This education page is designed for patients, families, and other individuals interested in learning more information about kidney failure and treatment options.
What is the function of the kidney?
The kidney has three basic functions:
What are the kidneys?
Everyone has two bean-shaped kidneys located in their lower back. Approximately 25% of one's blood passes through the kidneys each minute. The blood passes through nephons. Each nephon has a glomerulus and tubules. The glomerulus filters the blood and the waste products are removed. The blood then passes through to the tubule to the collecting tubule. The filtered material passes to the kidney pelvis, which connects to the ureter. The ureter passes the filtered product, urine, to the bladder.
What are the causes of kidney failure?
There are certain diseases that can lead to kidney failure. The kidney may show signs of beginning failure, but it has not progressed to kidney disease that requires dialysis or transplantation. The people with this condition are considered "approachers" because they are approaching the need for chronic kidney treatment. These people are usually followed by a physician every one to three months to monitor the progress of the kidney failure. There are also certain conditions that lead to acute kidney failure. These conditions may cause the kidneys to stop working for a time period, but usually can be resolved and the kidneys return to normal function. The third way a person can have kidney failure is through chronic kidney disease. In this circumstance dialysis or a kidney transplant is needed to sustain life.
The disease conditions that lead to kidney failure
What are signs and symptoms of approaching kidney failure?
What are the signs and symptoms of chronic or long-term kidney failure?
What are the treatment options for kidney failure?
Kidney failure in some acute phases and all chronic phases of the disease require treatment to sustain life. There are three options for treatment: hemodialysis, peritoneal dialysis, and kidney transplant. All three options have a team involved with their care. This team includes a dietician, social worker, nurse, and doctor. These people are also involved with those people approaching dialysis. The option of no treatment is a decision to be made by the patient, family and doctor.
Hemodialysis:
This treatment involves the person's blood being passed through a machine that contains a filter. Once the blood is filtered from the dialyzer (a semi-permeable filter) the blood without the added waste products and fluid is returned to the person. Hemodialysis can be done at home or in a dialysis center.
Home dialysis requires a partner to help the person with his or her dialysis. The partner can help placing needles in the person's access and assisting the person if symptoms of dialysis complications arise. A person doing home dialysis will be required to get lab work periodically to assess their dialysis needs.
Center hemodialysis requires the person to travel to a center that provides dialysis treatment. The center dialysis staff usually consists of doctors, nurses, dialysis technicians, social workers, dieticians, billing clerks and a manager or administrator.
Peritoneal Dialysis:
This treatment uses the lining of the peritoneum to act as the filter. A tube is placed in the person's abdomen for fluid exchanges that remove the waste products and fluid. There are two types of peritoneal dialysis, continuous ambulatory peritoneal dialysis (CAPD) or continuous cyclical peritoneal dialysis (CCPD). CAPD is when a person fills the peritoneum with dialysis fluid and allows this fluid to "dwell" or stay in the body for three to six hours. It is during the dwell time that fluid and waste products travel across the peritoneal membrane. After the dwell time the fluid containing waste products is drained into a collection bag. This process is usually done four times per day, everyday. A clean, dry area will be needed to hook up the catheter to the dialysis solution.
CCPD also moves fluid in and out of the peritoneum, but is done by a machine. The person who chooses this form of treatment will usually do CCPD at night when they are asleep. The average time for this procedure is nine hours. All the necessary exchanges are done at this time. The person is then free to unhook from the machine during the day.
The type of dialysis a person chooses is usually based on preference, lifestyle, or medical condition. A team of doctors and nurses can assist the person in determining what type of dialysis is best suited for them.
Choosing hemodialysis versus peritoneal dialysis
Home hemodialysis
Center hemodialysis
CAPD
CCPD
Kidney Transplant:
There are two types of transplantation, living and cadaver. A living transplant is a kidney donated by someone still alive. Living related transplants are when a family member is the donor of the kidney. A family member would be a mother, father, brother, or sister. This type of donation works the best since family members usually have the tissue type most closely matching the person receiving the kidney. Some transplant centers now perform living non-related transplants. This type of donation is when a kidney has enough tissues that match the person's tissues who will receive the kidney.
The other type of kidney transplant is from a cadaver. A cadaver is someone who has died and donated his or her organs. The person who needs the kidney will be placed on a list. The person near the top of this list will be offered the donated kidney if their tissue type matches the donated kidney's tissues.
All people who receive a transplant will need to take medications to prevent the kidney from being rejected by their body. The transplant center where a person receives the transplant will follow the person's lab values. The lab values will determine how well the new kidney is working.
What does dialysis feel like?
A person does not feel the blood enter in and out of their body during hemodialysis. Certain symptoms related to other problems can occur during the treatment. A person's blood pressure may drop because of the removal of fluid and waste products. The person can usually be placed in a position with their feet up or they can get some fluid back into the blood. This will make them feel better quickly. A person may also feel muscle cramps, hot, sweaty, or nauseated. A person who feels these symptoms are encouraged to let their partner or dialysis staff know so appropriate treatment of the symptoms can occur.
A person on peritoneal dialysis will feel the dialysis solution enter the peritoneum, but usually does not feel the fluid once it is in the body. Muscle cramping is the most common symptom for peritoneal dialysis.
What are the types of dialysis access?
A person who requires dialysis will need some type of access to be able to process the blood. An access may be a temporary or permanent device and may require a surgical procedure for placement. The access will enable the person to perform the dialysis treatment.
Peritoneal catheter: A peritoneal dialysis catheter is placed under sterile conditions. A tube approximately 24 inches in length is tunneled under the skin into the peritoneum. Some of the catheter will remain outside of the body. Care of this access includes keeping the catheter site clean and dry. A clean technique is used to open the catheter for use. This will help prevent infection. Signs and symptoms of infection are fever, redness, drainage, and/or warmth at the site. Infection can also be seen when blood or cloudy drainage is drained from the peritoneal dialysis fluid. A doctor or nurse should be contacted if these signs of infection occur.
Temporary access: A catheter may need to be placed temporarily for acute dialysis or until a permanent access is ready for use. There are three sites for temporary access. A subclavian catheter is placed in the subclavian vein under sterile conditions. The subclavian vein is located in the chest under the collarbone. An internal jugular catheter is placed in the internal jugular vein under sterile conditions. The internal jugular vein is located in the neck. The third type of catheter is a femoral catheter placed under sterile conditions in the femoral vein. The femoral is located in the leg at the groin area. The length of the catheter does not allow a person with this type catheter to sit upright or bend their leg. This type of catheter is usually left in place for only one to three days.
All three types of catheters are covered with a sterile dressing that should be kept clean and dry. Bleeding may occur for the first twelve hours. A doctor should be notified if bleeding continues after that time. Signs and symptoms of infection should be noted with each dressing change. The signs and symptoms are redness, drainage, and warmth at skin site, and fever. A doctor or nurse should be notified if symptoms of infection occur.
Permanent access: There are six sites for permanent access. They are the forearm, upper arm and the leg on both sides of the body. There are two types of permanent access, a native fistula or a Gore-Tex* graft. A native fistula is created by a surgeon. The surgeon takes an artery and vein and joins them together. This is called the anastamosis. The artery uses its pulsating flow to make the vein get bigger. This is necessary for needle placement. Hemodialysis requires two needles to be inserted into the permanent access. One needle is used to bring blood into the machine for cleaning. The other needle is used to return the clean blood to the person. A native fistula should be allowed six weeks to develop.
A person will want to exercise the fistula to help it get larger. A small, weak fistula makes it difficult for needle placement. A person should squeeze a small ball (tennis ball) 10-20 times four to five times per day. The person should also take the opposite hand and place it under the armpit of the arm with the fistula while squeezing the ball. This will slow the blood flow to the arm. By squeezing the ball under these conditions blood will be forced to flow through the fistula. This force will assist the fistula to get big. The more a fistula is exercised the better developed it will be when needles are placed. This will potentially prevent complications.
A graft is similar to a native fistula, but is a tube joining the artery and vein. The tube is usually made of a substance such as Gore-Tex*. No exercises will need to be done on this access since the tube will not get bigger. A surgeon will place the access. A graft can be used once the swelling is gone. This usually takes two to four weeks. A graft is used when the leg is used as the site for permanent access.
To make sure the permanent access will have good flow the following restrictions should be followed: no needle sticks of blood pressures to the access extremity, no tight fitting clothing to the access extremity, and avoid sleeping with your head directly on the access.
A person should learn to check for flow in the access once or twice per day. A person should be able to feel a pulsing flow or buzz when they touch the access. This is called a thrill. A person may also check for flow using a stethoscope. The person should hear a swishing sound. This is called a bruit, pronounced brew-ee. If a bruit or thrill is not present the person should contact a physician.
Most fistulas and grafts last for many years. A few will develop complications. One complication is a blood clot or thrombosis blocking the flow to the fistula. A procedure will need to be done to remove the clot. Infection can also develop in a fistula or graft, but is more common in a graft. Antibiotics may be needed to treat the infection. Finally, some fistula and grafts have a narrowing or an aneurysm. These conditions will need surgery to improve flows to the fistula.
What are the diet restrictions I should follow as a dialysis patient?
There are certain foods that should be limited from the diet. A dietician will help determine each dialysis patient's dietary needs and restrictions. Potassium intake that is too high can lead to an irregular heartbeat. Examples of foods high in potassium include potatoes, tomatoes, bananas, oranges, broccoli, chocolate and salt substitutes.
High phosphorus can lead to bone disease. If the level of phosphorus is high in the blood calcium may be lost from the bones. Dairy products, nuts, colas and chocolate are foods that contain high amounts of phosphorus.
Sodium or salt can make the cells in a person's body thirsty if too much sodium is present. Salt will also make the person thirsty. Bacon, luncheon meats, potato chips, and pickles are examples of salty foods.
Protein breaks down in the form of urea. It is the blood urea nitrogen level or BUN that doctors use to measure kidney function. This is because urea is removed from the kidney. Dialysis patients are encouraged to have a well-balanced intake of protein to build muscles and repair tissues.
Peritoneal dialysis patients may not have as many restrictions placed on the diet. This is because they dialyze daily. In fact potassium and protein is usually low for these people, however, phosphorus and sodium are usually restricted.
Should a dialysis patient limit the amount of fluids they intake?
The answer is yes. People on dialysis have a decreased urine output. Symptoms of shortness of breath, edema or swelling, and high blood pressure can be related to having too much fluid in the body. Many people will be limited to 1500cc or 1.5 quarts of fluid per day. Large fluid gains between hemodialysis treatments can be hard on a person's heart and lungs. Some people do not tolerate large amounts of fluid to be removed during the dialysis procedure. They can have complications associated with large fluid gains. These complications can include muscle cramps and low blood pressure or hypotension.
Fluids are the following: coffee, water, juice, soda pop, milk, ice cream, soup, ice cubes, juice packed in can fruit, and popsicles. The general guideline is anything that is a liquid at room temperature is considered a fluid.
Peritoneal patients do a treatment everyday and therefore do not need to limit fluids as much. The glucose in peritoneal solution will attract fluids. A person requiring additional fluid to be removed may need to adjust the glucose concentration of the peritoneal dialysis solution.
A dry weight or target weight will need to be established once starting dialysis. This weight is similar to what a person would weigh after urinating when they had normal kidney function. Weights need to be done just prior to a dialysis treatment and just after completion of a treatment. This is done to determine the amount of fluid to be removed during the treatment. A person may gain or lose actual weight and need to adjust the target weight. This is not the case when a person gains 10 pounds or more in a two day period. This is all fluid gain.
What medications may a doctor prescribe to people with kidney failure?
Calcium supplements may be taken as a supplement to dietary calcium. This is necessary to maintain adequate calcium levels, bind with phosphorus, and prevent bone disease.
Phosphorus binders may be taken to lower the phosphorus level in the blood. High levels of phosphorus in the blood may attract calcium from the bones and lead to bone disease.
Multivitamins may be taken to replace vitamins lost in the dialysis procedure. This is because vitamins are dissolved in water.
Epogen may be taken to replace the hormone erythropoetin. This hormone is usually produced in the kidney to stimulate red blood cell production. Lower red blood cell production can lead to anemia. This drug is a synthetic replacement of the hormone and is usually given by injection.
Iron may be taken to supplement dietary iron. Iron is important for the production of red blood cells.
Lasix and other diuretics may be taken to help remove excess fluid. This drug is usually taken as people are approaching kidney failure and will be stopped once dialysis started.
Sodium bicarbonate may be taken to normalize the blood pH. As kidneys start to fail waste products begin to build up making the blood more acidic. This medication will usually be stopped once dialysis is started.
Stool softeners and laxatives may be taken to prevent or treat constipation. A decreased fluid intake can lead to constipation. Laxatives with aluminum or magnesium should be avoided.
Blood pressure medication may be taken to control blood pressure. In some instances a person may be requested to not take blood pressure medications on dialysis days or before treatment. The medication will be not taken because dialysis may temporarily decrease the person's blood pressure.
Lotions, certain bath salts, and UV light treatments may be needed for relief of dry, itchy skin. Lotions and bath salts such as Aveeno bath can be purchased over the counter. UV treatments will need to be prescribed by a doctor.
What are the labs that will be drawn to assess the dialysis needs?
What are some issues the social worker can help with?
Support issues. A person may have difficulty dealing with a chronic illness and the associated lifestyle changes necessary to promote good health. It is not uncommon to have feelings of fear, anger, and depression. A social worker, nurse, or doctor can help a person and their family with support. The people involved should be encouraged to talk about their feelings.
There are dialysis units that have started support groups for patients and families. A person can learn more about dialysis by contacting the dialysis unit if a formal support group is not established. Most patients on dialysis are willing to share their experiences. The National Kidney Foundation is an organization that can also answer questions and provide support.
A person on dialysis may continue to work, but the time commitment for a dialysis procedure is similar to having a second part-time job. The person's employer may need to know about potential conflicts with work and dialysis schedules.
Payment. In 1970 End Stage Renal Disease was added to the Medicare Act. This means that Medicare pays for some of the medical expenses. A social worker will be able to help fill out all of the necessary paperwork. A person who continues to work may be able to use some of their employment health insurance to help pay for additional expenses. People over the age of 65 should subscribe to Medicare part B to help pay for medical costs.
Placement issues. Some elderly people or people unable to care for themselves at home may need to stay at a health care facility. A social worker can help find an appropriate facility for dialysis patients.
Transportation. Some people may need help arranging transportation to and from the dialysis center. A social worker can help arrange appropriate transportation.
What are some of the rehabilitation issues involved with dialysis?
A person may be weak or sick prior to starting dialysis treatment. The goal of dialysis is to help people return to near pre-disease condition. This means people are encouraged to get back to work, feel better about themselves, and be able to do things for themselves. Some people may need physical therapy to gain some strength back. Occupational rehab and vocational rehab may also be needed to help regain function. Nurses, doctors, and social workers can refer a person to the necessary assistance. The person needs to discuss the dialysis needs and schedule with their employer. An employer who understands kidney failure and the treatment plan will be able to make the transition for the dialysis patient easier.
A person on dialysis is encouraged to exercise. Many dialysis centers have a designed exercise program with stationary bikes and weights. The exercises can be performed while on the dialysis machine. Home hemodialysis and peritoneal dialysis patients are encouraged to develop an exercise program that fits their schedule.
Can a person on dialysis travel?
The answer is yes. A person on peritoneal dialysis may travel, but the necessary supplies to perform dialysis will need to be taken. A person on hemodialysis can ask the dialysis center about making arrangements to dialyze in a center near their travel destination. A person should not skip dialysis during the travel period. A person should also not just appear at a visiting dialysis center. The center may have a full schedule of patients and not be able to accommodate the person's needs.
How can dialysis affect a person's sexuality?
Males may have a problem with impotence once they develop kidney failure. A doctor can help by prescribing medication or suggesting an artificial device to improve impotence. Males with kidney failure are able to father children, but it may be more difficult.
Females may have a decreased libido after developing kidney failure. Females on dialysis are usually not able to become pregnant, but it is possible. A female after a transplant can become pregnant, however. Females who are sexually active should talk to their doctor about birth control.
Sexual intercourse is safe for people with kidney failure. Both males and females can talk with their nurses and doctors about emotions concerning changes in sexuality. A doctor or nurse can answer questions about sex affecting the access. A temporary or permanent access should not be affected by sexual intercourse.
Why is following a dialysis treatment plan important?
A person on dialysis needs to follow the prescribed dialysis treatment plan. They should avoid missing dialysis treatments. They should also follow the diet set up by them and a dietician. It is important to take medications as directed by their doctor. A person who does not follow the dialysis treatment plan will have more frequent complications and be less healthy. This may increase the risk of death if prolonged non-compliance happens.