Hemodialysis is the process of removing toxins and excess fluid from the blood and tissues by continually circulating your blood through a filter. The filter, known as a dialyzer or artificial kidney, is used with an artificial kidney machine. The amount of blood circulating through the artificial kidney at any given time is less than a cup.

The dialyzer has two compartments separated by a membrane that is semipermeable — only particles of a certain size can pass through it. A solution called dialysate circulates on one side of the membrane and blood flows through the other side. Dialysate is made up of water, dextrose (sugar), and chemicals, which make it similar to normal body fluids without toxins.

Hemodialysis is generally performed three times a week for 3 to 4 1/2 hours. Your doctor will prescribe how long your treatment will be. Hemodialysis can be performed in a dialysis facility by nurses and trained technicians, or if you qualify, can be performed at home with the help of a partner. This modality is called Home Hemodialysis.

Nocturnal hemodialysis is a form of dialysis that is done at night for an average of eight hours while you sleep. Like hemodialysis, it can be performed in a dialysis facility by nurses and trained technicians, or if you qualify, can be performed at home. This modality is called Nocturnal Home Hemodialysis. When nocturnal is performed in a dialysis facility, it is three times a week. If done at home, it’s every other day. Nocturnal Hemodialysis has longer, more frequent dialysis treatments.

If you will be performing home hemodialysis, the home training staff will evaluate your home and help arrange for any needed water and electrical modifications. They will also make sure that there is adequate space for the dialysis machine, water treatment system and supplies. You and your partner will be required to attend six to eight weeks of training classes.

If you choose Nocturnal Home Hemodialysis, you will need an intranet monitoring system and will be arranged by the home dialysis team. This monitoring system is a direct link to trained experienced staff called Observers. The Observers are located at a Central Monitoring Station. The Observers are continually monitoring your treatment and will contact you by phone if a problem occurs.

Hemodialysis Access

To allow blood to flow from your body to the dialyzer and back, a large vessel with a good blood flow is needed. To create this route, an access to your blood vessels is formed with minor surgery, usually in an arm or leg. There are several types of accesses, some temporary and some permanent. Your doctor arranges for the most suitable access for you.

Temporary accesses include the following kinds of catheters, which are flexible hollow tubes that are partially outside the body:

• Subclavian. This is a temporary catheter placed into the subclavian vein just below the collarbone. It should not be used for more than one to two weeks because it causes change to important vessels which affect future fistulas.
• Femoral. This is a temporary catheter placed in the large vein in the groin; it is used only while a patient is in the hospital.
• Internal jugular (IJ). This catheter is placed in the large vein in the neck and can be used for outpatient dialysis for several weeks to several months.

Catheters are covered with bandages or other types of dressing which should be kept clean and dry at all times.

The most common permanent accesses are fistulas and grafts. A fistula is formed under the skin by sewing a vein to an artery. This increases the amount of blood that flows through the vein and causes the vein to get larger. The process of the fistula becoming strong and large enough for needle insertion is called maturing. In general, this takes 4 to 12 weeks. You can do some easy exercises to help the fistula mature.

A graft is created underneath the skin by connecting an artery and a vein with synthetic material. Following surgery, it may take about three to four weeks for swelling over the graft to go down so that the graft can be used for dialysis. Both access placements are done by a doctor and in an operating room.

Care of the Hemodialysis Access

When your hemodialysis access is placed, your doctor or nurse will discuss access care with you. Because your access is your lifeline, a vital part of your dialysis, it needs ongoing, special attention. Access problems, if not dealt with right away, can cause infections, clotting and loss of the access itself. You play an important role in preventing access problems. The following are things to watch for with your new access:

Fistula or graph

• Examine the access daily.
• Some swelling & bruising after surgery for 1-2 weeks is not uncommon. Once the access is healed, or after the 2-3 week point, swelling and /or bruising should be reported to your doctor or nurse.
• Place your fingertips over the skin and feel for a rushing sensation, known as a thrill. The rushing or roaring noise can also be heard by placing a stethoscope over the access. This is called a bruit (bru-E). If you ever stop feeling the blood flow, tell your doctor or nurse right away, because the access could be clotted or closed off.
• Drainage at your access site can mean an infection. Let your nurse or doctor know if you notice any drainage. A culture, or sample of the drainage, will be taken to see if you have an infection.
• The skin surrounding the access should be warm to the touch. It should not feel hot or cold. Heat can mean that your access is inflamed or infected. Coolness may mean that there is a decrease in the blood supply to the access area.
• Pay attention to the color of the skin near the access. It should not be red or look pale, blue or blackened. There should be no signs of bruising.
• Your access should not hurt.
• If your access limb (arm, leg or hand where your access is located) is numb it may mean that your blood is not flowing the way it should. This must be reported to your doctor or nurse.
• Don’t wear anything that will put pressure on your access such as a tight watchband or tight clothing with elastic bands, or carry a heavy pocketbook.
• Once dialysis treatment has started, the dialysis technician will place the needles in different areas on the access site to prevent wear and tear on the access.
• Make sure that you remove the bandage or dressing 6-8 hours after dialysis. This allows the access to be open to the air so it will heal better. Don’t use tight tape or dressings on your access arm.
• Scabs over the previous needle sites may be present and are part of the normal healing process. These scabs should not be touched, picked or removed.

Catheter

Most hemodialysis catheter accesses are in the neck or chest. You will have a dressing over the exit site (where the catheter exits the skin). Your doctor will let you know how often dressing changes will need to be done. Once you start dialysis, the staff at the dialysis center will do the dressing changes as part of your treatment and will assess the exit site for any problems. You will need to monitor or watch your exit site for the following:

• Drainage noted through the dressing may mean that you have an infection. Let your nurse or doctor know right away if you notice drainage.
• There should be no redness around the exit site dressing. Redness may be a sign of infection & should be reported to your doctor or nurse right away.
• The skin around the exit site should be warm to the touch. If it feels hot, it may mean that your access is inflamed or infected.
• You should have no pain at the exit site. Be sure the end of your catheter is secured to your skin to avoid tugging and pulling.
• Always make sure that the clamps on your catheter are closed. Even though you will have a cap on the ends of the catheter, the clamps must be closed to prevent infection and blood loss.

Monitoring your access daily and reporting any changes or problems as soon as you notice them are important ways to maintain the health of your lifeline. Many access problems can be corrected or kept from getting serious if a doctor or nurse learns about them early.

The Hemodialysis Treatment

The hemodialysis treatment is performed by patient care staff who are nurses or trained technicians. When you arrive at the center for your scheduled appointment, a patient care staff person evaluates your weight, blood pressure and physical condition.

Then, following your doctor’s prescription, your treatment begins. A patient care staff person inserts two needles into your graft or fistula. One needle(arterial) is attached to a bloodline which is used to pump blood into the dialyzer. The other needle(venous) returns dialyzed blood to the body. If you have a catheter, bloodlines are connected directly to your catheter.

Heparin is a drug that keeps blood from clotting in the dialyzer. It may be given through your access before dialysis begins, and during dialysis if needed. The effect of the heparin should be minimal by the end of the treatment.

Next, your blood is pumped to the dialyzer where it is continually cleansed and returned to you over the length of the treatment. The patient care staff closely monitor your blood flow rate, blood pressure and overall condition.

The staff will help you learn about the hemodialysis machine as well as any symptoms you may have during the treatment or between treatments. Patient care staff regularly perform a series of checks on the dialysate and machine to ensure your safety and well-being.

When the treatment is completed, a patient care staff person will remove needles and apply bandaids to the puncture sites. The bandaids can generally be removed in a few hours. Catheter patients are disconnected from bloodlines. Caps are used to close and protect your access.

Your physical state and how you follow your diet and treatment plan are monitored regularly. Changes in treatment are made as needed. Some patients prefer the treatment option of dialysis in a center because care is mainly in the hands of dialysis professionals. Also, the center setting gives you a chance to socialize with other dialysis patients.

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