ABCs of Kidney Disease | Treatment Options for End-Stage Renal Disease
>> Hi, I’m Su Thavarajah. This is a presentation ofthe “ABCs of Kidney Disease,”Treatment Options forEnd-Stage Renal Disease. “This is a video in the seriesof the Johns Hopkins NephrologyPatient Education Programs,made possible through the fundingof the Edward Kraus Endowment Fundand the Shaw Foundation. So this section isgonna focus on treatmentof end-stage kidney disease. When the kidneys fail,we either call it end-stage renal diseaseor end-stage kidney disease. And then we have two optionsfor being able to replacethat kidney function. Either we can filter the bloodvia something called dialysisor we can transplant a new kidney. Now, in this presentation,we’re not gonna focus on transplant,that will be a different presentation. So dialysis is a term for us having a wayof artificially removing the wasteand extra fluid from the blood. And this happens when ourkidneys can no longer do this. There are two major types of dialysis,hemodialysis and peritoneal dialysis,and we’re gonna talk about both of thesedifferent types ofdialysis in further depth,but basics is thehemodialysis is another wayof cleaning the blood. The peritoneal dialysis,we’re not using a machinebut more using the innerlining of our abdomento clean the blood. Both types of dialysis,though, require surgeryfor a dialysis access, sothey do require some planningbefore we can get started with it. Now, neither type of dialysisis better than the other,so it’s really a matter ofgetting that informationabout the different types of dialysisand having that discussionwith your healthcare teamto figure out what’sthe best option for you,and what you’ll be most comfortable with. This is a picture that demonstratesthe basic setup of hemodialysis. And the principle is, there is some wayof getting blood from the individual,’cause remember, our kidneyswere cleaning our bloodduring the course of the day. They’re overall cleaning about 180to 200 liters worth of blood. During a dialysis treatment,we have to have another wayof getting the blood from an individual,and we run it through a machine,and through what we callan artificial kidney,or a dialyzer. The cleaned blood then isreturned back to the patient. So we have to have a way of being ableto get that blood out of the individual,into the machine. And so we focus on the starting point,the hemodialysis access. There are three major types,and we’re gonna talk aboutthe three types first,before we show you anyof the models of them. There’s the fistula, which is a shuntthat is created between yourown artery and your own vein. There’s no artificial material in it. This procedure is performedby a vascular surgeon. It takes about six to 12 weeksbefore it’s ready to be used,and the procedure itself is asame-day outpatient procedure,and a lot of times it doesn’t even needto be done under general anesthesia. The process starts by you being referredto the vascular surgeon,having an evaluation. They might do an ultrasoundof the veins in your armto figure out if you’re acandidate for a fistula. Sometimes people have veinsthat are either too smallor have been damaged over the yearsfrom different other medical treatments,and they don’t have veins thatcould be used for a fistula. In those cases, we use synthetic material,which we refer to as a graft,that would be the way ofconnecting that arteryand the vein. Now the shunt, because it’salready the right size,and it’s already pre-designedfor this purpose,only takes a couple of days to weeksbefore you need to use it,so a little less planningbefore you need to getstarted on dialysis. The third category is the catheter,and this is typically the onethat we try to minimize the use of,because it’s the highestrisk of infection. But it is the way we can startdialysis on an urgent basisif we need to start it the same day. This is a special IV linethat’s of the larger size,to be able to carry enough bloodfor the dialysis treatments,and it’s done in radiologyor in the operating room,and it can be used right away. So now we’re gonna takea look at the modelsof the hemodialysis access,reviewing the three different typesthat we just looked at on the slide. The first one is the fistula,and the second one isthe hemodialysis graft. Both of these are in this model here. One of the key things to look atis that there’s nothingoutside of the body,and this is why it’s reallythe lower risk of infectionwhen you have a hemodialysisfistula or a graft. Once you get past the original surgery,when you have the sutures,you won’t be needing any bandages,you won’t have any restrictionsin terms of bathing, showering, swimming,or any issues like that. We do ask you not to behaving any blood drawsor have a blood pressuremeasured on that arm,because then you could damage the access. What would happen duringthe dialysis treatment,is a nurse would put a tourniquet,just like when they’re drawing blood,that would cause the veinof the fistula to pop up. And then they would put a needle induring the treatment. Those needles would then stay induring the course of the treatment,and then be removed atthe end of the session. At the end of the session,they would put some pressureon there for about 10 to 15 minutes,and then you’d have a bandage on therefor about three to four hours. After that, you could remove the bandage,and then just not need tohave anything on there. Now, this lower part of the armis what we call a hemodialysis graft. Unlike when our veins inour arm might be too small,we sometimes put a pieceof synthetic material,tubing called a graft, in to connectthat artery in the vein. And this is a nice representation of thisbecause it’s in the lower part of the arm. Same type of principle for the fistula,the dialysis nurses wouldput two needles in itduring the course of the dialysis session. They would remove those needles,put some pressure on those pointsat the end of the treatment,and then you would have a bandage on therefor about three to four hours. The benefits of this, of course,are the reduced risk of infection,and the fact that youdon’t really have anythingoutside of your body duringthe dialysis session. So the third type of dialysis accessis the hemodialysiscatheter, and this is the onethat we can use right away. Now, a key part of this is this catheterhas to be a larger sizethan any of the typical IVsthat you get in the hospital,or the emergency room. And it needs to be a big enough sizeto have enough blood flowfor the dialysis treatment. Because of that, it’s gonna alwaysgo into one of the bigger blood vessels,and the tip is typically going all the wayto the level of the heart. Another challenge with these cathetersare there’s a large portion of itthat’s outside of thebody, so that’s wherethat increased risk of infection is. And so when we look at the catheter modelfrom this little blue piece here,that portion is alwaysoutside of the body,just under the skin surface. Now, when we have these catheters placed,they’re typically put in, or tucked inunderneath the collarbone,so you can’t see it whenyou’re wearing your shirtsor anything like that, butit is a large portion of itthat can get caught onthings, and can get infected. Now, because so muchis outside of the body,there is the risk of infection,so we are really carefulabout not getting these wet. So when you’re showering or bathing,you really can’t get this catheter wet,you really cannot be swimming,and the dressings arechanged by the nurseswhenever you come in foryour dialysis treatment. Now, these cathetershave two ports to them. During the treatment, thenurses would remove the capsand hook them up to the linesfor the dialysis treatment itself. At the end of the treatment,they would unhook the lines,and then just put new caps on ’em,and that’s how the catheter would stayuntil your next dialysis session. When we talk about hemodialysis,there are two different types,in-center hemodialysis,and home hemodialysis. So in-center, it’sperformed in a dialysis unitby medical staff. It’s happening three days a week,and often for about three to four hours. So when it’s three days a week,you’re either going on a Monday,Wednesday, Friday schedule,or a Tuesday, Thursday, Saturday schedule. There’s no training involved,because the treatmentis taken care of by the staff there. Now, when you come in for treatment,you’d be weighed before,and at the end of the each treatment. That’s how the staff figures outhow much fluid to takeoff with each session. They’re checking the blood pressure,the heart rate, and thetemperature before the treatmentand then every 15 to 30 minutesduring the course of the session. Blood work is often checkedduring those treatments,so you’re not havingto be going to the labon a separate basis. Also, certain medicationsthat you had been taking beforehandare either gonna be replacedby the actual dialysis treatment,or they’re gonna be givenduring the dialysis session,so a lot of times yourmedication list is changingonce you get started on dialysis. Now, because you’re goingto the dialysis unitthree times a week,you’re gonna be seeing your kidney doctorthere at the dialysis unit,instead of going to their office. So what are the downsides?The fact that you have a set schedule. You’re gonna have an appointment timeon a Monday, Wednesday, Friday. So you have to plan ahead ifyou need to be reschedulingfor another doctor’s appointment,or for going out of town. And it’s a little moreof a restricted diet. Remember when your kidneyswere doing the work,they were doing thework seven days a week. Now we’re gonna try tocompress that into treatmentsthat are happening justthree times a week. Now, home hemodialysis,we’re using the sametype of dialysis accessthat we are using for in-center,it’s just it’s a different machine. This treatment is gonnabe performed at homeby you and a partner. The sessions are happeningabout four to six days a week,and each session’s abouttwo to three hours. Training typically takesabout four to eight weeks,but if you need a little bit longer time,no one is gonna be releasingthat machine to you,or expecting you to do thatearlier than you’re ready to. During the training, you’dlearn about weighing yourself,checking your bloodpressure, your heart rate,how to access your hemodialysiscatheter or fistula,and how to draw yourlabs, and how to set upand take down the machine. Now your partner would learn about moreof the emergencytechniques, and we requirethat the partner would be therewhile you’re doing your treatments. You will still be coming to the clinicto followup with the dialysis nurseand the doctor about oneto two times a month. The downsides of the homehemodialysis treatmentsare that you do need tohave a partner at home,so this might be a limiting factorfor some people being ableto choose this as an option. Additionally, you needa lot of space at homefor all of the supplies. They’re shipped out on a monthly basis,so if you’re not in astable home situation,this may not be the best option for you. And we’re gonna take a lookat the home hemodialysis machine. So this is a model of ourhome hemodialysis machine. So as you can see, it’spretty self-contained. The front of it is a pretty user-friendlytouchscreen button, so it’s easyto be able to monitor the different steps,and be able to pull off the informationthat you need. This is considered medicallife-saving equipment,and so when you’re traveling,they have to make accommodations. These do not get checked,these are not in baggage claim. These are taken with you,and all of your other suppliescan be shipped to your destination. There isn’t any specialized changesthat you’re gonna needto make in your house. We do make some checksfor our home safety checkto make sure that it’ll be appropriatefor the electrical outlet,and things along that line. This equipment is not owned by you,it is owned by the dialysis company,and so therefore you don’t have to worryabout the maintenance. If there are issues with the machine,the company will switchout the machine for you. But the key parts of it, thatit is very user-friendly,and just simple things ofbeing able to pull a lever,pop in a cartridge, and a very easyuser-friendly touchscreen. The other type of home dialysisis peritoneal dialysis,and this one takes advantage of the factthat we all have a thinlayer, or membrane,on the inside of our abdomen,which can work as afilter to clean our blood. And we use a fluid thatgets piped into the abdomenand sits in there and pullsout all of the waste products. This treatment only takes place at homeand also requires training. Now there are two differenttypes of peritoneal dialysis,and an individual, when they’re trained,is trained on both options. There’s the manual exchanges,which don’t require anyspecialized equipmentor electricity, and a cycler,which about 90% of those individualswho are on peritoneal dialysis are using. Now, we start off with aperitoneal dialysis catheter,and when we talked abouta hemodialysis access,that required a lot more planning. The peritoneal dialysis cathetersonly need to be placed about one monthbefore you need to start the treatments. It takes about two to four weeks to healbefore the nurses can startflushing the catheter,and doing some of the exchanges. And then about fourweeks after the placementof the PD catheter, youcan fully use the catheter,and we can start doingsome of the training. And this picture is a image of someonewith a peritoneal catheter,and we have the modelthat we will be showing you as well. So this is our model of aperitoneal dialysis catheter. As you can see, it’s in the lower abdomen,and about 90% of our cathetersare in the lower abdomen. Sometimes they are put in the chestbecause of different considerations,but most of the time theyare in the lower abdomen. As you can see, there’sa portion of tubingthat’s outside of the body. Now, this is the portionthat will always be outside. Usually, people have this coiled upunderneath a gauze, or a belt,so it’s not getting in the way,or getting caught on their clothing. The catheter itself is anchoredjust underneath the skin surfacein two different places,and the rest of the catheteris coiled, freely floating in the abdomen. Now when you are doing your exchanges,you would be unrolling this,and hooking it up to the different ports. You’d take the cap off andhook it up to the tubing here. Now, because this catheteris in the lower abdomen,and you can see where it is on the body,you have to be careful if you’re soaking,you really can’t be soaking in a tub,you really can’t be taking tub baths,or a hot tub. Saltwater is okay, but not swimmingin a general pool. So these are all considerationsin your lifestylewhen you’re making a decisionabout doing peritoneal dialysis. So how does peritoneal dialysis work?It starts off with a specialfluid called dialysate. That fluid is put into theabdomen through that catheter,it sits in the abdomen fora certain amount of time. It either will be sitting therefrom about four to six hours,depending on someone’s body size,and the nature of theirperitoneal membrane. It’s pulling all the waste products out,it’s pulling all that extra fluid. That all gets drained outafter about four to six hours,and new fluid is instilled in. So while the fluid issitting in the abdomen,it’s pulling out all ofthose waste products,it’s pulling out extra waterand all of the chemicals. And this dialysate, becauseit doesn’t contain any blood,will then be able to bepoured down the drain,or in a toilet, and discarded. So peritoneal dialysis isperformed only at home. There’s not a requirement for a partnerbecause there’s no direct access to blood,so there’s less risk ofany emergency procedures. The training itself takesabout two to six weeks. During the training you’re learninghow to check your weight,your blood pressure,and how to determine whichof those dialysate fluidsto be using. You’re doing the exchanges,either doing manual exchangesabout three to four times a day,depending on your body size,or you’re doing somethingwhere you’re using a machinecalled a cycler, wherethat’s gonna do the exchangesduring the course of the night. Sometimes people will bedoing a combination of both. It’s really gonna be individualized,based on what your body needs. There are some downsidesto the peritoneal dialysis. You do need space at home,you’re getting those shipment of materialsabout once a month. So if you’re not in astable home situation,it’s harder to be ableto do this treatment. The other thing is thatthe dialysate fluidhas a high amount of sugar in it,and so sometimes it can be more difficultto control your diabetes. Now, in this picture, it’sstarting to demonstratehow someone is connectingbetween the different dialysate bags,and doing the connections. And we’re gonna show you the modelthat will show the manualexchange and the cycler. So for peritoneal dialysis,it’s done in two different ways,there’s the manualexchanges and the cycler. Now, during the training,you’re gonna be trainedon both types, both themanual and use of the cycler. Most people will tendto be using the cycler,and doing all of theirexchanges at nighttime,but the manual gives you that opportunityif you’re traveling for one night,or if there’s a power outage,you still have a way ofdoing these treatments. Sometimes people might need to do both. Now the manual exchangesall work basically with gravity. So if you have this peritonealfluid in there already,the dialysate fluid in, whenyour time to do your exchange,you would take yourcatheter, remove the cap,hook up to the line here,and then this bag would,you wanna imagine thisbag would be on the floor,because the bag is gonnabe draining to gravity. The fluid that’s sitting in your abdomenwould then drain intothis bag, fill the bag,and then once that baghad finished draining,you would open up the next larger,the new fluid bag, andthen drain that fluid in,and then leave that in forabout four to six hours. You would go through that process,the actual process itself,between draining the old fluid,and then putting the new fluid in,should take about 30 minutes. If it takes a little bit longer,then we might do some troubleshooting. For many people, theyare using the cycler,and the cycler is amachine that, at nighttime,they would be hooking up toabout 10:00 p. m. at night,and stopping the treatmentsmaybe about six in the morning. The cycler is designedto have all of theconnections already made,with all the bags of fluid,so that the machine would bedoing all of those exchanges. It also has a touchscreen to it,and then it would allow you to knowwhen it’s draining, how much it’s drained,and then the next bag offluid that it’s instilling. The lines for this cyclerare a little bit longer,so you do have theability to get out of bed,you don’t necessarily have to disconnectfrom the machine. Now, typically, if somebodyis using the cycler,they’re running their treatmentsthrough the course of the night,at the end of the nightthey would disconnectfrom the machine. Depending on their body sizeand what their prescription is,they might do a manual exchange,and carry that on through the day,or they might not have any fluid,and not have to do anythinguntil later that evening,when they would hookup to the cycler again. So who’s not a candidatefor peritoneal dialysis?You know, if somebody has hada lot of abdominal surgeries,they may have developeda lot of scar tissuein their abdominal wall,and that would prevent themfrom being able to filterthe blood appropriately. If they’ve had a issuewhere they have a VP shunt,where they’ve built up fluid on the brain,and they have a VP shunt,that could get infectedif they’re on peritoneal dialysis. If they’ve had an abdominal cancer,there’s always a risk thatthey could be spreadingsome of those cancer cells,so we don’t typically allow individualsto do peritoneal dialysisin those settings. And then the last category,if somebody has liver diseasewhere they already arebuilding up a lot of fluid,called ascites, they may not toleratehaving more fluid in their abdomenfor the peritoneal dialysis. So how do you choosewhich type of dialysisis the best one for you?You pick which one suits your lifestyle. You can transition from onetype of dialysis to the other. Neither type of dialysisis better than the other,both types have good outcomes. It’s more important to find the onethat you’re more comfortable with,and that’s gonna fit your lifestyle,because then you’re gonnahave better results. And if you wanna learn more informationabout treatment options forend-stage kidney disease,or end-stage renal disease,please refer to the following resources.