Dialysis ProceduresHemodialysis Access - Minimally Invasive Surgical Solutions and Treatments of Dialysis and Hemodialysis What is dialysis?
is for people who have kidney failure. When you have kidney failure,
your kidneys are not able to cleanse your blood of wastes, including
urea, and extra fluid. This process takes about three hours and is done
three times a week.
There are two types of dialysis for people with kidney failure:
Are there any other treatments for kidney failure?
where the blood is withdrawn from the body into a machine that uses a
special membrane (dialyzer) to filter wastes and remove extra fluid from
the blood. Hemodialysis also restores the electrolyte balance in the
- Peritoneal dialysis,
where a fluid is placed into the abdominal cavity through a special
tube called a catheter and is left in place for several hours, after
which it is removed. The fluid removes wastes and extra fluid from the
than dialysis, kidney transplantation is the only other option for
people with kidney failure. In kidney transplantation, a kidney received
from an organ donor or a living relative is placed into the body and
takes over the function of the failed kidneys. Kidney transplant is the
desired goal for most people with kidney failure. However, due to a
shortage of donor kidneys, the majority of people with kidney failure
are on dialysis. About Hemodialysis
Why do I need hemodialysis?
Hemodialysis is often started when symptoms or signs of kidney failure appear. These may include:
vomiting, anorexia, and fatigue due to "uremia", a buildup of urea and
other waste products in the blood that occurs when the kidneys are
unable to eliminate wastes from your body. These wastes are poisonous to
you when they reach high levels.
- High levels of potassium in the blood ("hyperkalemia")
- Fluid overload
- High levels of acid in the blood
Renal hypertension, or elevated blood pressure caused by narrowing or
blockage in the renal artery, puts stress on the kidney and is a
major cause of end-stage renal disease (chronic renal failure). This
renovascular disease causes decreased blood flow to the kidney, which in
turn leads to body-wide (systemic) constriction of blood vessels and a
corresponding increase in blood pressure. Patients suffering from
end-stage renal disease require either dialysis or kidney
transplantation to perform the kidney's job of ridding of the body of
toxic waste products and maintaining the appropriate fluid, electrolyte,
and acid-base balance in the blood.
Hemodialysis is sometimes used for people who have acute (sudden) kidney failure as well.
Are there any risks associated with hemodialysis?
is always used with extra caution in people who have acute kidney
failure. Dialysis can cause low blood pressure, an irregular heart
rhythm (cardiac arrhythmia) and other problems that can sometimes make
acute kidney failure worse. What is a hemodialysis access?
of the need to remove blood from the body and replace it during
hemodialysis, a means for accessing the patient's blood circulation -
called "vascular access" -- is necessary. There are three different
techniques for this, some of which are used interchangeably: dialysis
fistula, graft and catheter. All of these techniques are able to
withdraw and replace large amounts of blood at the same time - about one
quart per minute.What is a fistula?
most desirable form of hemodialysis vascular access is called a fistula.
To make a fistula, a surgeon connects an artery to a vein in the
forearm or upper arm. With time, usually one to three months, the vein
enlarges and becomes ready to receive the needles used to withdraw and
replace blood during dialysis. A fistula can last for many years if the
vein enlarges and the fistula "develops". About three-quarters of
fistulas develop or mature. During the time that a fistula is
developing, if hemodialysis is necessary, another form of vascular
access will be necessary, usually a catheter. What if my fistula does not develop?
non-developing or non-maturing fistula occurs in up to one fourth of
patients. There are two causes for a non-maturing fistula: narrowing of a
vein or too many competing veins. Interventional radiologists can
either open up the narrowed vein with a balloon (balloon angioplasty) or
close off the competing veins using several techniques. About three
quarters of people with non-maturing fistulae will benefit from one or
both of these treatments and have their fistula develop so it can be
used. These procedures are done as an outpatient and take about an hour.
Protect your veins!
In order to make a fistula you must have
good arteries and good veins. While you generally cannot do much about
your arteries, you are in control of your veins. As soon as a diagnosis
of kidney failure is made you should be very careful not to let anyone
puncture the veins of your forearm or upper arm for blood draws,
intravenous medications, or for any other reason. The hand veins should
serve this purpose. By doing so, you protect your important veins so the
surgeon will have a better chance of making a fistula. Even after a
hemodialysis access is created in one arm, you should protect the veins
of the opposite arm. What is a dialysis graft?
some patients, the arteries and/or veins are not suitable for making a
fistula. In these patients, a shunt (or graft) can be used as an
alternative form of dialysis access. A graft is a piece of plastic
tubing that is inserted by a surgeon and connects the artery to the
vein. Unlike fistulas, grafts do not need to "develop" and are ready for
use in most instances by four weeks after placement. A catheter may be
necessary for dialysis during this waiting period. The disadvantage of
grafts is that they do not last nearly as long as fistulas and can
develop narrowing and clotting more frequently. In addition, grafts can
get infected -- something which does not happen very often with
Just as with fistulas, narrowing veins with grafts can
be detected before they clot if the appropriate screening techniques
are used. These include self-examination, measuring flows during
dialysis with a special machine, and checkups by an interventional
radiologist. Once an abnormality is detected, you need to be scheduled
to have it treated by Interventional Radiology as quickly as possible.
It is very important that patients keep their appointments with
Interventional Radiology so that clotting does not occur. If clotting
does occur it can be treated by an interventional radiologist. What is a dialysis catheter?
are considered the least desirable form of dialysis access. Catheters
come in two forms: a short-term (non-tunneled) and longer-term
(tunneled) form. The best use of catheters is to provide short-term
access for dialysis for patients whose kidney function is expected to
recover, or for patients whose kidney function is not expected to
recover but who have a graft or fistula in place and are waiting for it
A catheter is inserted by an interventional radiologist
or a nephrologist (kidney doctor) through one of the large veins --
usually the jugular -- into the larger veins in the center of the chest
near the heart. This procedure can be done as an outpatient and lasts
less than an hour. The best results with catheter placement are achieved
when imaging guidance is used, including ultrasound to place a needle
into the vein and X-rays to guide correct positioning of the catheter.
have the advantage that they can be used for dialysis immediately after
they are placed. Patients also tend to find them attractive because
needle sticks are not necessary to remove and replace blood during
dialysis, as occurs with a graft or fistula. However, catheters have
significant disadvantages and risks. These include:
- Risk of
infection -- approximately half of all patients with catheters develop a
life-threatening infection during the first year the catheter is in
do not provide flow rates for dialysis that are as good as grafts or
fistulas. This can result in patients not receiving enough dialysis or
requiring a longer dialysis session.
can cause the veins they are placed into to clot off or develop
narrowing (stenosis). In fact, with certain chest veins called the
subclavian veins (just under the collarbone), the risk of clotting or
narrowing is approximately 50%. Therefore, subclavian veins should never
be used for catheters except in very rare instances when all other
veins have been used up. Patients can help to prevent this complication
by not allowing their doctors to use the subclavian veins for dialysis
catheters, rather insisting on the jugular veins where this complication
is quite uncommon (less than 10%).
- Many patients find catheters uncomfortable and/or unsightly.
Despite all of the problems with catheters, patients may need to have
them in place for a short period of time while a fistula develops or a
graft heals. Generally, this should be less than three months for a
fistula and one month for a graft. Some patients will need to have a
catheter placed while they are waiting for a visit to the surgeon for a
graft or fistula. It is very important that patients in this situation
make and keep their appointments with the surgeon so there is no delay
in getting the graft or fistula made. The sooner the catheter comes out,
Besides inserting dialysis catheters, interventional
radiologists also treat problems with catheters, including infection and
clotting. These problems are most commonly treated by exchanging the
catheter for a new one in a brief outpatient procedure lasting less than
Detecting problems with grafts and fistulas
a fistula is considered the best kind of access, problems can occur,
including vein narrowing, or "stenosis," and clotting, or "thrombosis."
Both of these problems can be treated by an interventional radiologist
with excellent results. Treating the vein while it is narrowed but not
clotted yields the best results and takes the least amount of time.
There are a number of ways to detect narrowing in the vein before
thrombosis occurs, through "screening" by your Dialysis Unit. Once an
abnormality is detected it is essential that you be seen by the
interventional radiologist as soon as possible to treat the problem.
What if my dialysis access is clotted?
the graft or fistula is clotted, interventional radiologists use a
variety of procedures to dissolve or remove the clot. First, X-ray
pictures (fistulogram) are taken which show the area(s) of narrowing
(stenosis). Then, a balloon is inserted to open up the clogged area(s)
in the vein, in a procedure called an "angioplasty." A clot can be
removed either with drugs that dissolve it or mechanical devices that
remove it or break it up into very small pieces.
are all done as an outpatient using conscious sedation and local
anesthesia (numbing medicine). In conscious sedation, medicines to
relieve anxiety and discomfort are given through an intravenous tube. In
order to receive conscious sedation, you must not have had anything to
eat or drink six hours before your procedure. Also, you may not drive
home after receiving conscious sedation, so be sure to arrange a ride
home after the procedure.
After angioplasty, your
self-examination should return to normal. Screening tests should be
repeated in the Dialysis Unit to ensure that they too have returned to
normal. While balloon angioplasty is effective in dialysis access it may
need to be repeated periodically, usually every six months. When
angioplasty is unsuccessful, interventional radiologists have other
alternatives available to them. Generally, the first of these is to
repeat the angioplasty. If this is unsuccessful, depending upon the
location of the narrowing, a small metal tube called a "stent" can be
inserted in the same outpatient procedure as the angioplasty. This is
done quite uncommonly and more often in the chest than the arms. When
angioplasty is unsuccessful, a patient may be referred to a surgeon for a
procedure called a "revision of the graft or fistula."
What is dialysis access self-examination?
dialysis graft or fistula should feel like a cat purring when it is
functioning well. You can feel this best by putting the palm of your
hand over your graft or fistula. You should examine at least three
different points on the access. If you feel the access pulsing (beating
like a drum), this is abnormal and you should inform the Dialysis Unit
staff immediately so a fistulogram and angioplasty can be scheduled. The
best way to detect problems with your graft or fistula is to examine it
on a regular basis (such as on your dialysis days) and note changes
from the last self-examination. If you cannot feel a pulse or a thrill,
your access is probably clotted and you may wish to call the Dialysis
Unit to inform them so you can get it treated.
Arm swelling is also
abnormal and may be an indication of a problem in the veins in the
chest. Some swelling after a surgical procedure may be normal but this
should get progressively better. Swelling that lasts more than a few
weeks after surgery should be investigated with a fistulogram.
or redness over a graft is a sign of infection and should be reported
to the Dialysis Unit staff immediately. In a clotted fistula, some
tenderness or redness may be normal, but never in a clotted graft.
What are the screening tests for a failing dialysis access?
for a failing dialysis access can be done in several ways. The simplest
is self-examination. Other techniques available during dialysis include
flow measurement (using a special machine connected to your dialysis
tubing) and pressures (measured by the dialysis machine). When a graft
or fistula is failing, the flow goes down and generally the pressure
goes up. Other signs that an access is failing include prolonged
bleeding after needle removal and trouble puncturing the access. Any of
these abnormalities should prompt a visit to Interventional Radiology
for a fistulogram and balloon angioplasty as needed.
^ Top of Page
About Peritoneal Dialysis
Why do I need peritoneal dialysis?
dialysis is for people who are very young, very old, or very sick.
During hemodialysis, blood pressure and electrolytes can change rapidly,
which can be dangerous for people whose body cannot tolerate these
sudden changes. People who bleed easily, and who have diabetes, are also
recommended for peritoneal dialysis, which does not use blood thinners
or sugars in the dialysate solution.
People who have scars or leaks
in the lining of their abdominal wall, or who have inflammatory bowel
disease, cannot use peritoneal dialysis.
How do I know which type of peritoneal dialysis is right for me?
best type of peritoneal dialysis for you depends on a number of
factors, including your health history. Your doctor will recommend one
of three types of peritoneal dialysis for you.
ambulatory peritoneal dialysis (CAPD) is the most common type of
peritoneal dialysis. In CAPD a solution from a plastic bag enters the
abdomen through a catheter. After about four to six hours the solution
is drained out of the abdomen back into the bag, and replaced with fresh
solution. This cycle repeats about four times per day.
cycling peritoneal dialysis (CCPD) is a continuous procedure where a
machine automatically fills and drains the dialysis solution from the
abdomen. CCPD takes about 10 to 12 hours, and can be done at night while
Like CCPD, intermittent peritoneal dialysis (IPD)
uses a machine to fill and empty the abdomen of solution, but it takes
about 24 hours. This type of peritoneal dialysis can be done at home but
is usually done in a hospital.
You should discuss your peritoneal dialysis options with your doctor. Some questions to ask:
- Am I a candidate for continuous ambulatory peritoneal dialysis?
- What are the risks and benefits of the type of peritoneal dialysis prescribed for me?
- Is it likely that I will have catheter problems, or need my peritoneal catheter replaced?
What is a peritoneal catheter?
Before you can
begin peritoneal dialysis, you must have a special tube (catheter)
placed in your abdomen so that dialysate solution can flow into and out
of your abdominal cavity. If possible, the catheter should be placed at
least 10 to 14 days before dialysis starts. Catheters often last for
about three years before they need to be replaced.
What is peritoneal dialysis catheter manipulation?
dialysis is performed through a tube passing through the abdominal wall
into the abdominal cavity. Occasionally, when this tube becomes blocked
or malfunctions, an interventional radiologist can reposition the tube
to restore function, without removing or replacing the tube. In this
outpatient procedure, a wire is passed through the tube under X-ray
guidance and the tube repositioned into a better location within the
abdomen. The procedure typically takes less than an hour and the patient
can return to peritoneal dialysis immediately. Catheter manipulation
can be repeated in the future if necessary.
Are there any risks of peritoneal dialysis?
is a risk of complications associated with peritoneal dialysis. These
include inflammation of the lining of the abdominal wall (peritonitis),
catheter tube infection, and increased abdominal pressure that may cause
a hernia. When you get your catheter, you will learn about the warning
signs of inflammation, infection and increased abdominal pressure due to
peritoneal dialysis. Screening tests at the Dialysis Unit and regular
self-examination of your catheter will help detect problems caused by
your peritoneal dialysis.
^ Top of Page