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Dialysis  What clinicians should know

By Karen Parker, RN, HCS-D


Normal Kidney Function:  Remove water & waste  Keep chemicals/hormones in balance

 Help control B/P  Help make RBC  Help bones

Normal Kidney Function:  If your kidneys are failing, you may need dialysis

to help control your blood pressure and maintain the proper balance of fluid and various chemicals — such as potassium and sodium — in your body. Dialysis also helps your body maintain the proper acid-base balance.

 Sometimes kidney failure is caused by a specific

kidney disease. In other cases, it's a complication of another condition

Other Causes of Kidney Disease  Diabetes # 1 cause- 38.4%  High blood pressure (hypertension)- 25%  Kidney inflammation (glomerulonephritis)-

14.6%  Polycystic kidney disease- 7%  Inflammation of blood vessels (vasculitis)3.2% *American Kidney fund, 2012

Cost of ESRD  In 2003, ESRD cost private insurers and Medicare more

than $27 billion and was 6% of entire Medicare expenditures ($9 billion absorbed by private insurers)

 In 2009,10% of the population had chronic kidney disease

and costs 33.8 billion

 Annual cost over $60,000, with highest cost the year of

initiation of dialysis

 Dialysis 2.8 times more costly than transplant    


KidneyDis, 2003, 41 Am Soc Nephrol., 2005, 16 3Report to the Congress: New Approaches in Medicare, June 2004 4 American Kidney Fund 2012 2J

Burden of disease in U.S.  Rising incidence and prevalence of kidney disease at

all stages – ESRD doubled in last 10 years  4% of the U.S. population (8 million people) have moderate to severe CKD  Expected to increase with hypertension and diabetes and aging population  Expected at 2015 to increase from 450,000 ESRD now to 600,000

Impact  Those under 65, Medicare begins after 3 months on

dialysis UNLESS…  They have private insurance, then Medicare begins after 33 months on dialysis  Analysis for CKD progression (before ESRD) estimated that if GFR decreased by only 10% per person, almost $20 billion could be saved in 10 years3  Nearly 45% of ESRD attributable to diabetes and 20% to chronic hypertension4 

3, 4Journal

of Managed Care Pharmacy, April 2007

Physical issues with ESRD patients

 Fatigue – secondary to anemia  Itching – phosphorus  Vascular access patency  Sleep disorders

 Pain and restless legs

Symptoms of ESRD  Decrease appetite-bad taste in mouth or a metallic

    

taste Nausea & vomiting Trouble sleeping Swelling of the hands, face, peri-orbital, ankles Shortness of breath Tiredness-extreme

Who Pays for Dialysis  Commercial insurances do cover after deductibles

etc. are required to cover them for 30 months-then  Medicare pays for it.  If no insurance Medicare will pay starting 3 months after they start unless they are trained in homecare (peritoneal) then first day of the month that they started training.

Accesses  Fistula: Surgical procedure to connect an artery 

    

& a vein. Natural uses patient’s own Usually in the arm either lower or upper— surgeon choice, try to use non-dominate whenever possible Can be in leg/thighs, abdomens Lower chance of infection Lower chance of clotting Last longer Can take 3-6months to mature

Accesses- Cont..  Grafts: Surgical procedure that places a synthetic

tube that connects an artery & vein  Can be used generally 1-2 weeks after being placed  Allows a large volume of blood to be remove/replaced  Can develop clots over time  Increase chance of infection  Shorter life then a fistula

Accesses- Cont..  Catheters: Can be used immediately  Prone to infection

 Usually short-term  Decrease in flows making treatment times longer

Dialysis Options  Hemodialysis: In-center most common  In home-need to have a caregiver who is willing to take

responsibility for performing the treatments  Overnight-Fairly new in this area but has been around for several years, originally started as another option for those who in-center were having a hard time either making it to their appt. or completing a full treatment  In-center: Depending on the size of the center can be overwhelming esp for older patients  Some units have 10-15 patients at a time on & larger ones have 30-50 at a time depending on location

Criteria for starting  There are strict guide lines for this, it is dependent

on a variety of things, such as lab values, comorbidities, patient preference, acute illnesses, weight loss  When patients start they are generally very ill & have not felt well for quite sometime

Drugs – phosphate binders  Types:  - Calcium carbonate  - Calcium acetate (PhosLo - $0.20/pill)  - Sevalamer hydrochloride (RenaGel -$1.50/pill)  - Lanthanum carbonate (Fosrenol - $2/pill)  Noncompliance is common (frequently due to forgetting)

Cost can also be a factor, MSW & Dietician will help patient’s fill out applications for assistance if they qualify.

 In the Dialysis Outcome Study, fewer than 50% met the

guideline recommendations for phosphorus control

Depression  Actual clinical depression high  Interferes with compliance with treatment regimen

 Identify when patients may be ready to give up –

withdrawal from dialysis occurs in about 20% of dialysis patients before their death  Encourage evaluation by behavioral health, PCP, or nephrologist for an SSRI

Anemia  Goal: keep Hgb. 10 – 11 gms/deciliter  Iron levels are monitored and iron given IV

 Epogen given to combat anemia, but inappropriate

use increases mortality  Anemia can lead to LVH and CHF

Problems that occur during hemodialysis  Cramping – due to volume changes  Hypotension – ultrafiltration with

inadequate vascular refilling  Arrhythmias – fluid and electrolyte changes  Hypoxemia – in 90% of patients, pO2 drops 5 – 35 mm Hg.  Hemolysis – biochemical and toxic insults. Half life of RBC is ½ to ⅓ of normal RBCs.

Medical complications of ESRD and dialysis

 Anemia – erythropoeitin not produced in kidney  Bone disease – calcium and phosphorus imbalance

 Hypertension – primary disease, fluid retention  Fluid overload – little to no output of kidneys  Pericardial effusion and pericarditis – inadequate

dialysis, fluid overload, and infection  Hyperkalemia – inadequate dialysis and noncompliance with dietary restrictions  Peripheral neuropathy – uremic toxins  Infection of vascular access

Emotional/psychosocial issues  Change in social position/role in family  Marital problems  Employment – loss of  Impaired libido and impotency  Diet  Compliance or motivation to comply  Appearance and clothing restrictions  Frequent loss of independence and control  Depression (upwards of 40%) and anxiety  Reported increased incidence of cocaine, heroin, and

methamphetamine use

Reasons for ER or hospitalization  Clotted access (decreased inpatient 24% as these

have moved outpatient)  Infection – due to catheter use, up 23% in last 10 years  CHF due to fluid overload/anemia  Cardiomyopathy  Hyperkalemia  Hypertension  Co-morbid conditions

Dry weight  This is what their weight would be without the

excess fluid, this is set by MD  Can take several weeks for this to be established & can change based on several factors  Dialysis does not remove muscle or fat, it removes fluid & toxins, many patients will report that they had a huge meal & that is why their weight is up  Most patient have been sick for a long time prior to starting so their EDW can be challenging in the beginning

What is a hemodialysis treatment like  A patient comes in & they remove outer clothing   

& get weighed, then they are escorted to their machine Newer machines are very eff. & take a little less time to get prepped & get a patient “on” Concept of osmosis & pressure gradient using acid & base & artificial kidney Fistula/graft are accessed using either 14 or 16 gauge needles—beginners start with 16 or 18 gauge depending on overall body size, graft age, fistula age Catheters are connected to lines

What is a hemodialysis treatment like- Cont..  The machines are programmed for the time &

amount of fluid to be removed, most can only handle 1k removal /hour. If patients are more then 5k over their dry weight they will leave with fluid still on them, some may need to return the next day for an extra treatment, reason for this is it is too much stress on heart.  A patient can bleed out & die within 8 minutes should they accidently pull needles out or become disconnected during a treatment.  Every patient is at all times in either a nurses view or a tech’s view  Room is open very little privacy while there

What is a hemodialysis treatment like- Cont..  New facilities have individual TV’s, patient’s can read, nap, or

    

do other activities as long as it does not decrease flow or cause problems with the return during the treatment, machines will alarm/flash When treatment is complete the blood is returned to patient using as little saline as possible, the sites are held for 5mins or longer depending on if they are on coumadin etc. They are weighed after every treatment as well Dialysis labs are drawn off the line/fistula/graft Patient’s often complain if being cold, at any given time during their treatment they have at least a pint of blood outside their body. During every treatment a small amount of blood is lost, coagulates or stays in the dialyzer /lines

What is a hemodialysis treatment like- Cont..  It may take up to 3-4 weeks of treatments before they

start to really feel any impact  Most patient are encouraged to take a nap after their treatment as they will feel better when they wake up  Most feel pretty good on the day after their treatments.  Can travel

Complications  Natural disasters: Patient’s still need to be

dialyzed. Most units have back-up generators. Staff will look at the weather & plan accordingly—have patient’s come in earlier/later  Only 2 holidays a year –schedules are changed as the patient’s still need their treatment Thanksgiving & Christmas  Cardiac arrest  Fire or other disaster that requires an evacuationmost in center patients are taught how to re-infuse their blood, still need staff to help disconnect/remove needles

What can Homecare nurses do to help these patients  Remind patients about their binders  Remind & teach fluid restriction  Remind patient’s that over the counter & herbals

should all be brought to the Dialysis staff/Nephrologists before taking or any changes any of their other doctors order

 Check for bruit & thrill if they have fistula or


What can Homecare nurses do to help these patients- Cont..  Check Central/tessio catheters that the tips are

covered, caps in place, no wetness, Remind patient that they cannot get these wet—showers with hand held devices so that they do not get these wet is ok but generally discouraged as patient’s don’t always know that they have gotten them wet.

 Remind patients not to sleep on the extremity that

has the fistula/graft in. Also no constricting clothing or watches on that extremity

What can Homecare nurses do to help these patients- cont…  Both fistula & grafts need to be checked several

times a day for bruit & thrill  Hear a bruit—feel a thrill  Notifying MD if either or both are absent ASAP  Never put ice on either as can cause clotting  Avoid constricting items/clothing  Treat/teach “Life line”  Pressure dressing placed after removal of needles— can be removed 4-6 hours later

What can Homecare nurses do to help these patients- cont…  The nephrologists reviews the meds on all new

patients & lets the staff & patient know if they should hold their B/P meds on treatment days— generally they are held  Weight gains between treatments: MD’s like 11.5kg weight gains occasionally this is lower (2.2lbs=1kg)  Working on developing a fax communication that would have patient specific’s.

Fluids & Diet  Fluids: anything at room temperature that is a liquid:  

 

pudding, gravy, ice chips, syrups Fluid restrictions are based on remaining kidney function if any Teach to take a container & either remove or add every time they have fluid, when they reach either full or empty they are done for the day—this includes water to take meds. This gives them a visual of how much they have already taken in or how much they have left for the day Protein, Sodium, Potassium, Calcium & phosphorus-Ask to see what the dietitian has instructed them on Most are restricted on all these

Diet  Limited in phosphorus, potassium, sodium, and

fluid  Processed meat and cheese, dried fruit, beans, peanut butter, and eggs are high in phosphorus  Challenge is to obtain enough protein and calories to prevent cell breakdown  More challenging with diabetes and other dietary restrictions, such as low fat for heart disease

Meds  Importance of binders: What are they & Why so important  Phosphate binders: hold onto the phosphorous in the

  

food/fluids that we eat so it can be removed/excreted via stool Remind to Bind whenever they have a meal or large snack, need to take/eat them immediately prior to/during meal/after a meal Several different types Renagel, Phos-lo, Tums, Velphoro (New med 2014) Phosphate binders can cause constipation

Meds- Cont..  B/P meds usually held on day of dialysis depending on time

  

of treatment, if am time will hold until after treatment if in pm will take earlier—if unsure check with dialysis center Potassium supplements—should send warning flags, typically do not see ESRD patients who are on hemodialysis on these. May see peritoneal patients on low dose. Also watch for herbals as many of these contain potassium, ie: St. John’s Wart Teach warning signs of high potassium: rubbery legs, weak/”feel like a worn out dish rag”. Calcium supplements should be taken between meals When in doubt about any meds check with the dialysis center or nephrologist

Meds- Cont..  Remind patients to take their med list with them,

also to let the staff know if any other MD has started them on a new med for any reason.  General rule of thumb for gaining weight between treatments—1-1.5kg (2.2lbs=1kg)  MD’s review the meds on new patients & lets the staff & patient know which meds to hold, most B/P meds are held on treatment days  Remind patient’s to take their binders & of their fluid restriction

Complications  Renal bone disease: can occur when calcium & phosphorus

 

  

are out of balance, calcium is removed from bone & circulates in blood causing increase is serum calcium, once corrected calcium will redeposit & cause bone malformations Anemia: procrit/epogen , RBC production of healthy RBC decreases with ESRD,life cycle of RBC normally 90-120 days in ESRD generally less then 90 days Patient’s that have a severe drop in B/P can lose their graft/fistulas—they will clot Patient non-compliance- end their treatments early, cancel treatments Diabetic whose treatment time is during a meal time Cramping Restless legs

Transplants  Patients referred to a transplant hospital  Long process

 Live donor vs cadaveric  Long term anti-rejection meds  Rejection can occur frequent checks for early

detection  Acute illnesses can cause rejection  Not a cure

Accesses 

Before you start hemodialysis, a surgeon creates a vascular access point for blood to leave for cleansing and then re-enter your body during treatment. There are three types of access points:

Temporary access. If you need emergency hemodialysis, the surgeon may insert a plastic tube (catheter) into a large vein in your neck or near your groin. The catheter is temporary. If it's left in place for too long, you face a risk of infection, clotting in the catheter and stenosis (narrowing) of surrounding blood vessels.

Arteriovenous (AV) fistula. A surgically created AV fistula is a connection between an artery and a vein, usually in the forearm. Once the connection is made, faster flowing arterial blood flows into the vein — causing it to grow larger and stronger. This makes repeated needle placements for hemodialysis easier. An AV fistula may take six weeks or longer to heal, but it can last for many years. An AV fistula is less likely than other types of access points to form clots or become infected.

Arteriovenous (AV) graft. If your blood vessels are too small to form an AV fistula, the surgeon may instead connect an artery and a vein with a synthetic tube. This tube functions like an artificial vein, usually in your forearm or upper arm. An AV graft often heals within two to three weeks. With proper care, an AV graft may last several years — but it's more likely to form clots and become infected than is an AV fistula.

Accesses- Care  Vascular access is a vital part of hemodialysis. Take special

care to prevent injury and infection:

 Keep the access area clean.  Don't use the arm with the access point for blood pressure readings or      

to draw blood samples not associated with the dialysis treatment. Don't lift heavy objects or put pressure on the arm with the access point. Don't cover the access point with tight clothing or jewelry. Check the pulse in the access point every day. Ask the nurse or technician to check the access point before each treatment. Don't sleep with the access arm under your head or body. If your access point stops working, the surgeon can create a new access point in your other forearm, your upper arm or your groin. Or you may consider peritoneal dialysis, another type of dialysis done through a catheter inserted in your abdomen.

What if a Patient decides not to start or to stop dialysis  Patient’s can choose not to start, but generally they

or family are in an emergent situation & the decision needs to be made immediately  Dying from Kidney disease is generally not painful, but can be uncomfortable from the fluid build up or the toxins building up  Some may decide to stop dialysis  Typically do not die from Kidney failure but rather from complications

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