Renal - Haemodialysis Treatment

This leaflet is to help you understand what haemodialysis treatment involves, the risks and benefits.

What is haemodialysis?

• This is a treatment that cleans your blood, by filtering out waste products and water (fluid) from your blood
• A haemodialysis machine pumps your blood through an artificial kidney (filter) and returns it back to you
• Your blood is removed from a vein or a dialysis catheter (a plastic tube in your vein)
• It can be done at home or in a haemodialysis unit (Renal unit) both independently (self-care) or by the unit staff
• It takes on average 4 hours, at least 3 times a week, although this can change if you do it at home
• At the end of the treatment all the blood is returned to you

What does it feel like?

• Generally people do feel better once they are settled on haemodialysis
• It may not improve all the symptoms you have before you ever start haemodialysis and some people report tiredness after the treatment. Some patients need to rest after their treatment and sometimes describe a “dialysis hangover”
• The treatment is not normally painful
• You can eat and drink whilst having the treatment
• You can read, watch TV, listen to music, use your computer, anything as long as you keep fairly still around the machine

How does it work?

• Blood is taken from your body and pumped through an artificial kidney which is a filter. Your blood is pumped through this filter many times during the treatment. The more blood that is filtered the better treatment you will have as more waste is removed from your body
• The filter removes some of the waste products that the kidneys would normally remove, such as potassium, calcium, phosphate and other waste products
• The filter also removes excess fluid that has built up (accumulated) in your body since your last haemodialysis session. You may find that you do not pass any urine at all once you start dialysis so you will need to restrict the amount of fluid you drink (see later in diet and fluid restrictions)
• You will have to record your blood pressure and your weight before and after each dialysis session. This will help to work out how much excess fluid needs to be removed at each treatment
• The haemodialysis machine is programmed to remove a set amount of extra fluid over a certain time, for example, 2 litres of fluid to be removed over 4 hours treatment
• In order to prevent your blood from clotting in the haemodialysis machine an injection is used to keep the blood thin (anticoagulant). This medicine is injected into the haemodialysis machine during your treatment
• The machine will alarm if it can not achieve the set blood flow or if there is a problem with the treatment. Don’t worry this can be dealt with quickly

Who can have haemodialysis?

Most people can have haemodialysis treatment if they need it but sometimes people with other health problems can find haemodialysis difficult.

Other health problems that can complicate haemodialysis treatment are:

• Long term/serious heart problems
• Problems with blood pressure
• Long term problems with bloods vessels and veins
• Bleeding and problems with clotting in the blood vessels
• People who are generally very unwell

It is important to discuss with your kidney team any health problems that may affect how you would manage haemodialysis, so that you can consider if this treatment would be effective for you and any side-effects you may experience.
 
It is important for you to consider the benefits and risks/ complications of haemodialysis.

Benefits of Haemodialysis

• Dialysis will remove the waste products and extra fluid that may be making you feel unwell
• It can be flexible, done at home or at a dialysis unit
• You can change from one treatment to another if it does not work or you are not happy with the treatment
• You can continue to work around your dialysis sessions
• Holidays can be arranged with dialysis
• You can be on dialysis for many years
• You can get support from other patients/relatives

Risks/Complications of Haemodialysis

• It does not do all the jobs that the kidneys should do
• You will still need to take important medication
• It may affect your lifestyle and work, depending on what you do
• It may not work well for you dependent on your overall health
• You will need to attend clinic/hospital for treatment or check ups
• You may feel tired or unwell during or after treatment
• If you stop dialysis without another treatment (dialysis or transplant) you may not live long
• There are risks of infections and damage to your blood vessels, heart
• You may drop your BP on dialysis and feel unwell (sickness, dizziness)
• You may have increased risk of bleeding after treatment  

Practical issues of having haemodialysis

Access to the blood stream

Haemodialysis treatment works by pumping your blood through an artificial filter. To do this, you will need a safe and effective way to get the blood from your body to the dialysis machine.

There are 2 main ways of doing this:
1.    A Fistula
2.    A Haemodialysis Catheter

A Fistula

This where your own vein and artery are joined together to create a strong flowing vein in your forearm or upper arm (see below).

The join is created through a small incision in your arm, normally at the wrist or elbow. It is generally done with a local anaesthetic to numb the skin so you do not experience any pain and you are awake through the procedure. You will not need to stay overnight unless there are any problems.

Image of a Fistula fitted into the arm

Benefits of a Fistula:

• A fistula is a safe and effective way to allow your blood to be pumped to the dialysis machine
• There is potentially less risk of infection including MRSA therefore fewer admissions to hospital than with a haemodialysis catheter
• Fistulas will last longer than a dialysis catheter and provide a better blood flow for your dialysis
• It is your own vein and artery that is used therefore there will be no visible tubing sticking out of your arm
• Most of the time the fistula works well (on average 80% work first time)
• We aim for patients to have a working fistula suitable for dialysis to be ready about 6 months before they may need to start dialysis. On average we would plan a fistula operation with you when your kidney function is about 12%

Risks or complications of a fistula:

• Occasionally it does not work first time and you may need to have another fistula created (on average this happens in about 15-60% of patients)
• You may need a second operation on your first fistula (sometimes called a” second stage procedure”)
• This is why a fistula operation would generally happen before you start dialysis treatment
• Sometimes the nerves to your hand can be affected by the operation (the risk is less than 1%)
• As the blood supply to the hand is affected this can sometimes cause a cold sensation in the hand (this is called Steals Syndrome - this can occur in 10-20% of patients
• Areas can become swollen (aneurysms) along the vein and there may be a small risk of rupture
• The wound infection rate is less than 1%

When you start dialysis with a fistula, needles are inserted (normally 2 needles) into the fistula, these are then connected to the dialysis machine so your blood can flow into the dialysis machine and be pumped through the artificial filter.

A Dialysis Catheter

Sometimes a fistula cannot be created successfully so a dialysis catheter is needed to allow your blood to flow into the dialysis machine. A dialysis catheter is a plastic tube that is inserted into your vein, either in your neck or your groin (see next page).

They are generally temporary and would either need to be removed or replaced at some point. They may be used for acute treatment.

The dialysis catheter is connected to the dialysis machine through tubing and the blood is then pumped around the dialysis machine and through the filter, just as with a fistula.

Image of a Dialysis Catheter fitted into the Neck

Benefits of a dialysis catheter:

• It can provide access to the blood stream for haemodialysis treatment
• It can be inserted quickly for urgent treatment and ready for use immediately
• It is not generally painful

Risks or complications of a dialysis catheter:

• Increase risk of infection into the blood and the around the skin, which may mean increased number of hospital admissions and potentially serious complications
• Damage to the vein and surrounding area
• Blockage and clotting of the tubing
• May not last long and may not provide a good blood flow for haemodialysis.
• It may become dislodged and fall out of position, it requires stitches to hold it in place
• Local reaction to dressings

Where can I have haemodialysis?

Haemodialysis can be done at home or in haemodialysis unit.

You can decide to have home haemodialysis at any point even if you have started treatment at the hospital. As long as there are not any complications that might mean it is unsafe for you to have treatment at home, most people can have home dialysis if they want too. Just ask your kidney care team about it. (There is a separate Information sheet about Home Haemodialysis).

Diet and Fluid restrictions

When you start dialysis you may need to make some changes to your diet and fluid intake. This is because the waste products and extra fluid can build up in your body in between your dialysis sessions.

You may need to adjust your diet to reduce the intake of the following things:

• Potassium (a mineral that causes your muscles to contract, high potassium can lead to heart problems)
• Phosphate and calcium (minerals that keep your bones healthy, too much can cause bone and blood vessel problems)
• Salt (too much salt can lead to water retention and blood pressure problems)
• Fluid (too much fluid in your body can cause high blood pressure and serious heart problems

Medication

You will need to continue on some medication once you start haemodialysis although it will be adjusted as needed. Your medical and nursing team will discuss your medication with you. Please tell them if you can not take a certain medication or are having any problems, as often there are other options that can be used.

When will I need to start haemodialysis?

If you choose to have haemodialysis, you may need to start the treatment if your kidney function gets below 10% and you develop symptoms that can no longer be managed well with medication.

These symptoms can include:

• Increasing tiredness and being unable to do “day to day” activities.
• Feeling or being sick
• Shortness of breath
• Swelling (oedema) in your ankles, face, abdomen or chest
• When you start haemodialysis you may need some time off work to get into a routine
• You may have some initial problems, either in how you feel or in how the treatment is working, such as blood pressure problems, getting needles in your fistula
• You will start dialysis slowly, having shorter and less frequent sessions to begin with

Work, Holidays/travel

Once you have started and are settled on the treatment you may need to adjust your working patterns to accommodate your treatment either at home or at the haemodialysis unit. Your nursing team will try hard to ensure you can continue to work.

Many patients still go on holidays whilst on this treatment. The Renal team can arrange holiday dialysis for you both in the UK and abroad. All you need to do is advise the team where you would like to go (do not book until you have holiday dialysis confirmed). The team will then discuss with you about planning for your holiday. Many kidney patients associations have holiday accommodation available for renting with nearby dialysis facilities; again speak to your team about this for more details.

Contact the renal clerical team for more information on holiday haemodialysis on 0161 206 0483.

What happens if haemodialysis doesn’t work for me or I want to stop the treatment?

For many patients, haemodialysis can greatly improve their quality of life. However, some patients find that haemodialysis treatment is not effective for them or they no longer want to continue with the treatment. This is a very difficult decision to make but often people make this decision because they may find haemodialysis treatment demanding, time consuming, or other health problems worsen and become more difficult to manage, or they become less able to tolerate haemodialysis treatment.  Some patients may wish to change to an alternative type of dialysis; other patients may wish to consider stopping dialysis treatment completely.

It is important that patients discuss these concerns with their family (if they wish) and their health care professionals. They will want to discuss the reasons for this decision and if there any other improvements that may benefit the patient. The health care team will then be able to discuss with the patient the next steps and plan ahead for the care the patient wishes. For some patients this may be starting another dialysis treatment, for others it may be making plans about the end of their lives. Please speak to your health care teams for more information if needed.

Where can I get more information?

• From your kidney care team
• Other information leaflets - see your kidney care team
• Patient education afternoons - see your kidney care team
• Renal patient view (ask your kidney care team how to apply)

Contact Details

Please contact the Renal (CKD Team) on 0161 206 1882.

Internet Sites:

www.Kidneypatientguide.org
National Kidney Federation (NFK) - www.kidney.org.uk
Patient.co.uk
NHS choices
Renal Association
NICE
Edren (Edinburgh renal unit website) - www.edren.org.uk
British Kidney Patients Association (BKPA) - 0142 054 1424
www.britishkidney.pa.co.uk
PKD Foundation - www.pkd.org.uk
GMKIN - http://gmkin.org.uk/young-adults/
Hope Kidney Patients Association - see your kidney care team info.hopekpa@gmail.com
National Kidney Federation (NKF) via website - 0845 601 0209
Diabetes UK - www.diabetes.org.uk