ABCs of Kidney Disease | Treatment Options for End-Stage Renal Disease


>>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.

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