What is dialysis?

Commitment is being dedicated to a cause, activity, or something without reservations.

When a patient needs dialysis treatment, their commitment is important because if they are not

100% committed, then more serious health problems will unravel. Hemodialysis is my life

currently and being a dialysis technician comes with great responsibilities. Everyday I see

patients who are committed and try hard to remain as healthy as possible and others who have

just given up. It’s tough being at work seeing a patient’s blood sugar running in the 500’s, which

is dangerously high (normal range for blood sugar is 70-120) and see them refusing dialysis

treatment, since they are tired of fighting. This life-saving treatment, although both physically

and mentally draining, is a necessary evil to combat end stage renal disease.

Diabetes, obesity, smoking, high blood pressure, family history, and countless other

factors heightened the risk that will increase someone’s chance of getting chronic kidney disease.

Dialysis starts with someone who has Chronic Kidney disease which entails the kidneys

beginning to lose function and stops filtering out waste and excess water like they are supposed

to. When kidneys do not function properly, the body has toxic levels of waste that show in lab

work. Two big symptoms in kidney failure are swelling, because the body is not getting rid of

excess fluid and fatigue. Across America, chronic kidney disease gets diagnosed in more than 1

out of every 7 people. The National Institute of Diabetes and Digestive and Kidney Diseases has

a website that shows statistics on chronic kidney disease, talks about awareness, and gives all the

information that is needed to understand what chronic kidney disease is. Chronic kidney disease

has 5 stages, which is determined by a blood test called eGFR or estimated glomerular filtration

rate and Albuminuria. This test estimates the waste products that is in someone’s blood and if the

eGFR number is low, that indicates that the kidneys are not functioning where they are supposed
to. Normal eGFR range for adults is greater than 90 (National kidney foundation). In Stage 1 of

chronic kidney disease, the kidney is damaged, but there is still normal kidney function with an

eGFR result of 90 or greater. In Stage 2, the kidneys are damaged with there only being mild loss

of function in the kidneys, with a test result being between 60-89. Stage 3 has mild-to-severe loss

of kidney function, with an eGFR at 30-59. Stage 4 has severe loss of kidney function bringing

their eGFR down to 15-29. Lastly, Stage 5 is End stage renal disease, which requires dialysis or

transplant for survival (National Institute of Diabetes and Digestive and Kidney Diseases). In

Stage 5, the eGFR blood test result is below 15 and the kidneys are in the worst condition. End

stage renal disease is very serious, and everyone should be more aware of this disease and the

effects it has on the patients and their families. Albuminuria is the other test that is taken to test

where kidney function is at. If we break down the word albuminuria, albumin is a protein that

keeps fluid in the bloodstream, while uria is a medical term that stands for in the urine.

Therefore, albuminuria is a urine sample that test the amount of protein in someone’s urine.

Since we now know what chronic kidney disease is, what causes someone to get into Kidney

failure?

Normal kidney function eliminates waste from your body and removes extra fluid. They

also make sure your potassium and sodium levels in your blood are at normal range. Kidney

failure is when your kidneys lose function and no longer filter out waste and excess fluid from

someone’s blood. There are a lot of things that can cause someone to be in kidney failure, but the

main three are diabetes, high blood pressure, and glomerular disease. These three alone covered

83.5% of people who were on dialysis in the years of 2010-2014. Type 2 diabetes is the leading

cause for people to be on dialysis because of how common it is in America. With type 2 diabetes,

someone’s body is either not producing insulin or rejecting the insulin your body creates, which
causes too much sugar in their blood. The kidneys then must work harder to filter the sugar out

of the blood, which can lead someone into kidney failure. High blood pressure is the second

leading cause of kidney disease. Extremely high blood pressure can harm the blood vessels that

lead to the kidneys, which again, over time, can cause someone to be in kidney failure. The third

highest cause of kidney failure is glomerular disease. Glomerular is a cluster of blood vessels

around the end of a kidney tubule. Glomerular disease can be caused by a couple different things,

including diabetes, an infection, or a drug that is harmful to your body (Core Curriculum for the

Dialysis Technician). Now that we understand why people get put on dialysis, what is dialysis?

Fig. 1 This image shows the process for hemodialysis for a fistula and a graft, showing where the

blood gets pulled from and what the blood goes through before it returns to the body (NIKKISO

CO.)
 Dialysis is what removes excess fluid and waste from a patient’s blood since their

kidneys aren’t functioning anymore. How does this whole process happen though? There are two

types of dialysis treatments that someone can choose from, hemodialysis or peritoneal dialysis.

Hemodialysis acts like a kidney, since a dialysis patient’s kidneys don’t function properly.

Before a patient receives hemodialysis, they need an access site for the technician. There are

three different types of access sites that hemodialysis patients can chose from, which are a

fistula, graft or catheter. The Core Curriculum for Dialysis Technician by Medical Education

Institute describes everything about the three in detail. A fistula is created by a surgical

procedure that joins a patient’s artery and vein together. A fistula is under the skin on either one

of the patient’s arms, usually the non-dominate side. At the site where the vein and artery

connect is an anastomosis (medical education institute). The fistula may not be accessed until 4-6

weeks after the procedure. To access a fistula, a technician will take two needles and stick one

needle in the arterial side and the other in the venous side of the fistula. Once the needles are

taped down and secured to the patient’s body, they can now be connected to the hemodialysis

machine. The tubing that is hooked up to the machine is then connected to the end of the needles

to begin the treatment process. The blood is then pulled from the arterial needle and starts to

make its way through the machine’s pumps and to the dialyzer. The dialyzer is the kidney of the

hemodialysis machine where the blood flows through tiny fibers and removes the excess fluid

and waste. After the blood goes through this filter process outside of the patient’s body, it then

can be returned to the patient’s body through the venous needle. A graft is similar to a fistula, but

the vein and artery are joined together by a soft tube. Grafts are then accessed the same exact

way as the fistula, by two needles with one in the arterial and one in the venous side. Finally, a

catheter is a piece of tubing that is placed in a large vein, which is a common site in the superior
vena cava. The catheter contains two lumens (one arterial and one venous) that are used to

connect the patient up to the machine. A fistula is usually the recommended choice out of the

three because of the smaller chance of infection and the access site lasts longer (National Kidney

Foundation). Hemodialysis can be completed either at home or in a dialysis facility. For

hemodialysis at home, patients can get their dialysis treatment for 7-8 hours at a slower rate

while they are asleep or at any time during the day for about 2.5-4 hours at a faster rate.

Hemodialysis in a dialysis clinic or hospital gets completed 3 days a week for roughly 3-4 hours.

One of the biggest challenges with hemodialysis in a facility is patients not wanting to be at a

hospital 3 days a week, or not having transportation to get them there that often.

Fig. 2 This image show a visual representation of what a hemodialysis catheter looks like near

the heart (Preferred vascular group).

membrane to clean the blood (medical education institute). Dialysate fluid is filled into the

peritoneal cavity through the PD catheter by using gravity. This process takes about 20-30

minutes, then the dialysate fluid is drained out by using gravity once again. The main difference

between hemodialysis and peritoneal dialysis is that in peritoneal dialysis, a patient’s blood is

filtered inside their body whereas on hemodialysis, the blood is filtered on the outside. The most

common complication for peritoneal dialysis is peritonitis. Peritonitis is an infection of the

peritonea, which is very painful and peritoneal treatment after this may not be possible anymore

(Medical Education Institute).

Fig. 3 This image shows the process for Peritoneal dialysis. Dialysate fluid hangs high as gravity

pushes fluid in to the peritoneal space, then drains with gravity back into a bag (Desai).

Fistula and grafts can also have complications during use which is important to look out

for. A common complication is infiltration. Infiltration happens when the dialysis technician
sticks the patient with the needle and the needle punctures through the both walls of the access.

A great example to help understand infiltration is thinking about a time where you have gotten an

IV and the surrounding area swells up and starts to hurt. This simply means the IV catheter could

have moved out of proper placement and the IV is now bad which can lead to painful bruising.

Another complication is bleeding during or after hemodialysis treatment. The needles that are

used during treatment are a 15-gauge needle which is roughly 1.8mm thickness. Due to the size

of the needle, a strong pressure needs to be held for 10 mins after the needle is removed, or the

patient can lose a good amount of blood. Its also important to make sure the needles are secured

down well with tape during treatment which prevents it from falling out. The above

complications are things that a dialysis technician can try and prevent from happening, but there

are complications that just happen naturally. Recirculation is a complication that happens during

treatment where the same blood is recirculating over and over, so the rest of the patient’s blood is

not getting cleaned like its supposed to. Steal syndrome is when the fistula steals too much

blood, so not enough circulates to the hand. When the hand isn’t getting enough oxygen, tissue

can start to die causing necrosis. Aneurysms is a thinning of the wall of the fistula which

balloons out. Patients that get aneurysms have more noticeable fistulas, which may upset the

patient about the appearance of how large it is. Stenosis is another complication that happens

when a blood vessel narrows, causing the blood flow to the fistula or graft to slow down.

Thrombosis is very common with fistulas, grafts, and catheters. Thrombosis is just a fancy word

for blood clot, but to help prevent blood clots almost every dialysis patient gets heparin either

before or during treatment. Heparin is a medication that thins out the blood to prevent blood

clots. Heparin is also placed in the lines of the catheter after treatment, so the lumens don’t go

bad. Infection is the last complication to look out for as signs of infection are very important to
notice because if an infection goes on for too long, the patient could end up in septic shock.

Signs of infection are swelling, redness around local area, fever, and fatigue and should not be

ignored.

Nutrition is very important when it comes to dialysis patients. Since dialysis patients’

kidneys don’t function properly, they need to pay close attention to what they eat in-between

treatment days. All dialysis patients are on fluid restrictions, which means that they are limited

on the amount of liquid that they eat and drink every day. Most patients are only allowed roughly

one liter of fluids a day. If patients don’t track their fluids that they intake, their body can go into

fluid overload. Having too much fluid may cause them to be short of breath due to buildup fluid

in the lungs or the proper medical term, Pulmonary edema. Swelling can also happen with fluid

retention with the common areas in the patient’s ankles and fingertips. All of the excess fluid the

patient is carrying is removed during treatment. A lot of patient’s typically can get around a liter

of fluid removed in one treatment while others can get around five liters removed. During

treatment, it’s important to watch a patient closely to make sure the goal that was set for fluid to

be removed isn’t too much. If too much fluid is removed from a patient during treatment, they

can become hypotensive and could even pass out. Hypotension is when a blood pressure is low,

typically under 90 for the systolic or 60 diastolic. For example, let’s say a patient’s blood

pressure is 124/80, 124 would be the systolic and the 80 would be the diastolic. In the long term,

leaving too much water in the body can worsen left ventricle hypertrophy (LVH), a leading cause

of death on standard in-center HD (Medical Education Institute). Dialysis patients should also

limit the amount of potassium, phosphorus, and sodium intake. Eating too much potassium can

be very dangerous for the heart or even cause death. Too much phosphorus will pull calcium

from a patient’s bones which will make patients weak. Excess sodium can cause fluid overload
and can also lead to hypertension (Eating & Nutrition for Hemodialysis). I cannot stress it

enough how important it is to focus on living a healthy lifestyle because of the number of

patients that regret the position they are in today.

Tung-Wei Hung, the author of “Long-term outcomes of dialysis in patients with chronic

kidney disease and new-onset atrial fibrillation: A population-based cohort study” is a scholarly

article that shows statistics on end stage renal disease and mortality rates in dialysis. Not only do

dialysis patients have to worry about end stage renal disease, but they also must be aware of the

disease that can come into course once their kidneys start to fail. End-stage renal disease (ESRD)

it is common for mortality resulting from cardiovascular disease. A study showed that chronic

kidney disease patients with new-onset atrial fibrillation had increased mortality, and patients at

the time of dialysis initiation with new-onset atrial fibrillation had significantly higher mortality

(Hung, Tung-Wei). Reading this article might cause a dialysis patient to be worrisome because

they’ll see in the conclusion that it says patients on dialysis have higher mortality rate.

Even though it says the mortality rate is higher, dialysis is still a life-saving machine and very

much needed if in renal failure. If there were two people with the exact same diagnosis of renal

failure and new-onset atrial fibrillation but one was on dialysis and the other was not, the person

not on dialysis would not live as long. “Effect of statin on life prognosis in Japanese patients

undergoing hemodialysis” by Ota, Yuki, is a great article to help lower the risk of getting

cardiovascular disease since it’s so common for dialysis patients. Anemia correction and

smoking cessation, blood pressure and diabetes management, calcium and phosphorus

management, and use of beta blockers have been associated with decreasing cardiovascular

events and reduction in mortality risk in dialysis patients (Ota, Yuki). In Ota article talks about a

study that was conducted in Japan at a hemodialysis clinic. Since cardiovascular disease is so
high, they have a medication that they give to dialysis patients to see if it can make a positive

outcome and help them decrease their chance of getting this disease. Statin is a common drug

given to dialysis patients to reduce the levels of fat in their blood. Statin is important for dialysis

patients to take since their kidneys don’t function properly nor filter blood the way they are

supposed to. A major prevention with taking statin drugs is to help lower the risk of

cardiovascular events. Pitavastatin was the other medication used in the study. Pitavastatin and

statin both improve cholesterol levels overall. At the end of the study, they concluded that

Pitavastatin could reduce a hemodialysis patient’s mortality. Statin remained debatable, but long-

term use of this drug could definitely lessen a dialysis patients mortality risk (Ota, Yuki).

Other medical problems that are common with renal failure are anemia, hyperkalemia,

decreased immune response, and pericarditis. Anemia is a low red blood cell counts in

someone’s body. Anyone can get anemia, but it is common for dialysis patients, due to the lack

of red blood cells in the body, oxygen flow to organs also decreases. Hyperkalemia is when there

is an extreme level of potassium in someone’s blood. Hyperkalemia is very dangerous because it

could affect the hearts function, which is life-threatening. Having a decreased immune response

can increases a patient’s risk of getting an infection since their body can’t fight of infection as

easily (Mayo Foundation for Medical Education and Research).

For dialysis patients, before they commit, I am sure there is a thousand questions going

on through their mind. They are probably curious what hemodialysis feels like or if it is painful,

how many years does someone have left once they start dialysis, if they can still have a normal

life and many more. For most patients, hemodialysis is usually painless. Before the treatment

begins, most patients put on a numbing spray or numbing cream, which makes the stick from the

needle not as painful. After the needle stick is done, the rest of the treatment is painless. If too
much fluid gets taken off a patient they do cramp up, or get a stomach ache, or have no

symptoms at all and their blood pressure drops. These are all things that don’t happen every

treatment though and they usually go away once the clinic finds a good dry weight for the

patient. Average life expectancy on dialysis is 5-10 years, however, many patients have lived

well on dialysis for 20-30 years (National kidney Foundation). When it comes to the question

whether a normal life is still possible, it all depends on how well the patient takes care of

themselves and with every other medical issue they have going on in their life. I have patients

that walk into their treatments and then go fishing every day, so yes, a normal life is still

possible. The National Kidney Foundation has a website that breaks down every frequently

asked question for someone who is about to start dialysis treatment.

Dialysis entails a lot as you can tell. It is a never-ending topic when talking to someone

who works in this field. Sure, the question “what is dialysis?” could just be answered as a

treatment that acts as the patient’s kidneys since their kidneys aren’t functioning like they are

supposed to anymore, but so much more goes in to dialysis than just that. To the patients and

family members of someone who is on dialysis though, it is more than just a machine or a

treatment. Dialysis is a life saving treatment. It is what keeps a person’s mom, dad, or

grandparents with them. There are so many pieces to put dialysis together and make it one big

puzzle but at the end of the day, I’m grateful for the technology and the science that was put into

medicine and the amount of lives a single machine can save a day. Every day I go to work proud

of the Hemodialysis team that I am apart of and making my patients treatment day go as

smoothly as possible. I’ve always knew I wanted to be a registered nurse, but never had a reason

for why, it just seemed like the right path for me. Working with dialysis patients has wanted me

to push a thousand times harder towards that goal. Every day I stick my patients and connect
them to a machine that is life saving for them, but every day I work with them, they change my

life for the better without even knowing it, which is life saving for me.
 Works Cited

Core Curriculum for the Dialysis Technician: a Comprehensive Review of Hemodialysis. 6th ed.,

Medical Education Institute, 2018.

“Dialysis Access Options.” Preferred Vascular Group, 16 Aug. 2019,

preferredvasculargroup.com/service/dialysis-access-options/.

“Eating & Nutrition for Hemodialysis.” National Institute of Diabetes and Digestive and Kidney

Diseases, U.S. Department of Health and Human Services, 1 Sept. 2016,

www.niddk.nih.gov/health-information/kidney-disease/kidney-

failure/hemodialysis/eating-nutrition.

“End-Stage Renal Disease.” Mayo Clinic, Mayo Foundation for Medical Education and

Research, 17 Aug. 2019, www.mayoclinic.org/diseases-conditions/end-stage-renal-

disease/symptoms-causes/syc-20354532.

“Hemodialysis Access.” National Kidney Foundation, 3 Feb. 2017,

www.kidney.org/atoz/content/hemoaccess.

Hung, Tung-Wei, et al. "Long-term outcomes of dialysis in patients with chronic kidney disease

and new-onset atrial fibrillation: A population-based cohort study." PLoS ONE, vol. 14,

no. 9, 2019, p. e0222656. Gale In Context: Opposing Viewpoints, https://link-gale-

com.sinclair.ohionet.org/apps/doc/A600424696/OVIC?

u=dayt30401&sid=OVIC&xid=1afe3b5e. Accessed 28 June 2020.

“Initiating Peritoneal Dialysis After Catheter Insertion.” Medscape, 26 Oct. 2017,

www.medscape.com/viewarticle/887404.
“Kidney Disease Statistics for the United States.” National Institute of Diabetes and Digestive

and Kidney Diseases, U.S. Department of Health and Human Services, 1 Dec. 2016,

www.niddk.nih.gov/health-information/health-statistics/kidney-disease.

Ota, Yuki, et al. "Effect of statin on life prognosis in Japanese patients undergoing

hemodialysis." PLoS ONE, vol. 14, no. 10, 2019, p. e0224111. Gale In Context:

Opposing Viewpoints, https://link-gale-

com.sinclair.ohionet.org/apps/doc/A603472004/OVIC?

u=dayt30401&sid=OVIC&xid=76160974. Accessed 28 June 2020.

“What Is Hemodialysis?: Medical: Products and Services.” NIKKISO CO., LTD.,

www.nikkiso.com/products/medical/dialysis.html.

“What Is Dialysis?” National Kidney Foundation, 29 June 2020,

www.kidney.org/atoz/content/dialysisinfo.