Dialysis in detail. Inclusive of peritoneal dialysis and hemodialysis

Dialysis is the unit that carries out a patient’s kidney functions artificially when the kidneys are not in the condition of working. Dialysis cleans up the blood by removing the additional fluid, urea, waste metabolites, and other waste matter. It is usually done in patients of stage 4 kidney disease and beyond. There are major two types into which dialysis is divided into. The first one is peritoneal dialysis which is further divided into two and is discussed later in this article. The second one is hemodialysis. 

Patients of any age group can be put on dialysis. This is a treatment type that has been in use since the 1950s. Kidney conditions have been increasing in number every day and a lot of patients have been living a normal life because of this method. When the glomerular filtration rate falls way below the normal range it is considered as an indication of dialysis.

Patients do not get cured because of dialysis. It only takes up the functioning of the kidneys and purifies the blood. This method of treating kidney conditions is safe but expensive. Many patients may require dialysis all along their lifetimes.

The apparatus of a dialysis unit consists of a power dialyzing machine, dialyzer, dialysis substance called dialysate, tubes for blood flow, and other surgical instruments.

Indication for undergoing dialysis.

• Chronic Kidney disease.
• Very low glomerular filtration rate.
• Old age where kidneys have reduced their functioning.
• Severe electrolyte imbalance.
• Tubular acidosis.
• Pericarditis, myocarditis, endocarditis.
• Ascites.
• Peripheral neuropathy.
• Uraemic attacks.
• Renal cancer.
• Infarction
• Temporary dialysis in recoverable issues.

What are the main five uses of dialysis?

• Purifies blood.
• Maintains electrolyte balance of the body.
• Maintains acid and base equilibrium if the body.
• Remove excess water content from the body.
• Metabolism produces waste and dialysis removes it.

How can dialysis affect the patient?

• It usually does not have any adverse effects.
• The patient may get immunocompromised in some cases.
• Pain at the site of administration of the needle.
• Weakness, body ache, vomiting, and sore muscles can be experienced.
• Unstable blood pressure can occur.
• Hypovolemia can cause a heart attack.
• It can be economically unaffordable for the patient.

How does dialysis basically work?

As mentioned earlier, dialysis is an artificial kidney. The dialysis unit is connected to the patient in the abdomen or other parts depending upon the type of dialysis. Connection is by getting access to the vein. This tube is further connected to the machine where the blood from the body moves for purification. Purified blood is further administered back into the body by another artificial tube. 

The urea and creatinine along with other unwanted material from the blood are filtered out through the membrane of the dialysis unit. And pure blood free of metabolites enters the body. 

Dialysis can have a few complications but is one of the best options for chronic Kidney disease patients unfit or unwilling to undergo a kidney transplant.

The patient may require 3-4 sessions of dialysis in a week. Each session lasts from 3 to 4 hours. The small surgical opening is done every time. But as that is not feasible, a fistula is made by hand. 

What is hemodialysis and how does it work?

 Haemodialysis is the unit that clears the uremic content in the blood by filtering it out. There is a thin membrane made up of cellulose or artificial substances acting as the filtering material for the blood. As the blood passes through this member the metabolites are left behind and blood becomes free of them. 

• This unit of hemodialysis contains two amongst which one being the blood part and the other being the dialysis part.
• These two parts are separated by cellulose or artificial membrane which carries out filtration.
• The connection is at the forearm.
• The patient may require a few hours for one session of hemodialysis.
• The requirement of sessions is based on the condition of the patient and is decided by the doctor.

What is peritoneal dialysis?

The peritoneum is a translucent membrane that covers the abdominal organs. This membrane itself acts as the partition and filters out the metabolites.

• Dialysate is used for about 2L.
•  Blood passes through the peritoneum itself and gets purified.
• There are two types of peritoneal dialysis which are continuous ambulatory peritoneal dialysis or CAPD. Another one is continuous cycling peritoneal dialysis or CCPD.
• In continuous ambulatory peritoneal dialysis, the dwelling period is pretty big. The dialysate is in the body for long hours during the day and night. About 4-5 cycles can happen in a day.
• In continuous cycling peritoneal dialysis, the dwelling period is more than the continuous ambulatory peritoneal dialysis during day time. But it is short at night.

What is the complication that can occur due to dialysis?

Haemodialysis can have certain complications specifically. A few of them are as follows:

• One of the serious complications of dialysis is excess loss of fluid from the body. It leads to hypovolemia and further leads to hypotension.
• It can also lead to venous tone complications and abnormalities.
• Acetate poisoning or excess acetate can lead to toxicity in the body.
• There can be autonomic neuropathy in the patient.
• Imbalance in the extracellular fluid in the body.

Other complications of hemodialysis include the following:

• The patient feels weak, lethargic, tired,
• The patient may have lightheadedness, and unconsciousness for a few seconds.
• Nausea, vomiting, and sore body can be felt.
• Body ache, muscle cramps, and joint function abnormalities can be experienced by any patient on dialysis.

Complications of dialysis when the patient is for a long time are as follows:

• Speech may become slurred or abnormal.
• The patient may have an episode of seizure. This denotes central nervous system involvement in the issue.
• Patients can become forgetful or medically called dementia.
• Aluminium poisoning or toxicity is another long-term complication.
• The patient can go into stroke or coma in serious cases when on dialysis for longer periods.
• Myoclonic jerks are seen in some cases.
• Patients on long-term dialysis have lower immunity as compared to healthy individuals. So they tend to have more chances of getting a viral or bacterial infection easily.

Are dietary modifications necessary for patients on dialysis?

By theoretical means, dietary restrictions are not necessary for patients on dialysis as kidneys do not function in clearing blood urea. The dialysis unit clears the metabolic waste at frequent intervals of time. So, as the kidney does not get any overall pressure in cleaning the waste product it is fine for patients to eat the food of their choice.

By practical and beneficial means for the patient, he or she must maintain a restricted diet to avoid any further deterioration of other body organs. Secondary complications have to be avoided and the best way to do so is by maintaining proper food habits. Various modifications are a must for the patients on dialysis. They include the following:

• Low sodium diet. Low sodium promotes less water retention and hence controls hypertension. Blood pressure fluctuations are frequently seen in such patients so maintaining that can prove to be life-saving.
• Low potassium diet. Even if the kidneys do not filter out the waste, potassium levels should be kept as low as possible. It ensures better blood composition and is healthy.
• Low protein diet. As mentioned in the theoretical aspect, urea is not filtered in kidneys but by dialysis, it is better to be on the safer side by reducing protein intake to lower the risks of other organ failures.
• Low triglycerides diet. This is true in all the conditions. Low oil, butter, and ghee intake keep your heart and blood vessels healthy avoiding hypertension and heart arrest.
• Patients on dialysis can eat more bland foods like rice , bread, plain Dal, khichadi, cooked vegetables, semolina dishes, vermicelli dishes, basil and lemon drinks, etc. 
• Foods to avoid are banana, spinach, avocado, beans, cashew, almonds, fig, meat, sweets, fried foods, packaged foods, soda, carbonated beverages, heavy diet, etc.

The dietary modifications are more likely to help patients who are not yet on dialysis and may need it someday. This dietary plan has a higher chance of avoiding dialysis or avoiding the need for a longer time before getting on. When kidneys are functional but not effectively, this diet can help reverse the condition or maintain it without further deterioration. Once on dialysis, this diet is mostly meant for avoiding other health disorders and to maintain a healthy lifestyle as far as possible.

If the patient is on any other medications, the diet has to be modified accordingly by consulting your dietitian and doctor. Patients undergoing dialysis can stay fit and fine like the one who does not require dialysis. This can be ensured by proper diet, physical therapy, and proper medical interventions. The lifestyle improvement and getting back to life are mentioned later in this article. Measuring the amount of water, and calories and keeping a track of it can prove profitable in the long run. Dietary changes should be made from time to time to avoid depletion of any required element. Maintaining a healthy body is the key for a dialysis patient to lead a long and independent life overall.

Dialysis in critically ill patients in detail.

As discussed earlier, dialysis has some complications. Critically ill patients cannot withstand those. For such cases, there is continuous renal replacement therapy which is supportive of renal function. Acute renal dysfunction cases cannot be put under the risk of hypotension or seizure hence, supportive therapy of CRRT is used. 

Most commonly used is venovenous hemodiafiltration. In hemodiafiltration, the dialyzer cleans the blood and purifies it. It also adds electrolytes and other substances to the blood for the enrichment of it.

Patients with fluid overload, cerebral issues, and unstable cardiac conditions undergo this type of dialysis.

Renal replacement therapy in critically ill patients.

Patients with acute kidney injury need RRT. It may be associated with mechanical ventilation. Patients with sepsis, burns, liver injury, major surgery, toxicity, and poisoning may require this treatment. Renal replacement therapy includes intermittent hemodialysis or IHD, prolonged intermittent renal replacement therapy or PIRRT, and continuous renal replacement therapy or CRRT. 

It works for the removal of solutes and clearing the blood and adding an electrolyte to it. Patients in the intensive care unit (ICU) have these for treatment to avoid acid and base imbalance, electrolyte imbalance, and volume overload. Intermittent hemodialysis takes 4 to 5 hours whereas prolonged intermittent renal replacement therapy PIRRT takes 7-12 hours to get completed.

Contraindications for dialysis.

Peritoneal dialysis is contraindicated relatively and absolutely in the following conditions:

• Patients with a hernia problem.
• A patient who has diverticulitis frequently.
• A patient who has abnormal peritoneum
• Needle phobia.
• The mental instability of the patient.
• The very unstable blood volume of the patient.
• Protein-energy malnutrition in the patient or very malnourished patient.
• Ischemic bowel disease, Whipple’s disease, Crohn’s disease.
• Alien body in the abdomen.
• Intra Abdominal infections or sepsis.
• Peritoneal leakage.
• Non functional peritoneum.
• Adhesion of peritoneal sheath.

Haemodialysis is contraindicated in the following conditions:

• Inability to get access to the blood vessel.
• Coagulopathy.
• A patient who has a history of recent cardiac arrest.
• Uncooperative patient.
• Psychiatry patient.

Why is dialysis becoming common in modern times?

• Kidney failure and severe kidney dysfunction syndromes are increasing in number day by day. Due to a bad lifestyle and poor health conditions, organ damage and failure are common to come across. 
• Comorbid conditions like diabetes and hypertension are prevalent in the younger population as well, paving a way for kidney failure at a later age. 
• Alcohol consumption is a major cause of kidney failure.
• Acquired immunodeficiency syndrome and other infections secondarily lead to such complications and may need dialysis for survival.
• In recent times most of the patients who have kidney issues land up requiring dialysis due to deteriorating health conditions.
• Bad sleep, overstress unhealthy food, less water consumption, and bad habits unknowingly lead to such complications and may require dialysis as an intervention.

How much does dialysis cost?

• Dialysis is a costly procedure worldwide. It takes about two to three thousand rupees per session of dialysis.
• Dialysis usually is permanent and may require a frequency of 2-3 times a week.
• It can cost more than lakhs of Indian rupees and hence can be unaffordable for some people.
• Hence it is better to avoid this treatment method when diagnosed early with other medications and lifestyle changes.

What is the alternative for dialysis?

Dialysis is done every now and then for the patient. It can be hectic, painful, irritating, and economically unaffordable for the patient party. Hence, renal transplantation is a surgical alternative to dialysis.

Removing the affected kidneys and replacing them with a donor’s kidney reverses the condition as the kidney starts functioning with the new transplantation. 

This process costs 5-6 lakhs Indian rupees once and for all. There is no dialysis required after the transplant. The amount is one time and the patient is not expected to pay repeatedly like dialysis. 

This is a major surgery and donor kidney matching is a legal task. Once the match is found and the legal formalities are completed the patient can undergo this treatment.

Until the surgery patient has to be on dialysis. Also, the patient has to be eligible to receive a kidney from the donor.

Life expectancy is fair. Patient recovers with care and proper interventions. Diet and exercise are a must to avoid going back to the same condition by damaging the new kidney. If the transplanted kidney is damaged, the patient goes back on dialysis again.

How do you enhance the quality of life of a patient on dialysis?

• The patient should be treated as an important individual as before. Motivation is a must and family support should be given.
• Encourage patients to have physical activities for better physical and mental health.
• The patient should be taken to social gatherings and the functions of his or her community.
• Physical therapy plays the main and ultimate role in bringing the patient back to his normal life.
• Meditation and yoga can be encouraged.
• Group therapy meaning treatment for people of the same disorders is done as physical therapy rehabilitation which makes the patient aware of other people suffering from the same issue and the patient gains faith and confidence in his or her abilities.
• The patient can go back to work and general activities after consulting with your physiotherapist and nephrologist and surgeon.
• Eat healthily and reduce stress levels in life.
• In severe cases, make the patient use assistive devices for walking and reaching activities. They can be walkers, crutches, cane, etc. 
• In some cases, psychologists, councillors, and social members play an important role in bringing the patient back to normal life mentally.
• To conclude, patients on dialysis can lead an absolutely normal life like other people. It does not hinder the patient’s intelligence and decision-making as a whole. With early interventional procedures, dialysis can also be delayed. Diet and healthy life are a must for patients on dialysis or on the verge of getting on dialysis