>> Hi, I'm Su Thavarajah.
This is a presentation of the "ABCs of Kidney Disease,
"Treatment Options for End-Stage Renal Disease."
This is a video in the series
of the Johns Hopkins Nephrology Patient Education Programs,
made possible through the funding
of the Edward Kraus Endowment Fund
and the Shaw Foundation.
So this section is gonna focus on treatment
of end-stage kidney disease.
When the kidneys fail,
we either call it end-stage renal disease
or end-stage kidney disease.
And then we have two options
for being able to replace that kidney function.
Either we can filter the blood
via something called dialysis
or 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 way
of artificially removing the waste
and extra fluid from the blood.
And this happens when our kidneys can no longer do this.
There are two major types of dialysis,
hemodialysis and peritoneal dialysis,
and we're gonna talk about both of these
different types of dialysis in further depth,
but basics is the hemodialysis is another way
of cleaning the blood.
The peritoneal dialysis, we're not using a machine
but more using the inner lining of our abdomen
to clean the blood.
Both types of dialysis, though, require surgery
for a dialysis access, so they do require some planning
before we can get started with it.
Now, neither type of dialysis is better than the other,
so it's really a matter of getting that information
about the different types of dialysis
and having that discussion with your healthcare team
to figure out what's the best option for you,
and what you'll be most comfortable with.
This is a picture that demonstrates
the basic setup of hemodialysis.
And the principle is, there is some way
of getting blood from the individual,
'cause remember, our kidneys were cleaning our blood
during the course of the day.
They're overall cleaning about 180
to 200 liters worth of blood.
During a dialysis treatment, we have to have another way
of getting the blood from an individual,
and we run it through a machine,
and through what we call an artificial kidney,
or a dialyzer.
The cleaned blood then is returned back to the patient.
So we have to have a way of being able
to 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 about the three types first,
before we show you any of the models of them.
There's the fistula, which is a shunt
that is created between your own artery and your own vein.
There's no artificial material in it.
This procedure is performed by a vascular surgeon.
It takes about six to 12 weeks
before it's ready to be used,
and the procedure itself is a same-day outpatient procedure,
and a lot of times it doesn't even need
to be done under general anesthesia.
The process starts by you being referred
to the vascular surgeon, having an evaluation.
They might do an ultrasound of the veins in your arm
to figure out if you're a candidate for a fistula.
Sometimes people have veins that are either too small
or have been damaged over the years
from different other medical treatments,
and they don't have veins that could be used for a fistula.
In those cases, we use synthetic material,
which we refer to as a graft,
that would be the way of connecting that artery
and the vein.
Now the shunt, because it's already the right size,
and it's already pre-designed for this purpose,
only takes a couple of days to weeks
before you need to use it, so a little less planning
before you need to get started on dialysis.
The third category is the catheter,
and this is typically the one
that we try to minimize the use of,
because it's the highest risk of infection.
But it is the way we can start dialysis on an urgent basis
if we need to start it the same day.
This is a special IV line that's of the larger size,
to be able to carry enough blood
for the dialysis treatments,
and it's done in radiology or in the operating room,
and it can be used right away.
So now we're gonna take a look at the models
of the hemodialysis access,
reviewing the three different types
that we just looked at on the slide.
The first one is the fistula,
and the second one is the hemodialysis graft.
Both of these are in this model here.
One of the key things to look at
is that there's nothing outside of the body,
and this is why it's really the lower risk of infection
when you have a hemodialysis fistula 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 restrictions
in terms of bathing, showering, swimming,
or any issues like that.
We do ask you not to be having any blood draws
or have a blood pressure measured on that arm,
because then you could damage the access.
What would happen during the dialysis treatment,
is a nurse would put a tourniquet,
just like when they're drawing blood,
that would cause the vein of the fistula to pop up.
And then they would put a needle in
during the treatment.
Those needles would then stay in
during the course of the treatment,
and then be removed at the end of the session.
At the end of the session, they would put some pressure
on there for about 10 to 15 minutes,
and then you'd have a bandage on there
for about three to four hours.
After that, you could remove the bandage,
and then just not need to have anything on there.
Now, this lower part of the arm
is what we call a hemodialysis graft.
Unlike when our veins in our arm might be too small,
we sometimes put a piece of synthetic material,
tubing called a graft, in to connect
that artery in the vein.
And this is a nice representation of this
because it's in the lower part of the arm.
Same type of principle for the fistula,
the dialysis nurses would put two needles in it
during the course of the dialysis session.
They would remove those needles,
put some pressure on those points
at the end of the treatment,
and then you would have a bandage on there
for about three to four hours.
The benefits of this, of course,
are the reduced risk of infection,
and the fact that you don't really have anything
outside of your body during the dialysis session.
So the third type of dialysis access
is the hemodialysis catheter, and this is the one
that we can use right away.
Now, a key part of this is this catheter
has to be a larger size than any of the typical IVs
that you get in the hospital, or the emergency room.
And it needs to be a big enough size
to have enough blood flow for the dialysis treatment.
Because of that, it's gonna always
go into one of the bigger blood vessels,
and the tip is typically going all the way
to the level of the heart.
Another challenge with these catheters
are there's a large portion of it
that's outside of the body, so that's where
that increased risk of infection is.
And so when we look at the catheter model
from this little blue piece here,
that portion is always outside of the body,
just under the skin surface.
Now, when we have these catheters placed,
they're typically put in, or tucked in
underneath the collarbone,
so you can't see it when you're wearing your shirts
or anything like that, but it is a large portion of it
that can get caught on things, and can get infected.
Now, because so much is outside of the body,
there is the risk of infection,
so we are really careful about 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 are changed by the nurses
whenever you come in for your dialysis treatment.
Now, these catheters have two ports to them.
During the treatment, the nurses would remove the caps
and hook them up to the lines
for 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 stay
until your next dialysis session.
When we talk about hemodialysis,
there are two different types,
in-center hemodialysis, and home hemodialysis.
So in-center, it's performed in a dialysis unit
by 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 treatment
is 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 out
how much fluid to take off with each session.
They're checking the blood pressure,
the heart rate, and the temperature before the treatment
and then every 15 to 30 minutes
during the course of the session.
Blood work is often checked during those treatments,
so you're not having to be going to the lab
on a separate basis.
Also, certain medications
that you had been taking beforehand
are either gonna be replaced
by the actual dialysis treatment,
or they're gonna be given during the dialysis session,
so a lot of times your medication list is changing
once you get started on dialysis.
Now, because you're going to the dialysis unit
three times a week,
you're gonna be seeing your kidney doctor
there 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 time
on a Monday, Wednesday, Friday.
So you have to plan ahead if you need to be rescheduling
for another doctor's appointment,
or for going out of town.
And it's a little more of a restricted diet.
Remember when your kidneys were doing the work,
they were doing the work seven days a week.
Now we're gonna try to compress that into treatments
that are happening just three times a week.
Now, home hemodialysis,
we're using the same type of dialysis access
that we are using for in-center,
it's just it's a different machine.
This treatment is gonna be performed at home
by you and a partner.
The sessions are happening about four to six days a week,
and each session's about two to three hours.
Training typically takes about four to eight weeks,
but if you need a little bit longer time,
no one is gonna be releasing that machine to you,
or expecting you to do that earlier than you're ready to.
During the training, you'd learn about weighing yourself,
checking your blood pressure, your heart rate,
how to access your hemodialysis catheter or fistula,
and how to draw your labs, and how to set up
and take down the machine.
Now your partner would learn about more
of the emergency techniques, and we require
that the partner would be there
while you're doing your treatments.
You will still be coming to the clinic
to followup with the dialysis nurse
and the doctor about one to two times a month.
The downsides of the home hemodialysis treatments
are that you do need to have a partner at home,
so this might be a limiting factor
for some people being able to choose this as an option.
Additionally, you need a lot of space at home
for all of the supplies.
They're shipped out on a monthly basis,
so if you're not in a stable home situation,
this may not be the best option for you.
And we're gonna take a look
at the home hemodialysis machine.
So this is a model of our home hemodialysis machine.
So as you can see, it's pretty self-contained.
The front of it is a pretty user-friendly
touchscreen button, so it's easy
to be able to monitor the different steps,
and be able to pull off the information
that you need.
This is considered medical life-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 supplies
can be shipped to your destination.
There isn't any specialized changes
that you're gonna need to make in your house.
We do make some checks for our home safety check
to make sure that it'll be appropriate
for 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 worry
about the maintenance.
If there are issues with the machine,
the company will switch out the machine for you.
But the key parts of it, that it is very user-friendly,
and just simple things of being able to pull a lever,
pop in a cartridge, and a very easy
user-friendly touchscreen.
The other type of home dialysis is peritoneal dialysis,
and this one takes advantage of the fact
that we all have a thin layer, or membrane,
on the inside of our abdomen,
which can work as a filter to clean our blood.
And we use a fluid that gets piped into the abdomen
and sits in there and pulls out all of the waste products.
This treatment only takes place at home
and also requires training.
Now there are two different types of peritoneal dialysis,
and an individual, when they're trained,
is trained on both options.
There's the manual exchanges,
which don't require any specialized equipment
or electricity, and a cycler,
which about 90% of those individuals
who are on peritoneal dialysis are using.
Now, we start off with a peritoneal dialysis catheter,
and when we talked about a hemodialysis access,
that required a lot more planning.
The peritoneal dialysis catheters
only need to be placed about one month
before you need to start the treatments.
It takes about two to four weeks to heal
before the nurses can start flushing the catheter,
and doing some of the exchanges.
And then about four weeks after the placement
of the PD catheter, you can fully use the catheter,
and we can start doing some of the training.
And this picture is a image of someone
with a peritoneal catheter, and we have the model
that we will be showing you as well.
So this is our model of a peritoneal dialysis catheter.
As you can see, it's in the lower abdomen,
and about 90% of our catheters
are in the lower abdomen.
Sometimes they are put in the chest
because of different considerations,
but most of the time they are in the lower abdomen.
As you can see, there's a portion of tubing
that's outside of the body.
Now, this is the portion that will always be outside.
Usually, people have this coiled up
underneath a gauze, or a belt,
so it's not getting in the way,
or getting caught on their clothing.
The catheter itself is anchored
just underneath the skin surface
in two different places, and the rest of the catheter
is 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 and hook it up to the tubing here.
Now, because this catheter is 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 swimming
in a general pool.
So these are all considerations in your lifestyle
when you're making a decision
about doing peritoneal dialysis.
So how does peritoneal dialysis work?
It starts off with a special fluid called dialysate.
That fluid is put into the abdomen through that catheter,
it sits in the abdomen for a certain amount of time.
It either will be sitting there
from about four to six hours,
depending on someone's body size,
and the nature of their peritoneal membrane.
It's pulling all the waste products out,
it's pulling all that extra fluid.
That all gets drained out after about four to six hours,
and new fluid is instilled in.
So while the fluid is sitting in the abdomen,
it's pulling out all of those waste products,
it's pulling out extra water and all of the chemicals.
And this dialysate, because it doesn't contain any blood,
will then be able to be poured down the drain,
or in a toilet, and discarded.
So peritoneal dialysis is performed only at home.
There's not a requirement for a partner
because there's no direct access to blood,
so there's less risk of any emergency procedures.
The training itself takes about two to six weeks.
During the training you're learning
how to check your weight, your blood pressure,
and how to determine which of those dialysate fluids
to be using.
You're doing the exchanges, either doing manual exchanges
about three to four times a day,
depending on your body size,
or you're doing something where you're using a machine
called a cycler, where that's gonna do the exchanges
during the course of the night.
Sometimes people will be doing a combination of both.
It's really gonna be individualized,
based on what your body needs.
There are some downsides to the peritoneal dialysis.
You do need space at home,
you're getting those shipment of materials
about once a month.
So if you're not in a stable home situation,
it's harder to be able to do this treatment.
The other thing is that the dialysate fluid
has a high amount of sugar in it,
and so sometimes it can be more difficult
to control your diabetes.
Now, in this picture, it's starting to demonstrate
how someone is connecting
between the different dialysate bags,
and doing the connections.
And we're gonna show you the model
that will show the manual exchange and the cycler.
So for peritoneal dialysis,
it's done in two different ways,
there's the manual exchanges and the cycler.
Now, during the training, you're gonna be trained
on both types, both the manual and use of the cycler.
Most people will tend to be using the cycler,
and doing all of their exchanges at nighttime,
but the manual gives you that opportunity
if you're traveling for one night,
or if there's a power outage,
you still have a way of doing these treatments.
Sometimes people might need to do both.
Now the manual exchanges
all work basically with gravity.
So if you have this peritoneal fluid in there already,
the dialysate fluid in, when your time to do your exchange,
you would take your catheter, remove the cap,
hook up to the line here, and then this bag would,
you wanna imagine this bag would be on the floor,
because the bag is gonna be draining to gravity.
The fluid that's sitting in your abdomen
would then drain into this bag, fill the bag,
and then once that bag had finished draining,
you would open up the next larger,
the new fluid bag, and then drain that fluid in,
and then leave that in for about 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, they are using the cycler,
and the cycler is a machine that, at nighttime,
they would be hooking up to about 10:00 p.m. at night,
and stopping the treatments maybe about six in the morning.
The cycler is designed
to have all of the connections already made,
with all the bags of fluid,
so that the machine would be doing all of those exchanges.
It also has a touchscreen to it,
and then it would allow you to know
when it's draining, how much it's drained,
and then the next bag of fluid that it's instilling.
The lines for this cycler are a little bit longer,
so you do have the ability to get out of bed,
you don't necessarily have to disconnect
from the machine.
Now, typically, if somebody is using the cycler,
they're running their treatments
through the course of the night,
at the end of the night they would disconnect
from the machine.
Depending on their body size and 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 anything until later that evening,
when they would hook up to the cycler again.
So who's not a candidate for peritoneal dialysis?
You know, if somebody has had a lot of abdominal surgeries,
they may have developed a lot of scar tissue
in their abdominal wall, and that would prevent them
from being able to filter the blood appropriately.
If they've had a issue where they have a VP shunt,
where they've built up fluid on the brain,
and they have a VP shunt, that could get infected
if they're on peritoneal dialysis.
If they've had an abdominal cancer,
there's always a risk that they could be spreading
some of those cancer cells,
so we don't typically allow individuals
to do peritoneal dialysis in those settings.
And then the last category, if somebody has liver disease
where they already are building up a lot of fluid,
called ascites, they may not tolerate
having more fluid in their abdomen
for the peritoneal dialysis.
So how do you choose which type of dialysis
is the best one for you?
You pick which one suits your lifestyle.
You can transition from one type of dialysis to the other.
Neither type of dialysis is better than the other,
both types have good outcomes.
It's more important to find the one
that you're more comfortable with,
and that's gonna fit your lifestyle,
because then you're gonna have better results.
And if you wanna learn more information
about treatment options for end-stage kidney disease,
or end-stage renal disease,
please refer to the following resources.