the procedure can be performed on an outpatient basis.
Forearm arteriovenous fistula.
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What is an arteriovenous graft?
If you have small veins that wont develop properly into a fistula, you can get a vascular
access that connects an artery to a vein using a synthetic tube, or graft, implanted under
the skin in your arm. The graft becomes an artificial vein that can be used repeatedly for
needle placement and blood access during hemodialysis. A graft doesnt need to develop
as a fistula does, so it can be used sooner after placement, often within 2 or 3 weeks.
Compared with properly formed fistulas, grafts tend to have more problems with clotting
and infection and need replacement sooner. However, a well-cared-for graft can last
several years.
One kind of AV graft.

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What is a venous catheter for temporary access?
If your kidney disease has progressed quickly, you may not have time to get a permanent
vascular access before you start hemodialysis treatments. You may need to use a venous
catheter as a temporary access.
A catheter is a tube inserted into a vein in your neck, chest, or leg near the groin. It has
two chambers to allow a two-way flow of blood. Once a catheter is placed, needle
insertion is not necessary.
Catheters are not ideal for permanent access. They can clog, become infected, and cause
narrowing of the veins in which they are placed. But if you need to start hemodialysis
immediately, a catheter will work for several weeks or months while your permanent
access develops.
Venous catheter for temporary hemodialysis access.
For some people, fistula or graft surgery is unsuccessful, and they need to use a long-term
catheter access. Catheters that will be needed for more than about 3 weeks are designed
to be tunneled under the skin to increase comfort and reduce complications. Even
tunneled catheters, however, are prone to infection.
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What can I expect during hemodialysis?
Every hemodialysis session using an AV fistula or AV graft requires needle insertion.

Most dialysis centers use two needlesone to carry blood to the dialyzer and one to
return the cleansed blood to your body. Some specialized needles are designed with two
openings for two-way flow of blood, but these needles are less efficient. For some people,
using this needle may mean longer treatments.
Some people prefer to insert their own needles, which requires training to learn how to
prevent infection and protect the vascular access. You can also learn a ladder strategy
for needle placement in which you climb up the entire length of the fistula, session by
session, so you wont weaken an area with a grouping of needle sticks.
An alternative approach is the buttonhole strategy in which you use a limited number
of sites but insert the needle precisely into the same hole made by the previous needle
stick. Whether you insert your own needles or not, you should know about these
techniques so you can understand and ask questions about your treatments.
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What are some possible complications of my vascular access?
All three types of vascular accessAV fistula, AV graft, and venous cathetercan have
complications that require further treatment or surgery. The most common complications
are access infection and low blood flow due to blood clotting in the access.
Venous catheters are most likely to develop infection and clotting problems that may
require medication and catheter removal or replacement.
AV grafts can also develop low blood flow, an indication of clotting or narrowing of the
access. In this situation, the AV graft may require angioplasty, a procedure to widen the
small segment that is narrowed. Another option is to perform surgery on the AV graft and
replace the narrow segment.
Infection and low blood flow are much less common in properly formed AV fistulas than
in AV grafts and venous catheters. Still, having an AV fistula is not a guarantee against
complications.
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How should I take care of my vascular access?
You can take several steps to protect your access:
Make sure your nurse or technician checks your access before each treatment.
Keep your access clean at all times.
Use your access site only for dialysis.
Be careful not to bump or cut your access.
Dont let anyone put a blood pressure cuff on your access arm.
Dont wear jewelry or tight clothes over your access site.
Dont sleep with your access arm under your head or body.
Dont lift heavy objects or put pressure on your access arm.
Check the pulse in your access every day.
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The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) has
many research programs aimed at improving the treatment of end-stage renal disease. The
NIDDK established the Dialysis Access Consortium, which consists of seven clinical
centers and a data coordinating center, to undertake interventional clinical trials to
improve outcomes in patients with fistulas and grafts.
Two randomized placebo-controlled clinical trials were designed and are nearly
completed. The first trial evaluated the effects of the antiplatelet agent clopidogrel
(Plavix) on prevention of early fistula failure. A second clinical trial is studying a drug
that combines dipyridamole with aspirin (Aggrenox), with the goal of preventing access
stenosis in hemodialysis patients with grafts.
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The NIDDK Kidney Failure Series includes six booklets and nine fact sheets that can
help you learn more about treatment methods for kidney failure, complications of
dialysis, financial help for the treatment of kidney failure, and eating right on
hemodialysis. For free single printed copies of publications in this series, please contact
the National Kidney and Urologic Diseases Information Clearinghouse.
The U.S. Government does not endorse or favor any specific commercial product or
company. Trade, proprietary, or company names appearing in this document are used only
because they are considered necessary in the context of the information provided. If a
product is not mentioned, the omission does not mean or imply that the product is
unsatisfactory.
[Top]
For More Information
Your health care team will help you learn more about how to care for your access site.
For a copy of the booklet Getting the Most From Your Treatment: What You Need to
Know About Hemodialysis Access, contact

30 East 33rd Street
New York, NY 10016
Phone: 18006229010 or 2128892210
For a copy of the booklet Understanding Your Hemodialysis Access Options, contact

3505 East Frontage Road, Suite 315
Tampa, FL 33607
Phone: 18007492257
The Life Options Rehabilitation Program has developed an interactive patient education
website called Kidney School. Module 8 of this program addresses vascular access for
hemodialysis. To view this module, go to www.kidneyschool.org or contact
Life Options Rehabilitation Program

c/o Medical Education Institute, Inc.
414 DOnofrio Drive, Suite 200
Madison, WI 53719
Phone: 18004687777
Email: lifeoptions@MEIresearch.org
Internet: www.lifeoptions.org
www.kidneyschool.org
The Centers for Medicare and Medicaid Services, the End-Stage Renal Disease
Networks, and the Institute for Healthcare Improvement (IHI) launched the National
Vascular Access Improvement Initiative in 2003. Materials from the Fistula First Change
Package are available through the IHI website or by contacting
The Institute for Healthcare Improvement

375 Longwood Avenue, 4th floor
Boston, MA 02215
Phone: 6177544800
Internet: www.ihi.org
www.fistulafirst.org
You may also find additional information about this topic by visiting MedlinePlus at
www.medlineplus.gov.
This publication may contain information about medications. When prepared, this
publication included the most current information available. For updates or for questions
about any medications, contact the U.S. Food and Drug Administration toll-free at 1
888INFOFDA (18884636332) or visit www.fda.gov. Consult your doctor for more
information.
[Top]
National Kidney and Urologic Diseases Information
Clearinghouse
3 Information Way
Bethesda, MD 208923580
Phone: 18008915390
TTY: 18665691162
Fax: 7037384929
Email: nkudic@info.niddk.nih.gov
Internet: www.kidney.niddk.nih.gov
The National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) is a

service of the National Institute of Diabetes and Digestive and Kidney Diseases
(NIDDK). The NIDDK is part of the National Institutes of Health of the U.S. Department
of Health and Human Services. Established in 1987, the Clearinghouse provides
information about diseases of the kidneys and urologic system to people with kidney and
urologic disorders and to their families, health care professionals, and the public. The
NKUDIC answers inquiries, develops and distributes publications, and works closely
with professional and patient organizations and Government agencies to coordinate
resources about kidney and urologic diseases.
Publications produced by the Clearinghouse are carefully reviewed by both NIDDK

scientists and outside experts.
This publication is not copyrighted. The Clearinghouse encourages users of this

publication to duplicate and distribute as many copies as desired.
NIH Publication No. 084554

February 2008
Hemodialysis (cont.)
In this Article
Introduction to Hemodialysis
How Diet Can Help
Financial Issues
Hope Through Research
Resources: Organizations That Can Help
Hemodialysis Index
Find a local Nephrologist in your town
In hemodialysis, your blood is allowed to flow, a few ounces at a time, through a special
filter that removes wastes and extra fluids. The clean blood is then returned to your body.
Removing the harmful wastes and extra salt and fluids helps control your blood pressure
and keep the proper balance of chemicals like potassium and sodium in your body.
One of the biggest adjustments you must make when you start hemodialysis treatments is
following a strict schedule. Most patients go to a clinic-a dialysis center-three times a
week for 3 to 5 or more hours each visit. For example, you may be on a Monday-
Wednesday-Friday schedule or a Tuesday-Thursday-Saturday schedule. You may be
asked to choose a morning, afternoon, or evening shift, depending on availability and
capacity at the dialysis unit. Your dialysis center will explain your options for scheduling
regular treatments.
Researchers are exploring whether shorter daily sessions, or longer sessions performed
overnight while the patient sleeps, are more effective in removing wastes. Newer dialysis
machines make these alternatives more practical with home dialysis. But the Federal
Government has not yet established a policy to pay for more than three hemodialysis
sessions a week.
Picture of Hemodialysis
Several centers around the country teach people how to perform their own hemodialysis
treatments at home. A family member or friend who will be your helper must also take
the training, which usually takes at least 4 to 6 weeks. Home dialysis gives you more
flexibility in your dialysis schedule. With home hemodialysis, the time for each session
and the number of sessions per week may vary, but you must maintain a regular schedule
by giving yourself dialysis treatments as often as you would receive them in a dialysis
unit.
COMPLICATIONS DURING HEMODIALYSIS
Even though the safety of the hemodialytic procedure has improved greatly over the
years, the procedure is not without risks. Common problems are listed below.
Hypotension
A decrease in blood pressure is the most frequent complication reported during

hemodialysis. When fluid is removed during hemodialysis, the osmotic pressure is
increased and this prompts refilling from the interstitial space. The interstitial space is
then refilled by fluid from the intracellular space. Excessive ultrafiltration with
inadequate vascular refilling plays a major role in dialysis induced hypotension. The
immediate treatment to hypotension is to discontinue dialysis and place the patient in a
trendelenburg position. This will increase cardiac filling and may increase the blood
pressure promptly.
Cramps
In the majority of hemodialysis patients, cramps occur toward the end of the dialysis
procedure after a significant volume of fluid has been removed by ultrafiltration. The
immediate treatment for cramps is directed at restoring intravascular volume through the
use of small boluses of isotonic saline. Prevention of cramps has been attempted with the
prophylactic use of quinine sulfate at least 2 hours prior to dialysis.
Febrile reactions
Febrile episodes should be aggressively evaluated with appropriate wound and blood
cultures. The suspicion of infection should be high. Treatment of endotoxin related fever
is generally supportive with antipyretics. Temperatures should be recorded at the
initiation and termination of dialysis treatment.
Arrhythmia
Patients on maintenance hemodialysis are at risk of cardiac arrhythmias. They occur
predominately in association with hemodialysis or may occur in the interdialytic period.
Both acute and chronic alterations in fluid, electrolyte, and acid-base homeostasis may be
arrhythmogenic in these patients.
Hemolysis
Hemolysis may result from a number of biochemical and toxic insults during the dialysis
procedure. The half-life of red blood cells in renal failure patients is approximately one
half to one third of normal and the cells are particularly susceptible to membrane injury.
Hypoxemia
A fall in arterial PO2 is a frequent complication of hemodialysis that occurs in nearly 90%
of patients. The drop ranges from 5 to 35 mm Hg, and reaches its peak between 30 - 60
minutes after beginning dialysis. This is obviously undesirable for patients with
underlying cardiopulmonary disease. Also, patients on mechanical ventilators with
constant minute volume and inspired oxygen concentration can still develop hypoxemia
during hemodialysis.
TYPES OF DIALYZERS
A dialyzer is an artificial kidney designed to provide controllable transfer of solutes and

water across a semi permeable membrane separating flowing blood and dialysate streams.
The transfer processes are diffusion (dialysis) and convection (ultrafiltration). There are
three basic dialyzer designs: coil, parallel plate, and hollow fiber configurations.
Coil dialyzer: An early design in which the

blood compartment consisted of one or two long
membrane tubes placed between support
screens and then tightly wound around a plastic
core. This design had serious performance
limitations, which gradually restricted its use as
better designs evolved. The coil design did not
produce uniform dialysate flow distribution
across the membrane. More efficient devices
have replaced the coil design.
Parallel Plate Dialyzer: Sheets of membrane

are mounted on plastic support screens, and then
stacked in multiple layers ranging from 2 to 20
or more. This design allows multiple parallel
blood and dialysate flow channels with a lower resistance to flow. The physical size of
the parallel plate dialyzers has been greatly reduced since their introduction. There have
been major improvements which provide (1) thinner blood and dialysate channels with
uniform dimensions, (2) minimal masking or blocking of membranes on the support, and
(3) minimal stretching or deformation of membranes
across the supports.
Hollow Fiber Dialyzer: This is the most effective design

for providing low-volume high efficiency devices with
low resistance to flow. The fibers in the device are
termed the fiber bundle. The fibers are potted in
polyurethane at each end of the fiber bundle in the tube
sheet, which serves as the membrane support.
Ultra filtration: All excess fluid must be removed from

the bloodstream as the patient's blood flows through the
dialyzer. The process of water removal from the
bloodstream is called ultra filtration, and the amount of
fluid removed is the ultra filtrate.
NEED FOR DIALYSIS
When patients have mild kidney failure (serum Creatinine is less than 400 umol/L), they
do not require renal replacement therapy such as dialysis or renal transplant because they
still have sufficient residual renal function to sustain life. However, they require certain
medications, such as phosphate binders, and need to restrict fluid, salt, and protein intake
to reduce the risk of further damage to the kidney. When the serum Creatinine rises to
900 umol/ L, it is considered severe renal failure and they require dialysis or a kidney
transplant. Additionally, it is customary to consider dialysis in any patient who 1) is
symptomatic from uremia, 2) has a complication of renal failure that is unlikely to
resolve by conservative treatment, 3) has a complication that is associated with a definite
risk to the patient, or 4) is suffering from an end-stage renal disease (ESRD).
MECHANICAL ASPECTS
Single-patient hemodialysis machines offer nephrologists tremendous flexibility in

adjusting dialysis regimens to address individual patient needs. Almost all single-patient
hemodialysis machines use a single pass system where the dialysate circulates through
the dialyzer once and is then discarded.
All systems require the same basic components:
1. a dialysate heater to warm dialysate to body temperature

2. a dialysate pump and flow meter to regulate the rate of dialysate delivery, and
3. sensors and alarms to monitor dialysate pressure, temperature, conductivity, and
air or blood leaks.
COMPLICATIONS DURING HEMODIALYSIS
Even though the safety of the hemodialytic procedure has improved greatly over the
years, the procedure is not without risks. Common problems are listed below.
Hypotension
A decrease in blood pressure is the most frequent complication reported during

hemodialysis. When fluid is removed during hemodialysis, the osmotic pressure is
increased and this prompts refilling from the interstitial space. The interstitial space is
then refilled by fluid from the intracellular space. Excessive ultrafiltration with
inadequate vascular refilling plays a major role in dialysis induced hypotension. The
immediate treatment to hypotension is to discontinue dialysis and place the patient in a
trendelenburg position. This will increase cardiac filling and may increase the blood
pressure promptly.
Cramps
In the majority of hemodialysis patients, cramps occur toward the end of the dialysis
procedure after a significant volume of fluid has been removed by ultrafiltration. The
immediate treatment for cramps is directed at restoring intravascular volume through the
use of small boluses of isotonic saline. Prevention of cramps has been attempted with the
prophylactic use of quinine sulfate at least 2 hours prior to dialysis.
Febrile reactions
Febrile episodes should be aggressively evaluated with appropriate wound and blood
cultures. The suspicion of infection should be high. Treatment of endotoxin related fever
is generally supportive with antipyretics. Temperatures should be recorded at the
initiation and termination of dialysis treatment.
Arrhythmia
Patients on maintenance hemodialysis are at risk of cardiac arrhythmias. They occur

predominately in association with hemodialysis or may occur in the interdialytic period.
Both acute and chronic alterations in fluid, electrolyte, and acid-base homeostasis may be
arrhythmogenic in these patients.
Hemolysis
Hemolysis may result from a number of biochemical and toxic insults during the dialysis
procedure. The half-life of red blood cells in renal failure patients is approximately one
half to one third of normal and the cells are particularly susceptible to membrane injury.
Hypoxemia
A fall in arterial PO2 is a frequent complication of hemodialysis that occurs in nearly 90%
of patients. The drop ranges from 5 to 35 mm Hg, and reaches its peak between 30 - 60
minutes after beginning dialysis. This is obviously undesirable for patients with
underlying cardiopulmonary disease. Also, patients on mechanical ventilators with
constant minute volume and inspired oxygen concentration can still develop hypoxemia
ALTERNATIVE HEMODIALYTIC TECHNIQUES
The major alternative hemodialytic therapies that have evolved are the slow continuous
renal replacement therapies. These therapies were devised in an attempt to improve the
treatment of acute renal failure in critically ill patients in intensive care unit settings. The
potential advantages of slow continuous therapy in treating this patient population are:
1. It does not cause hemodynamic instability since there is little change in plasma
osmolarity.
2. Allows better control of electrolyte and acid-base balance
3. It is very effective in removing fluid which may help patients in pulmonary edema
or acute respiratory distress syndrome.
4. The procedure is simple and does not require highly technical equipment.
Convection-Based Therapy
CAVH (continuous arteriovenous hemofiltration) -

Blood circulates with or without a blood pump
through a small hollow-fiber hemofilter. Access to the
circulation is by the femoral artery and vein. Heparin
is infused continuously proximal to the dialyzer. The
patient's blood circulates through the hemofilter
wherein the plasma and water is filtered and collected
in the collection bag. Replacement fluid is infused into
the venous return line.
CVVH (continuous venovenous hemofiltration) - This therapy is pump assisted and
achieves higher clearance. Because of its greater effectiveness, this technique is replacing
the pumpless CAVH mode. Blood access is achieved by placing a double lumen catheter
in the femoral, subclavian, or internal jugular vein. Continuous diffusive solute transport
is achieved by infusing a dialysis fluid that runs counter-current to blood at a flow rate of
15 ml/min or 1 L/hr.
Diffusive Therapy
CAVHD (continuous arteriovenous hemodialysis) -

This technique uses an infusion pump, hemodialysis
membrane and dialysate solution as well as the same
blood access circuitry as the CAVH technique. An
infusion pump pushes a continuous trickle of sterile
dialysis fluid into the dialysate compartment of a
hemodialyzer membrane. The blood/dialysate interface
is the hemodialysis membrane. CAVHD uses the
process of continuous diffusion dialysis to rid the body of fluid, electrolytes, and
nitrogenous wastes. The preferred arterial access site is the common femoral artery.
CVVHD (continuous venovenous hemodialysis) - This technique uses an infusion pump,

hemodialysis membrane and dialysate solution as well as the same blood access circuitry
as the CVVH technique. As with the CAVHD system, adding the dialysis membrane and
the dialysate solution increases the efficiency of the procedure. The process of continuous
diffusion dialysis in CVVHD is less effective than the CAVHD because the lower
pressure venous system does not filter as much blood per unit of time.
A = double-lumen subclavian vein access; B = venous air trap; C = venous pressure

monitor; D = air detector; E = dialyzer; x,y,z = blood and dialysate pumps.
VASCULAR ACCESS
Vascular access is the circulatory site that allows the connection between the patient's
circulation and the dialyzer.
The two most common types of chronic access used for hemodialysis are: 1) Arterio-
venous (AV) fistula and 2) Arterio-venous (AV) graft
Arterio-Venous Fistula
This is created internally and is used for

prolonged periods of time. This involves a
small operation to join an artery and vein,
allowing arterial blood to flow directly into
the vein.
The blood vessels of the arm are usually

chosen, e.g. at the wrist or at the upper
forearm. Due to the arterial pressure, the vein
will increase in size and its walls will thicken.
It takes about 3 to 7 weeks for the fistula vein
to mature. It is then easier to put a needle into this vein to allow blood to flow through the
dialyzer using the blood pump on the machine.
Arterio-Venous Graft
The arterio-venous graft

(AVG) is an artificial blood
vessel used to join artery and
vein. It is used when the
patient's own blood vessels
are too small for fistula
construction. Often, these
patients are the elderly or
have pre-existing diabetes
mellitus. The graft, which
may be either straight or
looped, is close to the
surface of the skin for easier
needle insertion. The graft
may be of an artificial
material such as polytetrafluoroethylene or Gortex, or can be obtained from the patient's
own body, e.g. the vein in the thigh.
Grafts are most commonly placed in the upper arm, lower arm, and thigh. Two to four
weeks should pass before the graft is punctured to allow adequate healing and sufficient
growth of tissue to stabilize the graft.
Temporary Access
These are temporary or immediate accesses created for use in cases where urgent dialysis
is needed, and the patient cannot wait weeks for the AV fistula to be ready for use. These
include 1) the subclavian catheter, 2) internal jugular catheter and 3) arterio-venous
shunt.
The subclavian catheter is a tube which is inserted into the subclavian vein near the neck.
The internal jugular catheter is placed in the veins by the side of the neck. It cannot be
used beyond a few weeks as it tends to get blocked by clotting blood or the site of
insertion gets infected.
An arterio-venous shunt is
surgically created which consists
of two pieces of silastic tubing,
each with a Teflon tip on one end.
The Teflon tip of one piece of the
shunt tubing is placed in an artery
and the Teflon tip of the other is
placed in an adjacent vein. The
tubing is then brought through two
puncture wounds in the skin and
connected. The AV shunt has
limited life-span due to clotting or
infection and does not usually work for longer than 6 months whereas an AV fistula can
be used for years.
For more information on Vascular Access see the National Kidney Foundation
guidelines
Learning Objectives: After you complete the sections below you should be able to:
1. Differentiate between the different types of dialyzers

2. Identify the different needs for dialysis
3. Recognize what mechanical aspects are involved in dialysis
4. Become familiar with the physicians orders relating to hemodialysis
5. Outline the goals for a hemodialysis procedure
6. Be aware of the complications during hemodialysis
7. Recognize alternative hemodialytic techniques
8. Recognize what peritoneal dialysis is and what is it used for
9. Identify the different vascular access areas for hemodialysis
REFERENCES:
1. Cogan, M. Introduction to Dialysis. Churchill Livingstone. New York. 1991.

2. Mandal, A. Diagnosis and Management of Renal Disease and Hypertension. Lea
& Febiger.
3. Philadelphia. 1988.
4. Nissenson, A. Clinical Dialysis. Appleton & Lange. Connecticut. 1990.
5. Nissenson, A. Dialysis Therapy. Hanley & Belfus. Philadelphia. 1993.
6. Stedman's Concise Medical Dictionary. 2nd ediction. Williams & Wilkins.
Baltimore. 1994.
7. National Kidney Foundation
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Hemodialysis Index
Our Hemodialysis Main Article provides a comprehensive

look at the who, what, when and how of Hemodialysis
Definition of Hemodialysis
Hemodialysis: A medical procedure that uses a special machine (a dialysis machine) to
filter waste products from the blood and to restore normal constituents to it. This
shuffling of multiple substances is accomplished by virtue of the differences in the rates
of their diffusion through a semipermeable membrane (a dialysis membrane).
Although hemodialysis may be done for acute kidney failure, it is more often employed
for chronic renal disease. Hemodialysis is frequently done to treat end-stage kidney
disease. Under such circumstances, kidney dialysis is typically administered using a fixed
schedule of three times per week.
There are other types of dialysis as, for example, peritoneal dialysis.
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Hemodialysis

From Wikipedia, the free encyclopedia

In medicine, hemodialysis (also haemodialysis) is a method for removing waste

Hemodialysis can be an outpatient or inpatient therapy. Routine hemodialysis is

Fluid removal (ultrafiltration) is achieved by altering the hydrostatic pressure of the

Note that this is a different process to the related technique of hemofiltration.

For a detailed history of successful and unsuccessful attempts at dialysis, including

[edit] Side effects and complications

Since hemodialysis requires access to the circulatory system, patients undergoing

Heparin is the most commonly used anticoagulant in hemodialysis, as it is generally well

AV (arteriovenous) fistulas are recognized as the preferred access method. To create a

[edit] Fistula First project

[edit] Conventional hemodialysis

The procedure of conventional hemodialysis are: patients attached to a dialysis machine;

[edit] Daily hemodialysis

The procedure of daily hemodialysis is similar to the conventional hemodialysis except it

[edit] Nocturnal hemodialysis

the procedure of nocturnal hemodialysis is similar to conventional hemodialysis except it

[edit] Advantages and disadvantages

Low mortality rate

Restricts independence, as people undergoing this procedure cannot travel around

Schematic of a hemodialysis circuit

A hemodialysis unit's dialysate solution tanks

An extensive water purification system is absolutely critical for hemodialysis. Since

[edit] Membrane and flux

[edit] Membrane flux and outcome

Whether using a high-flux dialyzer improves patient outcomes is somewhat controversial,

[edit] Membrane flux and beta-2-microglobulin amyloidosis

High-flux dialysis membranes and/or intermittent on-line hemodiafiltration (IHDF) may

[edit] Dialyzer size and efficiency

[edit] Reuse of dialyzers

[edit] Nursing cares for hemodialysis patient

Hemodialysis adequacy: Assesses patient constantly for signs and symptoms of

Hemodialysis treatment and complications: Performs head to toe physical assessment

[edit] See also

When Your Kidneys Fail

When Your Kidneys Fail

Getting Your Vascular Access Ready

Arteriovenous fistula. One important step before starting hemodialysis is preparing a

Equipment and Procedures

pump blood and watch flow for safety

Arterial and venous needles.

Tests to See How Well Your Dialysis Is Working

Conditions Related to Kidney Failure and Their Treatments

Anemia and Erythropoietin (EPO)

How Diet Can Help

Hope through Research

The End-Stage Renal Disease Program promotes research to reduce medical

The Hemodialysis Vascular Access Clinical Trials Consortium is conducting a

Organizations That Can Help

American Association of Kidney Patients

American Kidney Fund

Life Options Rehabilitation Program

National Kidney Foundation, Inc.

AAKP Patient Plan

Getting the Most From Your Treatment series

Medicare Coverage of Kidney Dialysis and Kidney Transplant Services

Newsletters and Magazines

Family Focus Newsletter (published quarterly)

For Patients Only (published six times a year)

Renalife (published quarterly)

Richard A. Sherman, M.D.