A Detailed Guide to Dialysis: Understanding Your Options

Serving as a vital intervention, dialysis is a critical step in the journey of those with end-stage renal disease (ESRD), offering a way to sustain life and maintain health while awaiting a potential kidney donor for a transplant. Amidst the array of medical treatments available, dialysis stands out as a cornerstone therapy, enabling individuals to navigate the complexities of kidney failure with resilience and determination. In this comprehensive guide, we embark on an exploration of dialysis, unravelling its intricacies, navigating its diverse options, and shedding light on the essential considerations that accompany this indispensable medical procedure. Let’s begin with understanding the procedure. 

What is Dialysis?

Dialysis is a medical procedure used to replicate some of the functions of healthy kidneys when they fail, serving as a life-sustaining treatment for individuals experiencing end-stage renal disease (ESRD) or acute kidney failure. Essentially, dialysis helps to remove waste products, excess fluids, and toxins from the blood, restoring balance to the body's internal environment. This process is crucial because when the kidneys fail, harmful substances can accumulate in the bloodstream, leading to serious complications. Often considered the final recourse before kidney transplantation, dialysis plays a pivotal role in extending and enhancing the lives of those grappling with kidney disease.

Types of Dialysis

Dialysis has two main forms: hemodialysis and peritoneal dialysis. Each type has its unique characteristics, advantages, and considerations, offering individuals with kidney failure different options to suit their lifestyle and medical needs. Understanding these types is crucial for patients and caregivers alike, as it empowers them to make informed decisions about their treatment plan. Let's explore each type in detail.

1. Hemodialysis

Hemodialysis is a type of dialysis that involves using a machine to filter waste products and excess fluids from the blood. It is one of the most common treatments for individuals with end-stage renal disease (ESRD) or acute kidney failure. This procedure mimics the natural function of the kidneys, and is an effective treatment for managing kidney failure and improving quality of life. However, it requires a significant time commitment and may pose certain risks and complications, which will be discussed in more detail later in this guide. 

Hemodialysis typically requires the individual to visit a dialysis centre several times a week for sessions that can last several hours each. Alternatively, home hemodialysis options are available for those who prefer to undergo treatment in the comfort of their own home, under the guidance of trained medical professionals.

What happens before Hemodialysis?

Before undergoing hemodialysis, several preparatory steps are typically taken to ensure the process is safe and effective for the individual. These preparations are crucial for optimising the dialysis session and minimising any potential risks. Here's what typically happens before hemodialysis:

1. Medical assessment: Prior to starting hemodialysis, the individual will undergo a thorough medical assessment by their healthcare provider. This assessment may include blood tests, imaging studies, and evaluations of overall health to determine the most appropriate treatment plan.
2. Vascular access evaluation: A critical aspect of hemodialysis preparation is assessing and establishing vascular access. This involves creating a pathway to access the bloodstream so that blood can be safely removed and returned during the dialysis process. Common types of vascular access for hemodialysis include arteriovenous fistulas, arteriovenous grafts, and central venous catheters. The healthcare team will evaluate the individual's vascular health and determine the most suitable access option.
3. Fluid and medication management: Before each hemodialysis session, individuals may be advised to restrict their fluid intake and adjust their medication regimen as directed by their healthcare provider. This helps maintain fluid balance and optimise the effectiveness of the dialysis treatment.
4. Pre-dialysis assessments: Prior to each hemodialysis session, vital signs such as blood pressure, heart rate, and weight are typically measured to assess the individual's health status. These assessments help monitor fluid status and guide adjustments to the dialysis prescription as needed.
5. Patient education: Education plays a vital role in preparing individuals for hemodialysis. Patients and their caregivers receive training on various aspects of the dialysis process, including how to operate dialysis equipment, recognize signs of complications, and adhere to dietary and fluid restrictions. Proper education empowers individuals to actively participate in their treatment and promote their overall well-being.

By addressing these pre-dialysis considerations, healthcare providers can ensure that individuals are well-prepared for hemodialysis and receive optimal care throughout their treatment journey.

What happens during Hemodialysis?

During hemodialysis, the individual undergoes a series of steps to effectively filter waste products and excess fluids from the bloodstream. Here's what typically happens during hemodialysis:

1. Vascular access: Before the dialysis session begins, the vascular access site is prepared. This may involve accessing an arteriovenous fistula, arteriovenous graft, or central venous catheter, depending on the individual's vascular health and access options.
2. Connection to dialysis machine: The individual is connected to the hemodialysis machine, which consists of a dialyzer (artificial kidney), tubing, and monitors. Blood is drawn from the vascular access site and circulated through the tubing into the dialyzer.
3. Blood filtration: Inside the dialyzer, the blood comes into contact with a special fluid called dialysate. This fluid helps remove waste products, toxins, and excess fluids from the bloodstream through a process known as diffusion and osmosis. The purified blood is then returned to the individual's body.
4. Monitoring: Throughout the hemodialysis session, vital signs such as blood pressure, heart rate, and oxygen saturation are closely monitored by healthcare professionals. This allows for real-time adjustments to the dialysis prescription and ensures the individual's safety and well-being during the procedure.
5. Comfort and support: During hemodialysis, individuals are encouraged to remain as comfortable as possible. They may be provided with blankets, pillows, and entertainment options to help pass the time during the procedure. Healthcare professionals are available to address any concerns or discomfort that may arise.
6. Duration: Hemodialysis sessions typically last several hours and may be scheduled multiple times per week, depending on the individual's treatment plan and medical needs. The duration of each session may vary based on factors such as the individual's body size, kidney function, and fluid status.

What happens after Hemodialysis?

After a hemodialysis session is completed, there are several important steps that individuals typically undergo to ensure their well-being and recovery. These post-dialysis procedures aim to address any potential complications, promote fluid and electrolyte balance, and support overall health. Here's what typically happens after hemodialysis:

1. Vital sign monitoring: Healthcare professionals continue to monitor the individual's vital signs, including blood pressure, heart rate, and oxygen saturation, to assess their post-dialysis status and identify any immediate concerns.
2. Fluid and electrolyte management: Following hemodialysis, individuals may receive guidance on fluid intake restrictions and dietary recommendations to help maintain fluid and electrolyte balance. This may involve limiting fluids and certain nutrients to prevent fluid overload or electrolyte imbalances.
3. Access site care: If the individual has a vascular access site, such as an arteriovenous fistula, arteriovenous graft, or central venous catheter, proper care and maintenance are essential to prevent infection and ensure optimal function. Healthcare providers may provide instructions on cleaning and dressing the access site to reduce the risk of complications.
4. Post-dialysis assessments: Additional assessments may be conducted to evaluate the individual's post-dialysis status and monitor for any signs of complications or adverse reactions. This may include checking for signs of hypotension (low blood pressure), nausea, dizziness, or other symptoms that may arise after dialysis.
5. Medication administration: Individuals may receive medications to manage specific symptoms or medical conditions associated with kidney failure. These medications may include phosphate binders, erythropoiesis-stimulating agents (ESA), or medications to control blood pressure and fluid balance.
6. Patient education: Education plays a crucial role in post-dialysis care, empowering individuals to take an active role in managing their health and well-being. Patients and caregivers may receive instruction on medication management, dietary guidelines, symptom recognition, and strategies for self-care at home.
7. Follow-up appointments: Regular follow-up appointments with healthcare providers are essential for monitoring the individual's kidney function, adjusting dialysis prescriptions as needed, and addressing any concerns or complications that may arise. These appointments help ensure ongoing support and management of kidney failure.

Potential risks and complications of hemodialysis

While hemodialysis is an essential treatment for individuals with kidney failure, it is not without potential risks and complications. Here are some potential risks or complications of hemodialysis:

1. Hypotension (low blood pressure): During hemodialysis, rapid fluid removal from the bloodstream can lead to a drop in blood pressure, resulting in symptoms such as dizziness, lightheadedness, nausea, and fatigue. Doctors monitor blood pressure closely and may adjust fluid removal rates or administer intravenous fluids to prevent or manage hypotension.
2. Muscle cramps: Some individuals may experience muscle cramps during or after hemodialysis due to fluid and electrolyte shifts in the body. Adequate hydration, proper electrolyte balance, and stretching exercises may help alleviate muscle cramps.
3. Infection: Infection is a potential risk associated with hemodialysis, particularly at the vascular access site (e.g., arteriovenous fistula, arteriovenous graft, central venous catheter). Proper care and maintenance of the access site, including regular cleaning and dressing changes, are essential to reduce the risk of infection.
4. Bleeding: Hemodialysis can increase the risk of bleeding, especially in individuals who are taking blood thinners or have clotting disorders. Healthcare providers take precautions to minimise the risk of bleeding during dialysis, such as using appropriate needle sizes and applying pressure to the access site after needle removal.
5. Blood clots: Blood clots may form in the bloodstream or within the vascular access site during hemodialysis, leading to complications such as thrombosis or occlusion. Adequate blood flow monitoring and anticoagulation therapy may be employed to reduce the risk of blood clots.
6. Electrolyte imbalances: Hemodialysis can disrupt electrolyte balance in the body, leading to complications such as hyperkalemia (high potassium levels), hypokalemia (low potassium levels), hypercalcemia (high calcium levels), or hypocalcemia (low calcium levels). Close monitoring of electrolyte levels and appropriate adjustments to the dialysis prescription are necessary to maintain electrolyte balance.
7. Dialysis disequilibrium syndrome: In some cases, individuals may experience dialysis disequilibrium syndrome, a rare but serious complication characterised by neurological symptoms such as headache, nausea, vomiting, seizures, or altered mental status. This syndrome occurs due to rapid changes in solute concentrations in the brain during dialysis. Preventive measures, such as gradual dialysis initiation and careful monitoring, can help mitigate the risk of dialysis disequilibrium syndrome.
8. Cardiovascular events: Individuals undergoing hemodialysis are at an increased risk of cardiovascular events such as heart attack, stroke, and arrhythmias. This risk is attributed to factors such as fluid overload, electrolyte imbalances, and the presence of underlying cardiovascular disease. Comprehensive cardiovascular assessment and management are essential components of hemodialysis care to reduce the risk of cardiovascular complications.

2. Peritoneal dialysis

Peritoneal dialysis (PD) is a type of dialysis that involves using the peritoneal membrane, a natural lining in the abdomen, to filter waste products and excess fluids from the blood. Unlike hemodialysis, which requires a machine to perform the filtration process outside the body, peritoneal dialysis can be done manually by the individual at home or with the assistance of a machine called a cycler.

Overall, peritoneal dialysis offers individuals with kidney failure an alternative to hemodialysis, allowing them to undergo treatment in the comfort of their own home and maintain a greater degree of independence and flexibility in managing their condition. It is important for individuals considering peritoneal dialysis to receive proper training and support from healthcare professionals to ensure safe and effective treatment.

Types of Peritoneal Dialysis

Peritoneal dialysis encompasses several techniques, each offering unique advantages and considerations. Let's explore the three main types of peritoneal dialysis:

1. Continuous Ambulatory Peritoneal Dialysis (CAPD): Continuous Ambulatory Peritoneal Dialysis (CAPD) is a manual form of peritoneal dialysis that does not require the use of a machine. Individuals perform CAPD exchanges manually, typically four times a day, using gravity to fill and drain the peritoneal cavity with dialysate. Each exchange involves instilling fresh dialysate into the abdomen, allowing it to dwell for several hours to facilitate the removal of waste products and excess fluids, and then draining the used dialysate.
2. Continuous Cyclic Peritoneal Dialysis (CCPD): Continuous Cyclic Peritoneal Dialysis (CCPD), also known as automated peritoneal dialysis (APD), involves the use of a machine called a cycler to perform peritoneal dialysis exchanges while the individual sleeps. The cycler automatically fills and drains the abdomen with dialysate, typically over a series of cycles throughout the night. In the morning, a dwell period may be included to allow for additional fluid removal during the day. CCPD offers convenience and efficiency, allowing individuals to undergo peritoneal dialysis while they sleep, minimising disruptions to their daily activities.
3. Intermittent Peritoneal Dialysis (IPD): Intermittent Peritoneal Dialysis (IPD) is a less common form of peritoneal dialysis that involves performing exchanges manually, typically on a less frequent basis than CAPD. Individuals may undergo IPD exchanges several times a week, with longer dwell times compared to CAPD exchanges. IPD may be preferred by individuals who require less frequent dialysis treatments or have specific medical needs that make it a suitable option. While less common than CAPD and CCPD, IPD provides flexibility in treatment scheduling and may be tailored to individual preferences and requirements.

Each type of peritoneal dialysis has its own advantages and considerations, and the choice of technique depends on factors such as individual lifestyle, medical needs, and personal preferences.

What happens before peritoneal dialysis?

Before initiating peritoneal dialysis (PD), several preparatory steps are taken to ensure the procedure is safe and effective for the individual. These include:

1. Medical assessment: Before beginning PD, the individual undergoes a comprehensive medical assessment by their healthcare provider. This assessment includes a review of medical history, physical examination, and laboratory tests to evaluate kidney function, overall health status, and suitability for peritoneal dialysis.
2. Vascular access evaluation: Unlike hemodialysis, which requires vascular access for blood circulation, peritoneal dialysis relies on access to the peritoneal cavity. A surgical procedure is performed to place a catheter into the abdomen, usually in the lower abdominal area. The catheter serves as the access point for introducing and draining dialysate during PD exchanges. The healthcare team evaluates the individual's anatomy and vascular health to determine the most suitable catheter placement and type.
3. Peritoneal dialysis training: Individuals and their caregivers receive comprehensive training and education on peritoneal dialysis procedures, techniques, and equipment. This training typically covers topics such as catheter care, infection prevention, sterile technique, dialysate preparation, exchange procedures, and troubleshooting common issues. Proper training empowers individuals to perform peritoneal dialysis exchanges safely and effectively at home.
4. Dialysis prescription: Based on the individual's medical condition and treatment goals, a peritoneal dialysis prescription is developed by the healthcare team. This prescription specifies the type of peritoneal dialysis (e.g., CAPD, CCPD), exchange frequency, dialysate volume, dwell time, and other parameters tailored to the individual's needs.
5. Home environment preparation: Individuals preparing for peritoneal dialysis may need to make adjustments to their home environment to accommodate the treatment. This may involve setting up a clean and designated area for performing dialysis exchanges, organising supplies, and ensuring access to necessary equipment and resources.
6. Support system: Establishing a support system is crucial for individuals undergoing peritoneal dialysis, especially if they require assistance with dialysis exchanges or have specific medical needs. Caregivers, family members, and healthcare professionals play a vital role in providing emotional support, practical assistance, and medical supervision throughout the peritoneal dialysis process.

What happens during peritoneal dialysis?

During peritoneal dialysis, several steps are involved in performing the dialysis exchange, which helps to remove waste products and excess fluids from the bloodstream. Here's what typically happens during a peritoneal dialysis session:

1. Dialysate preparation: Before starting the dialysis exchange, the individual or caregiver prepares the dialysate solution according to the prescribed specifications. The dialysate solution contains electrolytes and other substances that facilitate the removal of waste products and excess fluids from the body.
2. Catheter connection: The individual connects the catheter, which is implanted in the abdomen, to the tubing of the dialysis bag or cycler machine. The catheter serves as the access point for introducing and draining the dialysate into and out of the peritoneal cavity.
3. Fill phase (inflow): Once the catheter is connected, the dialysate solution is introduced into the peritoneal cavity through the catheter. Gravity or the cycler machine is used to fill the abdomen with the prescribed volume of dialysate. The solution remains in the peritoneal cavity for a designated dwell time, during which waste products and excess fluids are removed from the bloodstream.
4. Dwell phase: After the peritoneal cavity is filled with dialysate, the dwell phase begins. During this phase, the dialysate solution remains in the abdomen for a predetermined period, typically several hours, to allow for the exchange of solutes and fluids across the peritoneal membrane. This process helps to remove waste products, toxins, and excess fluids from the bloodstream.
5. Drain phase (outflow): Once the dwell time is complete, the individual or caregiver drains the used dialysate solution from the peritoneal cavity back into the empty dialysis bag or cycler machine. Gravity or the cycler machine is used to facilitate the drainage process. The used dialysate contains waste products and excess fluids removed from the bloodstream during the dwell phase.
6. Completion and disconnection: After draining the used dialysate, the peritoneal dialysis exchange is complete. The individual disconnects the catheter from the dialysis tubing or cycler machine and secures the catheter in place. The used dialysate solution is disposed of properly, and the catheter exit site is cleaned and dressed as needed to prevent infection.
7. Monitoring and documentation: Throughout the peritoneal dialysis session, the individual or caregiver monitors vital signs, assesses for any signs of complications, and documents relevant information, such as fluid balance, dialysate volume, and any observed changes in health status. This documentation helps track the effectiveness of the dialysis treatment and informs future adjustments to the dialysis prescription.

Peritoneal dialysis is a continuous process that involves filling, dwelling, and draining the peritoneal cavity with dialysate to remove waste products and excess fluids from the bloodstream. Proper technique, adherence to the prescribed regimen, and vigilant monitoring are essential for ensuring the safety and effectiveness of peritoneal dialysis treatment.

What happens after peritoneal dialysis?

After completing a peritoneal dialysis exchange, several post-dialysis procedures and considerations are typically addressed to ensure the individual's well-being and treatment effectiveness. Here's what typically happens after a peritoneal dialysis session:

1. Catheter care: Following the dialysis exchange, the catheter exit site is cleaned and dressed as needed to prevent infection and promote healing. Proper catheter care is essential for maintaining the integrity of the peritoneal dialysis access and minimising the risk of complications.
2. Monitoring vital signs: Healthcare providers monitor the individual's vital signs, including blood pressure, heart rate, and temperature, to assess their post-dialysis status and identify any immediate concerns. This monitoring helps detect potential complications such as hypotension (low blood pressure) or infection.
3. Fluid and electrolyte Management: After peritoneal dialysis, individuals may receive guidance on fluid intake, dietary restrictions, and medication management to help maintain fluid and electrolyte balance. This may involve monitoring fluid intake and output, adhering to dietary guidelines, and adjusting medication doses as needed to prevent fluid overload or electrolyte imbalances.
4. Disposal of dialysate: Used dialysate solution containing waste products and excess fluids removed during the dialysis exchange is properly disposed of according to healthcare guidelines. This may involve emptying the used dialysate into a designated drain or toilet and disposing of the dialysis bags or cycler waste in accordance with waste disposal regulations.
5. Documentation and monitoring: Relevant information, such as fluid balance, dialysate volume, and any observed changes in health status, is documented for each peritoneal dialysis session. This documentation helps track treatment effectiveness, identify trends or patterns, and inform future adjustments to the dialysis prescription.
6. Lifestyle considerations: Individuals undergoing peritoneal dialysis may receive guidance on lifestyle modifications to support their overall health and well-being. This may include recommendations for physical activity, stress management, and social support to help individuals cope with the demands of chronic kidney disease and peritoneal dialysis treatment.
7. Follow-up care: Regular follow-up appointments with healthcare providers are scheduled to assess the individual's overall health, monitor kidney function, and review treatment outcomes. These appointments provide an opportunity to address any concerns or complications that may arise and make adjustments to the peritoneal dialysis regimen as needed.

By addressing these post-dialysis procedures and considerations, healthcare providers ensure that individuals undergoing peritoneal dialysis receive comprehensive care and support to optimise treatment outcomes and enhance their quality of life. 

Potential risks and complications of peritoneal dialysis

Peritoneal dialysis is generally considered a safe and effective treatment for individuals with kidney failure. However, like any medical procedure, it is associated with potential risks and complications. These include:

1. Peritonitis: Peritonitis is a serious and potentially life-threatening infection of the peritoneal cavity, which can occur as a complication of PD. It is usually caused by bacteria entering the peritoneal cavity through the catheter exit site or during the dialysis exchange process. Symptoms of peritonitis may include abdominal pain, fever, cloudy dialysate effluent, and nausea. Prompt recognition and treatment with antibiotics are essential to prevent complications and preserve peritoneal membrane function.
2. Catheter-related complications: Complications related to the PD catheter, such as catheter malfunction, migration, or infection, can occur and may require intervention. Catheter-related infections, including exit-site infections and tunnel infections, can lead to peritonitis if left untreated. Proper catheter care, including regular cleaning and dressing changes, is essential to minimise the risk of catheter-related complications.
3. Exit-site and tunnel infections: Exit-site infections and tunnel infections are common complications associated with PD catheters. These infections occur at the exit site of the catheter or along the subcutaneous tunnel and are typically characterised by redness, swelling, tenderness, or drainage at the catheter insertion site. Prompt treatment with antibiotics and proper wound care are essential to prevent the spread of infection and preserve catheter function.
4. Fluid overload or dehydration: Improper fluid management during PD exchanges can lead to fluid overload or dehydration, which can result in complications such as edema, hypertension, or electrolyte imbalances. Close monitoring of fluid intake, output, and weight is essential to maintain fluid balance and prevent complications.
5. Hernias: Chronic intra-abdominal pressure from repeated PD exchanges may increase the risk of developing hernias, particularly in individuals with weakened abdominal muscles or previous abdominal surgeries. Hernias can cause discomfort, pain, and complications such as bowel obstruction and may require surgical intervention.
6. Encapsulating Peritoneal Sclerosis (EPS): Encapsulating peritoneal sclerosis is a rare but serious complication of long-term PD characterised by fibrosis and thickening of the peritoneal membrane. EPS can cause bowel obstruction, malnutrition, and abdominal pain and may require surgical intervention or discontinuation of PD. Early recognition and management of risk factors, such as prolonged PD duration and high glucose concentrations in dialysate, are important for preventing EPS.
7. Other complications: Other potential complications of PD include dialysate leakage, abdominal discomfort, electrolyte imbalances, back pain, and inadequate dialysis adequacy. Close monitoring, proper technique, and adherence to treatment guidelines are essential to minimise the risk of complications and optimise treatment outcomes.

While peritoneal dialysis offers many benefits, including flexibility, independence, and improved quality of life, individuals and healthcare providers should be vigilant in recognizing and managing potential risks and complications to ensure safe and effective treatment. Close collaboration between patients, caregivers, and healthcare professionals is essential for optimising peritoneal dialysis care and minimising the chances of complications.

Final words

Understanding the dialysis options available is crucial for individuals facing kidney failure as well as their caregivers. Whether considering hemodialysis or peritoneal dialysis, each option comes with its own set of considerations, benefits, and potential risks. At Max Hospitals, our team of nephrologists, dialysis specialists and healthcare professionals is dedicated to providing comprehensive care and support to individuals undergoing dialysis treatment. Whether you have questions about the different dialysis options, need assistance with treatment management, or require specialised care for kidney disease, our experts are here to help. Book an appointment with one of our specialists for personalised guidance and support on your journey towards a healthier life.