Dialysis: Types, Procedures & Tips

What is Dialysis?

Dialysis is an important medical procedure that involves removing waste products, excess fluids, and toxins from the blood that would normally be filtered by the kidneys. This treatment is used when the kidneys are unable to function adequately. It is recommended for people with kidney failures or severe kidney dysfunction to maintain proper fluid and electrolyte balance in the body.

Different Types of dialysis

Types of dialysis can include

1. Haemodialysis (HD):

• This is the most common type of dialysis. It filters blood outside the body by using a machine called a dialyzer.
• During the procedure, blood is pumped out of the body through a dialysis access, such as an arteriovenous fistula or graft into the dialyzer.
• Inside this machine, the blood flows through special membranes that filter out waste products, excess fluids, and toxins.
• Once the blood is cleaned, it is then returned to the body. This process typically takes several hours and is usually done 3 times a week.

Points to Remember:

• Haemodialysis can be done at a dialysis centre, hospital or home.
• The procedure takes about 3-5 hours when done at a hospital or dialysis centre.
• It is done three times a week.
• At-home, haemodialysis is mostly done four to seven times a week, and the sessions are shorter.
• Home haemodialysis can also be done at night when you are sleeping.

2. Peritoneal dialysis (PD):

• This type of dialysis uses the peritoneum (membrane lining inside the abdomen) as a filter to remove waste and excess fluids directly inside the body.
• A sterile cleansing fluid called dialysate is used to filter and remove waste from the blood. The fluid is introduced into the abdomen through a catheter. This fluid stays in the abdomen for a specific amount of time (dwell time) to absorb waste and toxins from the blood through the peritoneal membrane.
• Once the dwell time is over, the fluid containing waste products is drained out of the abdomen and replaced with fresh dialysate. This process is repeated several times throughout the day and night to allow continuous filtration.

Types of Peritoneal Dialysis

There are two types of peritoneal dialysis:

• Continuous Ambulatory Peritoneal Dialysis (CAPD)
• Automated Peritoneal Dialysis (APD)

Peritoneal dialysis requires you to fill the abdomen with dialysate solution, let it stay for 4-6 hours, empty the used solution, and refill your stomach with fresh solution several times a day. This process is called exchange. You can do these exchanges manually (CAPD) or with the help of a machine (APD). Let’s understand both these types in detail.

A) Continuous Ambulatory Peritoneal Dialysis (CAPD)

• This is a type of dialysis that does not require a machine.
• The exchanges are done by hand in a clean and well-lit place. Each exchange may take about 30-40 minutes. You can talk, read, watch TV, or sleep during this time.
• The dwell time, or the time you must keep the solution in your stomach, is about 4-6 hours.
• You don’t have to worry about doing the exchange at night. You can sleep with the solution in your belly and exchange it in the morning.

B) Automated Peritoneal Dialysis (APD)

• This type of peritoneal dialysis uses a machine called a ‘cycler’.
• The cycler performs exchanges 3-5 times when you are asleep at night.
• Fresh solution is introduced into the abdomen in the morning. You can leave it in your stomach all day or do one exchange in the afternoon without using the machine.

Points to Remember:

• Peritoneal dialysis involves a small surgery, which is done 3 weeks before starting the procedure. It is done by permanently inserting a soft, thin tube called a catheter into the peritoneum through the stomach.
• Peritoneal dialysis is done at a dialysis centre, hospital, or home.
• The procedure can also be done at work and when you are travelling.
• While most dialysis patients can do this procedure on their own, others may need the help of a trusted caregiver.

3. Continuous Renal Replacement Therapy

• Continuous renal replacement therapy (CRRT) is used for patients with acute kidney injury (AKI) and fluid overload.
• Before CRRT, the dialysis catheter is placed in the body. This sterile procedure is done by an ICU doctor. A radiologist trained and skilled in catheter placement can also do this.
• To start the procedure, the patient is connected to the CRRT machine. Blood is drawn from the patient’s body through the catheter and passed through the filter in the CRRT machine.
• Once the filter has removed waste and extra fluid from blood, saline or a specialised electrolyte solution is added to the filtered blood as replacement fluid to maintain proper balance.
• The treated blood enters the patient’s body through another catheter.
• The CRRT machine also monitors the patient’s temperature, blood pressure, and other vital signs.

Points to keep in mind:

• This 24-hour dialysis therapy is recommended after acute kidney injury or when the patient looks swollen or puffy, and the blood test shows excessive waste products in the body.
• The procedure involves intermittent haemodialysis and peritoneal dialysis.
• CRRT does not improve kidney function but helps remove waste and extra fluids from the body until the kidneys recover.
• The duration of the procedure depends on the patient’s health issue and the type of CRRT used. It can last for several hours or even days.

Benefits of Performing Dialysis

A) Of Haemodialysis

Haemodialysis benefits include —

• Convenience: The procedure is done 3 times a week. Therefore, in one week, you can have 4 dialysis-free days.
• Flexibility: Haemodialysis can be done at the dialysis centre or home. If you don’t want to go to the dialysis centre every time, you can learn to use the equipment at home anytime at your convenience.
• Takes less time: Haemodialysis takes less time than peritoneal dialysis. Haemodialysis is done 3 times a week, and each session may last about 3-5 hours. On the other hand, peritoneal dialysis is done every day. It has 4-6 hours of dwell time, and you may need about 4 exchanges every day.
• Low risk of infection: For haemodialysis, an AV fistula connection (connecting an artery to a vein in the arm) is created by a vascular specialist. With proper hygiene and care, the infection risk of AV fistula is quite low.
• Less surgical interventions: The AV fistula connection created for haemodialysis lasts much longer when compared to catheters and transplanted kidneys for peritoneal dialysis.

B) Of Peritoneal Dialysis

The following are the benefits of peritoneal dialysis —

• Fewer visits to a dialysis centre: The procedure can be done at home or even when you are travelling. Therefore, you will not have to visit the dialysis centre every time.
• No needles involved: This type of dialysis is done through a catheter tube permanently inserted in the belly. Therefore, no needles are involved in the process. In haemodialysis, two needles are inserted in the vein at the beginning of each dialysis session to clean blood outside the body.
• Less restrictions on diet: Since peritoneal dialysis is done continuously, you will not have to worry about sodium, potassium, and fluid building up in the body. Therefore, peritoneal dialysis helps you follow a more flexible diet.
• Helps maintain remaining kidney function: Kidney failure prevents the kidneys from functioning properly, but they can still perform a small part of their function. Peritoneal dialysis might help keep this remaining kidney function longer than haemodialysis.

C) Of Continuous Renal Replacement Therapy

The following are the benefits of CRRT —

• Continuous support:It offers continuous support to patients with acute kidney failure or severe kidney injury.
• Removes waste from the body: It removes waste products and excess fluids from the body till the patient’s kidneys restore their normal function.
• Preferred for ICU patients:CRRT is ideal for ICU patients who cannot tolerate regular dialysis.
• Less strenuous:This type of dialysis is slower in nature. Instead of doing it for 4-6 hours, CRRT is done continuously for 24 hours. Therefore, it does not put excess stress on the heart.

Side-effects & Risks Associated with Dialysis

A) With Haemodialysis

Although haemodialysis is an important procedure for replacing lost kidney function, some may experience one or more of the side effects and complications listed below —

• Low blood pressure: The drop in fluid levels during dialysis causes the blood pressure to drop during this medical procedure. Nausea, vomiting, abdominal cramps, muscle cramps, and shortness of breath often accompany low blood pressure.
• Muscle cramps: Some people may also experience muscle cramps, particularly in the lower leg. This reportedly happens due to fluid loss during this dialysis process.
• Itchy skin: Minerals can build up in the body between dialysis sessions and cause itchy skin in dialysis patients.
• Anaemia: Anaemia, or a low number of red blood cells in the body, is common among kidney patients. When the kidneys don’t function properly, they do not produce an adequate amount of the hormone erythropoietin, which is important for the formation of RBCs. Some other possible causes of anaemia in kidney patients are diet restrictions, removal of iron and other important nutrients during haemodialysis, and poor absorption of iron in the body.
• Bone conditions-: Kidneys help maintain the right balance of many important substances, including vitamin D, calcium, phosphorous, and parathyroid hormone, that are important for your bones. Therefore, restricted functioning of the kidneys can lead to bone conditions.
• Dry mouth: Reduced salivary flow, restricted intake of fluids, advanced age, and medicines can cause dry mouth in haemodialysis patients.
• Insomnia: Haemodialysis can cause insomnia or sleep problems due to pain, discomfort, or irregular breathing (sleep apnoea).
• Anxiety or depression: Many people also experience changes in mood during haemodialysis. A decreased quality of life is one of the main reasons.

B) With Peritoneal Dialysis

The following side effects, risks, and complications are associated with peritoneal dialysis —

• Peritonitis: This bacterial infection of the peritoneum or the inner lining of the abdomen, particularly happens if the dialysis equipment is not kept clean. Some symptoms of peritonitis are high fever, abdominal pain, feeling sick, and experiencing chills.
• Infection at the catheter site: This infection starts at the spot where the catheter is placed. Keeping the catheter clean and dry can help prevent this.
• Hernia: This is the formation of a lump in the abdomen. In peritoneal dialysis, fluid is held inside the peritoneal cavity for hours. This strains the muscles of the abdomen and increases the risk of hernia.
• Low blood pressure: This may happen due to excessive loss of fluid and salt during dialysis.
• Bleeding: A slight mistake while placing/removing the catheter can hurt an internal organ and cause bleeding.
• Weight gain: The dialysate fluid used during the procedure contains sugar molecules. Some of these sugar molecules get absorbed into the body and cause weight gain.
• Becomes less effective: This procedure may not work after some years, and you may have to switch to haemodialysis.

C) With CRRT

The side effects, potential risks, and complications of CRRT are —

• Hypothermia: Hypothermia or extremely low body temperature is one of the main side effects and complications of CRRT. It can cause the body temperature to fall below 35 degrees Celsius or 95 degrees Fahrenheit. The condition can affect the functioning of the brain, cardiovascular system, and other organs in the body.
• Anaemia: Patients undergoing CRRT may lose blood through the extracorporeal circuit. Mechanical haemolysis or destruction of RBCs can also lead to anaemia.
• Loss of nutrients: The filtration process in CRRT may also remove micronutrients and macronutrients from the body and affect overall well-being.
• Delayed mobility:Patients receiving CRRT may also experience deconditioning or delayed mobility. They may require physical therapy in the ICU for improved physical functioning.
• Dialysis disequilibrium syndrome (DSS) : This is characterised by neurological symptoms that happen to dialysis patients due to rapid shifts of solutes. Although slower clearance of solutes reduces the risk of DSS in CRRT, the condition cannot be ruled out completely. Some patients receiving CRRT may experience dialysis disequilibrium syndrome.
• Other risks and complications: Some other side effects, risks and complications of CRRT are:
• Cardiac stunning
• Low blood pressure or hypotension
• Venous thrombosis, or formation of blood clots in a vein
• Haemodialysis-related complications
• Peritonitis
• Coagulopathy or impaired ability of the blood to clot
• Catheter-related infection and other complications
• Disconnection from the CRRT machine
• Blood loss
• Variations in salt balance
• Protein loss

When to call the doctor?

A) For Haemodialysis

When undergoing haemodialysis, you must call the doctor if you experience problems such as fever, redness, swelling, bleeding, or a drop in blood pressure. These may indicate an infection or other dialysis-related complication. Therefore, you must call your doctor without delay for timely medical attention.

B) For Peritoneal Dialysis

You must call the doctor if you notice issues, such as a decrease in urine output, signs of low blood pressure (dizziness and unusual thirst), nausea, vomiting, fever, redness at the catheter site, severe stomach pain, and an unusual hernia-like bulge in the abdomen or groin.

C) For Continuous Renal Replacement Therapy

You must call the doctor if you get a fever or notice other signs of infection, such as swelling and redness on the catheter site, uneasiness, dizziness, nausea, abdominal pain, or discomfort.

Pros vs. Cons

In case of kidney failure due to an illness or injury, dialysis can help remove waste products from your body and support your overall health. However, the procedure has both advantages and disadvantages.

Pros

• Dialysis does not require major surgery. While haemodialysis is done without surgery, peritoneal dialysis requires a small, one-time surgical procedure.
• Dialysis can alleviate symptoms associated with kidney failure, such as fatigue, nausea, and swelling, by maintaining proper fluid and electrolyte balance.
• With proper training, you can do both types of dialysis at home and choose a time that works best for you.
• It allows the patient to choose a treatment method that best suits their lifestyle, medical condition, and preference.
• In case of kidney damage, doctors can start dialysis treatment immediately. It can help bridge the gap between kidney failure and kidney transplant.

Cons

• Dialysis treatment is time-consuming, especially haemodialysis, typically require several hours per session, several times a week, which can be physically exerting and also limit a patient’s daily activities.
• The procedure can cause low blood pressure, infection, and muscle cramps.
• Some individuals who opt for haemodialysis develop an infection of the AV graft.
• Haemodialysis can also cause other complications, such as blood clots or poor blood flow.
• Peritoneal dialysis can cause a skin infection around the catheter.
• Peritoneal dialysis can also cause peritonitis, a bacterial infection that happens when bacteria enter the abdomen through the catheter. The condition can lead to fever, stomach pain, nausea, and vomiting.
• Dialysis patient need to follow strict dietary restrictions, such as limiting potassium, phosphorus, and sodium intake, and control fluid intake to prevent complications and maintain health.
• Undergoing dialysis can be emotionally challenging and have a psychological impact, leading to stress, anxiety, and depression in some patients.

Managing Dialysis Treatment

If you are on dialysis, the following tips can help you manage the treatment —

• Make a schedule: Dialysis is done at least three times a week, so talk to your doctor about it and make a schedule for the procedure. Dialysis is mostly done on alternate days, and each session lasts for about 3-5 hours. Think of your work and other engagements and fix a suitable schedule accordingly so you don’t miss a session.
• Take medications as prescribed: Dialysis patients are prescribed quite a few medicines, so make a list of them and note down their dosage. Also, talk to your healthcare team to understand the right time to take the medicines. Make sure to take them as prescribed. For instance, some medicines are taken before food and some after, and taking them the right way is important for kidney care.
• Tell your doctor about other medications: If you are taking medicines for any other existing condition, such as high blood pressure or diabetes, tell your doctor about it. Certain medicines may be inappropriate for dialysis patients, so your doctor may prescribe substitutes.
• Consume a healthy diet: If you are on dialysis, you must consciously consume a kidney-friendly diet to stay healthy, energetic, and active. For example, you must include more high-protein foods in your diet and check the intake of foods high in salt, potassium, and phosphorous. Some healthy options are grains, nuts, apples, cherries, berries, grapes, peaches, broccoli, carrots, cabbage, eggs, fish, etc.
• Take care of your mental health: This is important, as dialysis can lead to mood changes. If you feel low, depressed or frustrated, talk to your loved ones about it or seek professional help.

Diet and Nutrition

If you are on dialysis, you must follow a special diet to check the build-up of waste products in the body. The following are some important dietary guidelines for individuals on dialysis:

• Consume foods high in protein to promote your overall health. High protein foods also produce less waste in the body and aid the dialysis procedure.
• Reduce your salt intake, as too much sodium can cause high blood pressure and fluid build-up around the lungs and heart.
• Avoid foods rich in potassium, as high amounts of this mineral can be dangerous for your heart.
• Phosphorous can lead to calcium loss from the bones in dialysis patients, so it is important to limit the intake of foods high in phosphorous.
• Reduce your fluid

Lifestyle tips for dialysis patients

The following are some important lifestyle tips for dialysis patients:

• Eat fewer salty foods to keep your blood pressure in check.
• Consume high-protein foods to boost energy levels.
• Talk to your doctor and follow a workout regimen.
• Make sure you get 7-9 hours of sleep every night.
• Try to stick to your old routine, i.e., the routine you followed before kidney failure, and try to do as many activities as you can.
• Continue doing the things you love, such as playing games, spending time with family and friends, and watching movies for better mental health.

Future trends in dialysis technology

Some renowned companies around the world are looking to introduce devices that can make dialysis easier and affordable. The following are some examples:

• Fist Assist Devices, a company based in Las Vegas, is developing a device that can inflate and deflate veins. This device can help make the vein bigger for holding a dialysis catheter.
• AWAK Technologies, a medical technology company in Singapore, has introduced an ultraportable wearable artificial dialysis device that can be used anywhere, anytime. It requires only 1-2L PD fluid per day and can be monitored and managed remotely by a healthcare provider.

Conclusion

To sum up, dialysis is an important procedure for people with ESRD (i.e., end-stage renal disease) or kidney failure. Also, when you are looking for a kidney transplant, you can be on dialysis until the transplant is done. With the option to do dialysis at home or in a hospital, you can choose a treatment that suits you the best. Since each dialysis session can cost you up to INR 5000, it is wise to keep an adequate health insurance policy handy to cover the bills. Insurance companies also offer special plans for kidney patients, so make sure you check the options before zeroing in on a plan.

Source: preferredvasculargroup, mayoclinic, my.clevelandclinic, davita.com, awak.com, stellarix, nhs.uk