>> Hi, I'm Sumeska Thavarajah,
I'm one of the nephrologist at Johns Hopkins,
and welcome to the ABCs of Kidney Disease.
In this session today,
we're going to talk about treatment options
for end-stage kidney disease.
There are a couple of different categories when we talk
about end-stage kidney disease in terms of treatment.
When they fail, it's either called
end-stage renal disease or end-stage kidney disease.
These terms are used interchangeably.
We can think of it as either replacing
the function either through dialysis or
transplantation or sometimes we do
medical management when maybe dialysis or
transplantation doesn't make sense
in the setting of someone's other health conditions.
Those are referred to as
either conservative care or active medical management.
Dialysis is a way of artificially cleaning
the blood or removing
those waste products when your kidneys can't do the work.
There are two major types.
Hemodialysis or peritoneal dialysis.
Both of these methods will require
some type of surgery to create an axis.
Now, neither type of dialysis though is better than the other.
So really it's a matter of figuring out what is the best option
for you medically and what fits your lifestyle.
We're going to start with hemodialysis.
This is the more common type of
dialysis that you may have heard of.
It involves filtering or cleaning the blood using a machine.
It can take place at home or at an outpatient dialysis unit.
Now, on the left-hand side of the screen,
you see a home hemodialysis machine.
As you can see, it's much smaller than what we would use in
an outpatient center or in a hospital setting.
It's designed to be much more user-friendly, easier to use,
and won't require any specialized plumbing
or electrical work in the household.
Because it is smaller in size and it doesn't require those things,
you're going to be doing those dialysis treatments a
little more frequently because you're not going to
be able to do as much cleaning per session
as you would when you're going to
an outpatient unit three times a week.
The kidneys are focused on cleaning the blood
and filtering the blood and they do
that several hundred times a day.
If we're going to be doing this with the machine,
we have to have a way of getting the blood
from the individual to the machine,
and so we focus a lot on the hemodialysis access.
Several of these types require a lot of
preparation before we're able to use them.
We're going to first start talking about the fistula,
which is a connection between your own artery and vein.
It won't contain any synthetic material or plastic material.
It will take about 6-12 weeks before it's ready to use.
The type of surgeries and outpatient surgery
usually takes about 25-30 minutes,
and it can be done under local or
it can be done under general anesthesia.
Now sometimes people do not have veins that are big enough
to make that connection to create a fistula,
so we use some synthetic material
and that helps us connect the artery and the vein.
That is easier to use earlier on,
and so we're able to use this within days to weeks.
We rely on the consultation with
a vascular surgeon to determine
what's the best option for an individual.
They'll examine the individual,
take a look at their history,
and they'll be able to decide whether it
will be a fistula or graft.
Now, sometimes we don't have a lot of time to prepare
for someone being on dialysis or needing to start.
Or maybe they have a lot of
problems with their veins that we aren't
able to do a fistula or a graft,
in which case we would do an IV line that's placed in radiology,
and this can be used right away.
Next, we're going to start to show you some of
these different models so you can get
a better sense of what the differences
are between these three categories.
We were just talking about different hemodialysis access,
so we're going to start off by looking at what
the artificial kidney is or the filter,
and this is a series of fibers that has micropores in it.
Blood will go through this dialyzer and then
dialysate fluid will go in the opposite direction.
It'll pull out all the waste products
and those are what go down the drain.
Then the cleaned blood goes back through
this filter and out back to the patient.
We do this several hundred
times over during the course of the dialysis session,
so we need a type of dialysis access
that's going to be able to supply that blood flow.
We're going to start by talking about
the different types with the catheter.
The catheter it's not going to be one of these small IVs,
it's going to be placed by radiology or
surgery and it goes into the major blood vessels.
The tip of it actually goes down to the first chamber of
the heart to get the maximum blood flow that we need for this.
Now, a portion of this catheter is always outside of the body.
If we're looking at this little blue tip here,
that portion from that part
out is going to be outside of the skin.
We usually bring these catheters out
underneath the collarbone so that they're covered by
your shirt and your clothing and they
aren't bothering you throughout the course of the day.
When you go to the dialysis unit,
the nurses would uncap
these ports of the catheter and then hook up the dialysis line.
One line would go to the machine to pull the blood
in through the dialyzer and then
the other port will be where the blood returns back.
Now, these catheters can stay in for up to a year,
but because a portion is always outside of
the body and outside of the skin surface,
there's a constant risk of infection,
so we try to minimize the use of these as much as possible.
Now, the other major type of
dialysis axis is either the fistula or the graft.
Now, the benefit of both of these compared to the catheter is
once you've had the surgery and the incisions have healed up,
all of the material is below the skin surface.
So the skin is your natural protective barrier.
Just like when you're getting blood drawn or getting an IV put in,
they will put a tourniquet on,
and that will cause the vein or
the graft to be a little more prominent.
Then they would be putting in
two needles during the course of the treatment.
One needle would be for pulling the blood into the machine,
the other needle for returning the blood.
On this arm model,
we have a representation of a graft.
This is in the lower portion of the arm,
and then the fistula is in the upper portion of the arm.
Really when we're connecting that artery to
the vein or connecting the graft between an artery and vein,
we're making those veins a little bit bigger
and easier to stick for the treatment.
When you have that hemodialysis access,
regardless if you're doing in-center or home hemodialysis,
this is what you would be experiencing with each different type.
If you're going in-center,
where you're going to an outpatient
dialysis unit three times a week,
the treatments are going to be performed by medical staff.
It's going to be about three days a week for 3-4 hours at a time,
and what will you expect or
what's going to happen when you get there?
You come in, you get weighed before and after your treatment.
You're going to have your blood pressure, your heart rate,
your temperature checked before the treatment,
and then they're monitored every 15-30 minutes.
The blood work will be checked during your treatments.
You'll be receiving different medications to
replace things that the kidneys are not generating on their own,
and you'll be seeing the doctor there at the dialysis units.
You won't be going to your outpatient clinic
where you see your kidney doctor now,
you'll be seeing that doctor right there at the dialysis unit.
The downside is that it is a set schedule.
You'll have an appointment time,
you'll be coming in either Monday, Wednesday,
Friday or Tuesday, Thursday,
Saturday at a set time during the week.
It's a little more of a restricted diet
because unlike when your kidneys were doing the work,
you're going to be relying on
these treatments just three times a week.
When someone is doing home hemodialysis,
it's going to be performed at home by you and a partner.
The treatments are happening about 4-6 days a
week and they can be about 2-3 hours.
The prescription you end up
having will be dependent on what your lab work looks like,
what your fluid removal needs are,
and they're individualized per person.
Now, this requires about 4-8 weeks of training.
Some people pick it up faster,
some people take longer.
We don't kick you out of training until
you're fully comfortable with setting up the machine,
running the machine, and being able to do the treatments.
But this gives you a rough timeframe
to know how long it will be taking.
During the training, you're going to learn how to weigh yourself,
check your blood pressure,
check your heart rate, your temperature,
how to access your dialysis access.
Either stick your fistulas or graft or work with the catheter,
and you'll be able to learn how to perform
your dialysis set up and run the machine.
Your partner is going to learn how to be able to
take you off the machine and do
any troubleshooting, so they are a backup.
Usually, their training takes about two weeks.
Now, you're going to be following up with
the doctor about 1-2 times a month.
You'd come to the outpatient home training clinic
to be having those visits.
Now, the downside is you will need some space at home
for all the equipment and all the supplies,
and it can sometimes be a little bit of a burden for
the care partner because of the amount of
time it may take for setup.
>> Now the other type of dialysis is peritoneal dialysis.
This involves filtering your blood through
a thin layer of tissue that lines your abdomen,
and that one is thin enough for
different waste products and water to go through.
We use a special fluid called dialysate,
which is piped into the abdomen.
It sits there, pulls all the waste products,
pulls out the extra water,
and then it gets drained out of the abdomen.
This type of dialysis only takes place at home.
You go through to a training center.
You're at the training center for a couple of weeks time.
You'll learn how to do both types of the peritoneal dialysis.
One is the manual exchange where you're working with gravity.
Then one is the cycler.
Now the peritoneal dialysis catheter is different
than the fistula graphed in the other catheter.
It's placed in the abdomen.
It's placed by radiology or surgery and it takes
about one month before you're ready to use that.
2-4 weeks is usual healing time about two weeks after it's placed,
the PD nurses will start to be able to flush
the catheter and start some of the training at 4 weeks,
you're fully able to use the catheter.
We were just talking about the peritoneal dialysis catheter.
We're going to look at two models of what it looks like.
This model represents where the PD catheter
or peritoneal dialysis catheter would be going in the body.
It's usually in the lower abdomen.
There is a portion of the catheter
that would be outside of the body.
Typically, people have this rolled up under
some gauze and tape or under a belt.
Now here I have a catheter so you can get a sense of
how long this catheter is and this is what's in the abdomen.
It's actually anchored only in
two places right under the skin surface.
The skin tissue grows in and holds that catheter in place.
The tip of it is free-floating,
and that's why when you're doing the PD training,
your nurses will talk to you about
making sure you're not getting constipated
how to move around to help maximize the catheter function.
Now when we use the PD catheter
will be connecting to the different bags,
either for the manual exchanges or to the cycler at night
by just taking off the cap and connecting to the different lines.
This is a diagram that lets us know how the PD works.
Basically, you have a dialysate fluid,
which is a specialized fluid that
has a certain amount of sugar in it,
potassium, calcium, phosphorus, and it drains into the abdomen.
The fluid stays in the abdomen for a certain amount of time.
That's the dwell time and after
a period of time that gets drained out.
Then new fluid is put in.
Peritoneal dialysis is performed at home.
It does not require a partner because
there's no direct access to blood.
It takes about 2-4 weeks of training.
Again, if you're not
comfortable at the training mark at the 4 weeks,
we're not kicking you out of training.
You stay in training as long as you need
to be able to do this at home.
You're taught how to do manual exchanges where
you're just needing gravity to do those exchanges,
that's about 3-5 times a day,
or you're doing exchanges at night using a cycler,
which is in this lower picture here,
where all the bags are hooked up and it
does all of the exchanges during the night while you're sleeping.
Really what your final prescription will depend on is really what
your lab work will show, and you're preference.
Now you'll be again seeing the doctor about
1-2 times a month in the outpatient clinic.
The downside is the same for home hemodialysis in that
you need space at home for
all the supplies and the dialysate fluid.
The dialysis solution does contain sugar,
we do sometimes have some challenges with
trying to keep someone's blood sugar under control.
Talking about the peritoneal dialysis setup,
there are two different ways that we do the peritoneal dialysis.
One will be the manual exchanges,
which is done by gravity.
Really the only equipment that you're using is an IV pole.
You'll have the bag of dialysate hanging on the pole.
You'll unclip the clamp.
You'll hook it to your catheter
and you'll drain the fluid into the abdomen.
You'll then disconnect and then the fluid will stay in
the abdomen for about 4-6 hours
depending on what your prescription is.
When you're ready to do your next connection,
you will take the catheter hooked up to an empty bag,
will put the empty bag on
the floor and the fluid will drain in by gravity.
Then once that bag is full,
you'll unclamp and then drain in a new bag of dialysate fluid.
Now, in the middle of the night,
some people do their dialysis exchanges using a cycler and
the machine would take over doing all of
these different exchanges and
the connections of all the bags draining in and out.
The cycler is designed to be pretty user-friendly.
You'd be putting all the bags of fluid that you would be using
throughout the course of the night onto the cycler.
It would have a warmer,
it will have multiple connections and it will
be connected to your PD catheter.
Then during the course of the night,
it would drain fluid and put new fluid in multiple times over.
Then in the morning, you would disconnect from
the catheter and then go about your day.
About 90 percent of the people who do
peritoneal dialysis in the US are using the cycler at night.
But some people prefer to do the manual exchanges because A,
they don't need as much equipment
and especially for when they're traveling,
they would prefer to not have as much equipment coming with them.
Who's not a candidate for peritoneal dialysis?
If somebody's had a lot of abdominal surgeries,
they may have built up a lot of scar tissue
and that peritoneal membrane may not work as well.
If somebody has a VP shunt where they're
draining fluid from the brain,
we don't want to run the risk of infection.
If they have a history of an abdominal cancer,
there's a concern that they might be irritating
something along when by putting that much fluid in the abdomen.
If somebody has significant liver disease where they have SIDs,
they can not be able to tolerate the peritoneal dialysis.
How do you choose? You really choose
based on what you're comfortable with,
what suits your lifestyle,
medically, what makes sense and it's
not you make a decision and
you can never switch to another modality.
People shouldn't feel that pressure that,
if I make the wrong choice I'm stuck with this throughout,
for the rest of the time I'm on dialysis.
Now we're going to briefly talk a
little bit about transplantation.
It is another type of management for end-stage kidney disease.
It replaces the kidney function by getting a new kidney.
There is an extensive medical workup to
make sure you're going to be able to tolerate
the surgery and to be able to
tolerate the medication after transplantation.
Then I'm going to also mention
conservative care or active medical management.
This is an option when maybe due to other health problems,
somebody may not be in the best shape
for dialysis or transplantation.
It doesn't mean that we're not treating somebody.
We're treating them with all the same medications
for the anemia management,
the bone disease, the acid management.
We're just not going to the next steps of
preparing them for dialysis or transplantation.
Thank you for listening to our presentation.
This has been a presentation of
the Johns Hopkins nephrology patient education program
with the goal of improving the lives of
those individuals living with kidney disease.
If you want to learn more about the different dialysis options,
what options might be a better choice for you?
These are several resources. Thank you.