Hemodialysis

Overview
What is hemodialysis?

Hemodialysis is a type of dialysis. If you have a condition that prevents your kidneys from
working properly, dialysis does the work for them — it filters your blood to remove waste
products and excess fluids. Common waste products include nitrogen waste (urea), muscle
waste (creatinine) and acids.

During hemodialysis, a machine removes blood from your body, filters it through an artificial
kidney (dialyzer) and then returns the cleaned blood to your body.

How does hemodialysis work?

The dialyzer is the part of the hemodialysis machine that filters your blood. Your blood flows
through tiny mesh tubes inside the dialyzer’s core. Waste products and excess fluids in your
blood pass through the mesh tubes into dialysate. Dialysate is a fluid that consists of water,
salts and electrolytes.

Your filtered blood returns to your body. The dialyzer then disposes of the dialysate, which
contains your blood’s waste products and excess fluid.

What are the two types of hemodialysis?

There are two main types of hemodialysis. Talk to your healthcare provider about what type of
hemodialysis is best for you.

The main types of hemodialysis include:

In-center hemodialysis
For this type of hemodialysis, you go to a special healthcare facility that specializes in providing
hemodialysis. A hemodialysis nurse or technician performs the procedure.

Most people get in-center hemodialysis at least three times per week. Each session takes
between three and four hours to complete.

Home hemodialysis

This type of hemodialysis takes place in your home. Over several weeks or months, your
healthcare providers will teach you how to perform hemodialysis and resolve common
problems that may develop. You then perform the procedure yourself on your own schedule.

In hemodialysis, a machine filters wastes, salts and fluid from your blood when your kidneys are
no longer healthy enough to do this work adequately. Hemodialysis (he-moe-die-AL-uh-sis) is
one way to treat advanced kidney failure and can help you carry on an active life despite failing
kidneys.

With hemodialysis, you'll need to:

Follow a strict treatment schedule

 Take medications regularly

 Make changes in your diet

Hemodialysis is a serious responsibility, but you don't have to shoulder it alone. You'll work
closely with your health care team, including a kidney specialist and other professionals with
experience managing hemodialysis. You may be able to do hemodialysis at home.

Why it's done

Your doctor will help determine when you should start hemodialysis based on several factors,
including your:

 Overall health

 Kidney function

 Signs and symptoms

 Quality of life
  Personal preferences

You might notice signs and symptoms of kidney failure (uremia), such as nausea, vomiting,
swelling or fatigue. Your doctor uses your estimated glomerular filtration rate (eGFR) to
measure your level of kidney function. Your eGFR is calculated using your blood creatinine test
results, sex, age and other factors. A normal value varies with age. This measure of your kidney
function can help to plan your treatment, including when to start hemodialysis.

Hemodialysis can help your body control blood pressure and maintain the proper balance of
fluid and various minerals — such as potassium and sodium — in your body. Normally,
hemodialysis begins well before your kidneys have shut down to the point of causing life-
threatening complications.

Common causes of kidney failure include:

 Diabetes

 High blood pressure (hypertension)

 Kidney inflammation (glomerulonephritis)

 Kidney cysts (polycystic kidney disease)

 Inherited kidney diseases

Long-term use of nonsteroidal anti-inflammatory drugs or other medications that could harm
the kidneys

However, your kidneys may shut down suddenly (acute kidney injury) after a severe illness,
complicated surgery, heart attack or other serious problem. Certain medications also can cause
kidney injury.

Some people with severe long-standing (chronic) kidney failure may decide against starting
dialysis and opt for a different path. Instead, they may choose maximal medical therapy, also
called maximum conservative management or palliative care. This therapy involves active
management of complications of advanced chronic kidney disease, such as fluid overload, high
blood pressure and anemia, with a focus on supportive management of symptoms that affect
quality of life.

Other people may be candidates for a preemptive kidney transplant, instead of starting on
dialysis. Ask your health care team for more information about your options. This is an
individualized decision because benefits of dialysis may vary, depending on your particular
health issues.

Risks:

Most people who require hemodialysis have a variety of health problems. Hemodialysis
prolongs life for many people, but life expectancy for people who need it is still less than that of
the general population.

While hemodialysis treatment can be efficient at replacing some lost kidney function, you may
experience some of the related conditions listed below, although not everyone experiences all
of these issues. Your dialysis team can help you deal with them.

 Low blood pressure (hypotension): A drop in blood pressure is a common side effect of
hemodialysis. Low blood pressure may be accompanied by shortness of breath,
abdominal cramps, muscle cramps, nausea or vomiting.

 Muscle cramps: Although the cause is not clear, muscle cramps during hemodialysis are
common. Sometimes the cramps can be eased by adjusting the hemodialysis
prescription. Adjusting fluid and sodium intake between hemodialysis treatments also
may help prevent symptoms during treatments.

 Itching: Many people who undergo hemodialysis have itchy skin, which is often worse
during or just after the procedure.

 Sleep problems: People receiving hemodialysis often have trouble sleeping, sometimes
because of breaks in breathing during sleep (sleep apnea) or because of aching,
uncomfortable or restless legs.

 Anemia: Not having enough red blood cells in your blood (anemia) is a common
complication of kidney failure and hemodialysis. Failing kidneys reduce production of a
hormone called erythropoietin (uh-rith-roe-POI-uh-tin), which stimulates formation of
red blood cells. Diet restrictions, poor absorption of iron, frequent blood tests, or
removal of iron and vitamins by hemodialysis also can contribute to anemia.

 Bone diseases: If your damaged kidneys are no longer able to process vitamin D, which
helps you absorb calcium, your bones may weaken. In addition, overproduction of
parathyroid hormone — a common complication of kidney failure — can release calcium
 from your bones. Hemodialysis may make these conditions worse by removing too
much or too little calcium.

 High blood pressure (hypertension): If you consume too much salt or drink too much
fluid, your high blood pressure is likely to get worse and lead to heart problems or
strokes.

 Fluid overload: Since fluid is removed from your body during hemodialysis, drinking
more fluids than recommended between hemodialysis treatments may cause life-
threatening complications, such as heart failure or fluid accumulation in your lungs
(pulmonary edema).

 Inflammation of the membrane surrounding the heart (pericarditis): Insufficient

hemodialysis can lead to inflammation of the membrane surrounding your heart, which
can interfere with your heart's ability to pump blood to the rest of your body.

 High potassium levels (hyperkalemia) or low potassium levels (hypokalemia):

Hemodialysis removes extra potassium, which is a mineral that is normally removed
from your body by your kidneys. If too much or too little potassium is removed during
dialysis, your heart may beat irregularly or stop.

 Access site complications: Potentially dangerous complications — such as infection,

narrowing or ballooning of the blood vessel wall (aneurysm), or blockage — can impact
the quality of your hemodialysis. Follow your dialysis team's instructions on how to
check for changes in your access site that may indicate a problem.

 Amyloidosis: Dialysis-related amyloidosis (am-uh-loi-DO-sis) develops when proteins in

blood are deposited on joints and tendons, causing pain, stiffness and fluid in the joints.
The condition is more common in people who have undergone hemodialysis for several
years.

 Depression: Changes in mood are common in people with kidney failure. If you
experience depression or anxiety after starting hemodialysis, talk with your health care
team about effective treatment options.
How you prepare
Preparation for hemodialysis starts several weeks to months before your first procedure. To
allow for easy access to your bloodstream, a surgeon will create a vascular access. The access
provides a mechanism for a small amount of blood to be safely removed from your circulation
and then returned to you in order for the hemodialysis process to work. The surgical access
needs time to heal before you begin hemodialysis treatments.

There are three types of accesses:

Arteriovenous (AV) fistula. A surgically created AV fistula is a connection between an artery and
a vein, usually in the arm you use less often. This is the preferred type of access because of
effectiveness and safety.

AV graft. If your blood vessels are too small to form an AV fistula, the surgeon may instead
create a path between an artery and a vein using a flexible, synthetic tube called a graft.

Central venous catheter. If you need emergency hemodialysis, a plastic tube (catheter) may be
inserted into a large vein in your neck. The catheter is temporary.

It's extremely important to take care of your access site to reduce the possibility of infection
and other complications. Follow your health care team's instructions about caring for your
access site.

What you can expect

You can receive hemodialysis in a dialysis center, at home or in a hospital. The frequency of
treatment varies, depending on your situation:

In-center hemodialysis. Many people get hemodialysis three times a week in sessions of 3 to 5
hours each.

Daily hemodialysis. This involves more-frequent, but shorter sessions — usually performed at
home six or seven days a week for about two hours each time.

Simpler hemodialysis machines have made home hemodialysis less cumbersome, so with
special training and someone to help you, you may be able to do hemodialysis at home. You
may even be able to do the procedure at night while you sleep.
There are dialysis centers located throughout the United States and in some other countries, so
you can travel to many areas and still receive your hemodialysis on schedule. Your dialysis team
can help you make appointments at other locations, or you can contact the dialysis center at
your destination directly. Plan ahead to make sure space is available and proper arrangements
can be made.

The procedure:
During treatments, you sit or recline in a chair while your blood flows through the dialyzer — a
filter that acts as an artificial kidney to clean your blood. You can use the time to watch TV or a
movie, read, nap, or perhaps talk to your "neighbors" at the center. If you receive hemodialysis
at night, you can sleep during the procedure.

Preparation: Your weight, blood pressure, pulse and temperature are checked. The skin
covering your access site — the point where blood leaves and then reenters your body during
treatment — is cleansed.

Starting: During hemodialysis, two needles are inserted into your arm through the access site
and taped in place to remain secure. Each needle is attached to a flexible plastic tube that
connects to a dialyzer. Through one tube, the dialyzer filters your blood a few ounces at a time,
allowing wastes and extra fluids to pass from your blood into a cleansing fluid called dialysate.
The filtered blood returns to your body through the second tube.

Symptoms: You may experience nausea and abdominal cramps as excess fluid is pulled from
your body — especially if you have gained a significant amount of fluid in between dialysis
sessions. If you're uncomfortable during the procedure, ask your care team about minimizing
side effects by such measures as adjusting the speed of your hemodialysis, your medication or
your hemodialysis fluids.

Monitoring: Because blood pressure and heart rate can fluctuate as excess fluid is drawn from
your body, your blood pressure and heart rate will be checked several times during each
treatment.

Finishing: When hemodialysis is completed, the needles are removed from your access site and
a pressure dressing is applied to the site to prevent bleeding. Your weight may be recorded
again. Then you're free to go about your usual activities until your next session.
Results:
If you had sudden (acute) kidney injury, you may need hemodialysis only for a short time until
your kidneys recover. If you had reduced kidney function before a sudden injury to your
kidneys, the chances of full recovery back to independence from hemodialysis are lessened.

Although in-center, three-times-a-week hemodialysis is more common, some research suggests

that home dialysis is linked to:

Better quality of life

Increased well-being

Reduced symptoms and less cramping, headaches and nausea

Improved sleeping patterns and energy level

Your hemodialysis care team monitors your treatment to make sure you're getting the right
amount of hemodialysis to remove enough wastes from your blood. Your weight and blood
pressure are monitored very closely before, during and after your treatment. About once a
month, you'll receive these tests:

Blood tests to measure urea reduction ratio (URR) and total urea clearance (Kt/V) to see how
well your hemodialysis is removing waste from your body

Blood chemistry evaluation and assessment of blood counts

Measurements of the flow of blood through your access site during hemodialysis

Your care team may adjust your hemodialysis intensity and frequency based, in part, on test
results.

Between treatments:
Between hemodialysis treatments, you can help achieve the best possible results from your
hemodialysis if you:

Eat the right foods. Eating properly can improve your hemodialysis results and your overall
health. While you're receiving hemodialysis, you'll need to carefully monitor your intake of
fluids, protein, sodium, potassium and phosphorus. A dietitian can help you develop an
individualized meal plan based on your weight, personal preferences, remaining kidney
function and other medical conditions, such as diabetes or high blood pressure.

Take your medications as prescribed. Carefully follow the instructions from your health care
team.

Allow your team to assist you by discussing your concerns. Your health care team can present
options to you and help you deal with any concerns.

What happens before hemodialysis?

Before you start hemodialysis, you’ll undergo a minor surgical procedure to make it easier to
access the bloodstream. You may have:

Arteriovenous fistula (AV fistula): A surgeon connects an artery and vein in your arm.

Arteriovenous graft (AV graft): If the artery and vein are too short to connect, your surgeon will
use a graft (soft, hollow tube) to connect the artery and vein.

AV fistulas and grafts enlarge the connected artery and vein, which makes dialysis access easier.
They also help blood flow in and out of your body faster.

If dialysis needs to happen quickly, your provider may place a catheter (thin tube) into a vein in
your neck, chest or leg for temporary access.

Your provider will teach you how to prevent infections in your fistula or graft. This provider will
also show you how to do hemodialysis at home if you choose to do so.

What happens during hemodialysis?

During hemodialysis, the dialysis machine:

Removes blood from a needle in your arm.

Circulates the blood through the dialyzer filter, which moves waste into a dialysis solution. This
cleansing liquid contains water, salt and other additives.

Returns filtered blood to your body through a different needle in your arm.

Monitors your blood pressure to adjust how fast blood flows in and out of your body.
What happens after hemodialysis?

Some people experience low blood pressure during or immediately after hemodialysis. You may
feel nauseous, dizzy or faint.

Other side effects of hemodialysis include:

 Chest pain or back pain.

 Headaches.

 Itchy skin.

 Muscle cramps.

 Restless legs syndrome.

Pros of hemodialysis:
When AV fistulas are used for vascular access, the risks complications of hemodialysis are
reduced.

AV fistulas for hemodialysis can last many years, longer than transplanted kidneys, catheters for
peritoneal dialysis and other forms of vascular access, with usually no need for additional
surgical intervention.

Hemodialysis at dialysis centers is done 3 times weekly leaving most of the week dialysis free.

Trained staff at the centers continuously supervise and monitor patient’s health and treatments

Hemodialysis at treatment centers allows for social interactions with people undergoing the
same process

Hemodialysis sessions can be used for work, reading and relaxation

Hemodialysis carries a relatively low risk of infection

Hemodialysis can also be done at home, at your own convenience. Hemodialysis done at home
is generally done daily, with assistance from a partner.

Nocturnal hemodialysis done at home is a relatively gentle form of treatment, leaving the
patient feeling stronger

Nocturnal hemodialysis allows for sense of normality and for regular work/school schedules

Cons of hemodialysis:
If hemodialysis is done in a clinic you will to travel to the clinic, and spend 3-4 hours there each
session.

Hemodialysis schedule must be stringently kept.

Travel is more complex, requiring advance planning and arrangements.

Diet and fluid restrictions must be adhered to strictly.

Fistula may seem ungainly and ugly to patient

If undergoing home hemodialysis, a partner must be home, and must be involved in the
nursing.

If done at home space, electrical and plumbing needs must be considered

Possible side effects include low blood pressure, shortness of breath and nausea.