Dialysis is an artificial process that imitates the kidneys. There are two types: (1) peritoneal (abdominal), which requires infusing a special solution into the abdomen and draining it back out, and (2) hemo (blood), which involves the complete transfer of the blood through a machine and back into the body.

Qualified Nurses Only

Dialysis requires special training because of the complex technology. The consequences of making a mistake can be fatal. Both abdominal and renal dialyses require the understanding of certain scientific principles with the acquisition of technical skills. Nurses must be certified in the type of dialysis they are performing. Most nurses certified in the renal method are also certified in the abdominal. The reverse is not always true. Many floor nurses receive the additional training for abdominal dialysis without learning the hemodialysis process. Hemodialysis requires a higher level of technical skill, so if you or a loved one is scheduled for dialysis, ask the nurse if he or she has a certificate of completion from a dialysis course.

Peritoneal (Abdominal) Dialysis

Peritoneal dialysis is the preferred method if it has to be done on an emergency basis and/or if the need for it is expected to be temporary. The renal specialist (nephrologist) places a dual lumen tube (two tubes in one) into the abdomen. The patient comes out of the operating room with the external end of the tube capped or plugged. The inside of this closed system is sterile. The nurse then hangs a bag of dialysate solution on an IV pole and infuses it into the abdomen. After one to two hours, the nurse drains the solution from the abdomen into a collection bag. While in the abdomen, the solution draws off metabolic waste from the blood (components of urine). The risks of this procedure are abdominal infection, sudden loss of blood pressure with too much fluid draining from the blood (hypovolemic shock), and blood-related complications.

How to reduce the chance of abdominal infection

With abdominal dialysis, infection comes from contamination. It may be unavoidable, but maintaining strict sterile technique in handling the tube substantially reduces the risk. The nurse has to provide dressing changes every eight hours to keep the insertion site as germ-free as possible. Additionally, he or she must treat this tube as a closed sterile system. That means that the crucial moments come every time the nurse opens the system to connect the abdominal tube to the infusion and drainage bags. Thus the nurse must cleanse the tube end with rubbing alcohol or another disinfectant before removing the cap.

In order to minimize the number of times the system is open, nurses will leave the tubing connected after the first dialysis session and simply change the bag each time. This way, the system is reopened only once in twenty-four hours to change the external tubing. You would be helping yourself or your loved one by asking the nurse to tell you what he or she is going to do to minimize the chance of infection. If you are told anything other than what was just described, call the nursing supervisor to observe the procedure.

How to avoid shock

Abdominal dialysis requires a large shift of fluid (two to three liters) into the belly with another shift from the blood vessels into the abdominal cavity. The fluid then shifts back to the outside with the added liquid from the blood. In view of this, there is the possibility of a sudden loss of blood pressure if the exchange takes place too quickly. The inflow and outflow tubes have a thumbwheel regulator on them by which the nurse can slow down the flow. The blood pressure also must be taken once before, during, and after the procedure. As the patient or family member, you will want to keep an eye on this to make sure it is being done properly.

How to deal with anemia, loss of protein, and loss of electrolytes

The abdominal dialysis process often causes anemia, loss of albumin (blood protein), and loss of electrolytes (potassium, sodium, magnesium, etc.) because the solution also draws off these blood contents. Therefore, it is imperative that the blood be tested every day for low levels of blood cells, albumin, and electrolytes and that replacements are infused as needed. You would avoid serious complications by asking the nurse or doctor to tell you whether these blood levels are normal. If not, the nurse or doctor should make you aware when you or your loved one is receiving replacement infusions.

Hemodialysis

Hemodialysis is the method of choice for those who are in irreversible renal failure. The renal specialist inserts an inner tube into the wrist or elbow in order to join an artery with a vein (arteriovenous, or A-V, fistula). This tube is made of a combination of silicone and plastic (silastic) and can be pierced a few times with a needle without leaking blood. After the nurse inserts the needle into the A-V fistula, the dialysis machine draws all the patient's arterial blood into it for cleansing and then pumps it back into the veins. The blood circulates through the machine, which contains a dialyzer (artificial kidney). The dialyzer has a thin membrane that separates two spaces. Blood passes on one side of the membrane, and dialysis fluid passes on the other. The wastes and excess water pass from the blood through the membrane into the dialysis fluid, which is then discarded. The machine pumps the cleaned blood back to the patient's bloodstream. Although some patients and family members learn to do it themselves without a nurse, in my view the dialysis nurse should remain at the bedside from start to finish. This flow has to be monitored continuously, or there could be dire consequences. The complications commonly associated with hemodialysis are loss of blood volume (with nausea, vomiting, a sudden drop in blood pressure, and shock), blood infection such as hepatitis, AIDS, and staphylococcus), and worsening of anemia.

How to prevent shock

It is important to understand that when a person is on hemodialysis, all of his or her blood is being pumped into a machine where water is drawn off. This could result in a loss of blood pressure and shock. This is why someone has to monitor the fluid volume loss and replace it as needed. If someone tells you that you or your loved one doesn't need constant monitoring because the machines are more sophisticated, do not accept it. Surveillance is the key to maintaining a proper fluid balance.

How to lower the risk of infection

Hemodialysis has a greater risk of infection than abdominal dialysis. Every machine that you use has had someone else's blood going through it. Additionally, people on dialysis usually have a weakened immune system and are more susceptible to germ invasion. There are two sources of infection: cross contamination from other patients with infectious disease like hepatitis and AIDS and bacterial and/or viral invasion at the point of needle insertion. There have been many outbreaks of hepatitis among hemodialysis patients reported by the Centers for Disease Control and Prevention. One possible explanation is that the dialysis centers have so many patients that nurses and technicians don't have the time to do a proper disinfection between treatments. You or your loved one have a right to insist on complete disinfection and discarding of all used disposable components before hooking up. If you have any doubts, stop the process, call the supervisor, and complain.

Regarding needle insertion, the silastic tube under the skin, while quite innovative, is not perfect. The nurse has to avoid sticking the needle in the same spot more than once. At some point this becomes less likely, and leaks are liable to occur, causing blood clots to form under the skin. With the patient's immune system in depression, the clot and the leaky tube usually become infected with rapid spread into the bloodstream. The best way to prevent this scenario is for the nurse or technician not to inject the needle into a previous needle mark. Once the needle marks become too numerous to avoid that, it is time for the nephrologist to change the A-V tube. Again, it is up to you to maintain the high standard of quality to which you are entitled. You cannot rely on the system of doctors, nurses, and administrators, because they are simply too busy to be so meticulous.

Dealing with anemia

Anemia is a common complication of renal failure. Patients with chronically high levels of urea in the blood suffer from bone marrow depression, which slows the production of red blood cells. If the dialysis machine is not properly maintained, it can worsen the anemia through blood loss and destruction of red cells in the cleansing process. Thus it is imperative that you check the maintenance record of the dialysis machine before connecting to it. Ask the nurse to tell you what the manufacturer's recommended maintenance schedule is and whether it is being followed.