Reversing Medical Disease Clinic
HEMODIALYSIS VS. PERITONEAL DIALYSIS
- Part 1: describes the differences in these dialysis modalities. Dialysis is an artificial way to rid your body of metabolic wastes and excess water when your kidneys work at a rate per minute -15% or less.
- Part 2: describes the pros and cons for each modality.
Part 1: What exactly entails a “healthier” lifestyle?
Sure, you could exercise more and cut down on unhealthy foods, but how long will you keep it up? One week, three weeks, maybe a couple of months? Once you have learned your new health skills and habits, it is very important to keep it up for the rest of your life.
Dr. Mary Washington aka RapperMD (RMD) expresses that 80% of the patients she sees who have diabetes, high blood pressure and kidney failure, eat unhealthy and are physically inactive. They all want to blame it on their family genes when in actuality it is their own unhealthy lifestyle. Sadly, so many early deaths happen from patients who waited too late to try to make a healthier change. The most compelling stories I’ve heard are about the patients that have to go through the different types of dialysis. Hemodialysis (HD) and Peritoneal dialysis (PD).
Dialysis is the cleaning process of the blood when your kidneys are no longer doing this adequately. In hemodialysis (HD), a machine with an artificial kidney filters the metabolic wastes and fluid from your blood. But how does your blood get connected to this machine? Surgery is needed to make an access joining an artery to a vein under your skin to make a bigger blood vessel called a ‘fistula’. RMD specifically uses vascular surgeons to create this access in your forearm, upper arm or thigh. However, if your blood vessels are too calcified or too small, the surgeon places a soft plastic tube to join an artery and a vein under your skin. This is called a ‘graft’. When one needs dialysis urgently, an access is made by means of a narrow plastic tube, called a catheter, which is inserted into a large vein in your neck or groin. This type of access may be temporary (Quinton catheter) but is sometimes used for long-term treatment (eg. tunneled tessio-catheter).
I am sure you see the different dialysis centers around your neighborhoods. In a center, the dialysis treatments are given either on Monday-‐Wednesday-‐Friday or Tuesday-‐Thursday-Saturday. One hemodialysis session can last anywhere from 3 hours (eg. small elderly lady) to 5 hours (eg. a large male).
Peritoneal (per-‐ih-‐toe-‐NEE-‐ul) (PD) dialysis is another way to remove waste products from your blood when your kidneys can no longer do the job adequately. The peritoneal area is the cavity below your diaphragm that contains your liver/stomach/ pancreas/intestines/gallbladder/ and urinary bladder.
During peritoneal dialysis (PD), blood vessels lining your peritoneum (peritoneal membrane) do the job for the kidney arteries . A machine is used to warm and push cleansing fluid called dianeal (or dialysate-‐ which is a solution that contains glucose,potassium, salt ,calcium etc) into your peritoneum. A surgeon places a plastic tube called a Tenckhoff Catheter into your peritoneal cavity to make an access so that the dianeal can flow easily into and out of your peritoneal space. As blood enters the lining of your peritoneum membrane it is in close proximity to the dianeal. There is a shift of urea/minerals/ glucose/water/etc.between this membrane. The excess water and waste products are then removed when the peritoneum is drained via the Tenckhoff Catheter into a separate bag or with extension tubing that is place in the patient’s toilet. This whole process (pushing fluid in/filling the cavity/draining out of cavity)…..is called an “exchange.”
So RMD writes a prescription for the peritoneal dialysis nurse to set the machine for ‘X’ number of exchanges the dialysis patient must do to get good cleaning of his/her blood. One exchange (or dialysis Rx): Fill time: 10-‐20 minutes to place the volume in your cavity. Dwell time: how long it takes to undergo the chemistry that I attempted to oversimplify for you above across the peritoneum membrane. Drain time: another 20 minutes. In other words a person can undergo 5-‐7 of these ‘exchanges’ in one day.
There are various ways to receive PD. Acute schedule, chronic schedules CAPD, CCPD, NIPD or various combinations thereof. Below are the two most popular.
Continuous Ambulatory Peritoneal Dialysis (CAPD) is the only type of peritoneal dialysis that is done without machines. You do this yourself, usually four or five times a day; at home and/or at work. You put a bag of dialysate (2-‐2.5 liters of dianeal) into your peritoneal cavity through the catheter. The dialysate stays there for about three or four hours before it is drained back into an empty bag and thrown away. This is called an exchange. You use a new bag of dialysate each time you do an exchange. While the dialysate dwells in your peritoneal cavity, you can go about your usual activities at work, at school or at home. There are usually about 5 exchanges that take place during the day. None at night/bedtime.
Automated Peritoneal Dialysis (APD) usually is done at home using a special machine called a cycler. This is similar to CAPD except that a number of cycles (exchanges) occur usually while sleeping. Each cycle usually lasts 1-‐1/2 hours and exchanges are done throughout the night. There are about 7 to 8 exchanges that take place during the night and none during the day. The fluid is drain though a tube that extends to the patients toilet.
Fortunately, dialysis does some of the work that a healthy kidney would do; however it does not cure kidney disease. If your kidneys have failed your other option is a kidney transplant.
Life expectancy on dialysis can vary. It all depends on what disease put you there to begin with. RapperMD has a small percentage of patients that have been on dialysis for 10-‐15 years and an even smaller percentage that still work, go to school and even go on cruises. They do their dialysis as prescribed and make some dietary changes. RMD asks why go through any type of dialysis? We both urge you to start living healthy TODAY before its too late!
Part 2: All access are at risk of not working properly
clotting off, getting infected if you donʼt protect it as instructed, and is the number one cause for patients frequent visits to access centers or admissions to the hospital. And death from sepsis.
However there are certain medical conditions in which a doctor would recommend one modality over the other. So i would like to break this section into the pros and cons of both with concrete examples of patients medical condition so you can follow me.
1- a structure rountine is needed. the patient needs to be monitor more regularly w/fluid removal, medication changes, or until i get their blood pressure under better control. They can always switch modalities later.
2- social network . especially for the elderly who are home bound /nursing home during the day, with dialysis, they have somewhere to go and share w/ people in this same circumstances to talk to.
3-temporary . For ex. while you heal from a gall bladder surgery when your modality was PD OR you develope Acute Kidney Injury because you took too many ibuprofen after becoming dehydrate and achy from too much weekend touch football.
4-Prefer NOT to do this at home. Some clients don’t want their grand children no where near the equipment.
6- awaiting a living donor transplant . For example, You have a cousin who matched and has plan the summer to take off of work to go through the surgery with you. so using tunnel dialysis catheter in the meantime.
7- enviroment at home is not conducive to PD.
Hemodialysis (HD) CONS
1- peripheral vascular disease (PVD). For example you already have an amputation below your knee. Or diabetic neuropathy causing tingling in your fingers or a non healing ulcer on your toes. A vascular access in your arm or leg in will put you at risk of losing your hand or foot. Called ʻSteal Syndromeʼ.
2- heart disease. Your arteries are block, valves are calcified, or the heart only pumps <20 % of the blood to the rest of your organs every time it beats…..whichever you probably would not be able to handle a HD session. Your blood pressure may drop, or develope chest pain and/or start cramping all while still having a difficult time breathing because you are so full of water from the BBQ you couldnʼt resist last night and you make no urine! Just how much of my blood is being clean? *
** HD is very fast, we pass 400-500 cc/min of your blood thru this artificial (artificial kidney or dialyzer) in a four hour session.
That is 96 liters of a person’s blood is clean in a 4 hour HD session.
I told you in the October RMD newsletter about fluids: pg 2 I broke down water from blood. I know repetition is the key. So an adult 70kg man ( 1.0 kilogram =2.2 lbs. ) x 60%. This is 42 liters of total body fluid. That is total water and blood plasma. (How much plasma/blood: 70kg x 75 = 5.2 liters of blood.)
Divide that 96 liters by your plasma volume…do the math all of your blood has pass through this artificial filter about 18 times. whew!!!. And don’t forget that 36.8 liters of body fluid that is being shift in between body compartments and/or removed.
then you need to get disconnected and leave so the next individual can get connected.
3- diet/fluid intake is very strict. should gain no more than 2 liters between each session and no more than 4 during your weekend.
4- Home HD. if you have private insurance …not all of them of course.
Peritoneal Dialysis (PD)
A normal kidney works every minute just like your heart. Therefore waste products/balancing minerals/water is done at a slower rate all day long. Thatʼs 168 hours of cleaning per week vs HD 12 hours a week. And Hemodialysis patients still want to cut short their treatment times…smh!
1- Spare your arms/legs especially with PVD or amputations already as outlined above.
2- children who we want to preserver their extremitiys until they get a transplant .
3- slower rate of cleansing means less shift in fluids. less cramping.
4- Your *diet is not as strict. especially when it comes to fluids . because you still urinate. With less drop in blood pressure you maintain residual GFR–you still make little urine even if its 9%. (after about a year on HD you make NO Urine. with all the shifts in fluids and drop in your blood pressure whatever little residual urine you could make, that knocks out the remainer nephrons).
*Every body is different. Some patients lose lots of potassium in through their peritoneal membran. Yeah more watermelon!
*In fact you the my team encourages you to eat frequent small portions since you lose more albumin though the peritoneum w/PD. You want to make sure your bowel movʼts are regular so that the tenchoff catheter doesnʼt float up in your peritoneal cavity.
7- Patients with heart disease as described above.
8- a support system at home that is willing to do the dialysis for you. At my center we trains 2 people at the same time. the patient and a back up in case the patient is too sick to do his/her exchanges.
10- PD nurse is available like your doctor 24/7. you have monthly visits with your nephrologist/PD nurse/dietician/social worker.
11- Travel is convenient. the machines are very transportable. looks like your a member of a rock band to me–the suit cases.
1- Multiple abdominal surgeries. ( gallbladder remove/hernia repairs), you have have lots of scar tissue on your peritoneum membrane. There will be no surface area for your membrane to remove any waste products. HD would be your best option
2-obesity . A relative contraindication. We let the surgeon evaluate where you where your belt line or skirt line so as to the placement of the tenchoff catheter is either above i or below this line. The actual site of where the catheter comes out to the outside of your body so you can connect yourseft to do the solutions is called the exit site.
3- poorly controlled diabetic: the dianeal or dialysate is a high sugar content to make the osmolar shifts across your peritoneal blood vessel lining into the peritoneal space. My point is that more sugar is being absorbed into your blood stream so your medications has to be adjusted.
4- too many peritoneal infections makes me suspect your technique needs to be reviewed or you just not doing this right. or there is an intra-peritoneal process like diverticulitis, rupture gallbladder ….quick surgical consult.
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article written by Dr Mary Washington