Renal replacement therapy is commonly known as dialysis and is great for kidneys that are to damaged and unable to function properly to do their job. Dialysis is an action that is a life supporting measure to help give a patient a more sustainable life. When the kidneys are healthy they help eliminate the waste product produced by metabolism. They also help sustain all the fluids and electrolyte and they are involved in producing hormones that help maintain strong bones, help in making red blood cells, and help in regulating blood pressure. So, when the kidneys have low function they are unable to accomplish these things adequately. Resulting in becoming tired, reduction in appetite, trouble breathing, itching, disturbed sleep and when the patients get to the end stage of renal disease the changes are more noted by their consciousness. When the kidney functions have a glomerular filtration rate (GFR) that has a decrease or blood work that displays constant fluid accumulation and a considerable amount of urea and other wastes in the blood, the healthcare provider may start discussing dialysis treatment. Hemodialysis does not reverse kidney failure. There are many medications that are prescribed to supplement and aide in helping kidney functions and can be given through the dialysis machine during the treatment. Patients may also need to take medications to maintain blood pressure and lessen the volume of phosphorous that they have in their body. Hemodialysis is done in a clinic that specializes in renal failure and requires a big commitment because it is a life altering course. Its imperative to remind the patients that they are not by their self, there is a team of compassionate medical staff right beside them every step of the way. Each staff member plays a precise role and they work together to provide support, teaching, training, and specific care. Many individuals will go three times a week and be connected to the machines. There are three types of access connections for dialysis: Arteriovenous fistula (AVF) which is a surgery done to connect an artery and a vein, this is usually done in the non-dominant arm, it is the preferred access and can take time to mature. Arteriovenous graft (AVG) this is where a surgeon will use a synthetic material to connect the artery to vein, it takes several weeks before it is able to be used, the down fall with this access would be that you are more prone to infections and clotting. Central venous catheter (CVC) this is used in emergency’s and is placed in the large neck vein and goes down below the collarbone and is also prone to infections and blockages. The machines will monitor the flow of blood, the blood pressure and the amount of fluids being taken out throughout the procedure. The pump on the machine will move the blood through the dialyzer and circulate it back around into the body. The dialyzer acts as the kidney though this treatment process. Before anything can be started the vitals must be checked. The port of access will be cleaned, and two connections will be made, one will take blood to the dialyzer for manipulating and the other one will return blood back to the body. The blood pressure will be closely watched while in treatment. It is not unusual for the alarms to sound but helps staff know when required variation is needed. During treatment, the patients may watch tv, read a book, take a nap, or have a chat with somebody nearby. Post treatment the vital signs will be reevaluated to see how well the treatment took and how much waste was removed. Then they will be able to continue with their daily task until the next treatment time. Peritoneal Dialysis is where a catheter is placed into the abdominal area. This is used to pull out waste substance with a special fluid called dialysate. There are two different types of Peritoneal Dialysis: Continuous ambulatory peritoneal dialysis (CAPD), this is where the abdomen is filled and drained several times a day. The first phase, the dialysate is retained in the abdomen for 8 hours and then drained out. Then directly filled again with more dialysate and this is done for several more times throughout the day. Continuous cycler-assisted peritoneal dialysis (CCPD), this is where a special machine is used to support and circulate the dialysate fluid throughout the abdomen and back out. This procedure is typically completed at night while the patient sleeps. The labs are checked frequently on all dialysis patient. Blood is taken during the treatment from the port that connects the patient to the apparatus. The outcomes will tell the staff how well the patient is being cleaned out and guide the nephrologist in adjusting their treatment limitations, their diet, and their medication regimen. The nurse plays an imperative role by providing education, explaining the process, and answering any questions or concerns they may have. The nurse will help avoid snags by looking over the lab results before initiating the procedure to confirm that the fluids and electrolyte are in tolerable limits. Its very imperative to keep tract of vitals such as weight to make sure that the right volume of fluid is given back and making sure that the patient’s medication will not cause problems throughout dialysis. Post treatment the nurses will look for problems such as disequilibrium syndrome and all concerns will be conveyed to the physician immediately. Kidney disease is an illness that is continuing and life-threatening. Many patients can become angry and dispirited for the treatment process. The nurse will be a great source of information for the patient and/or the family to help reassure them to express their emotions, helping them deal with the process and helping them participate in their dialysis. Dialysis has many phycological effects on the patients. “The treatment is palliative in nature, in the sense that it prolongs life and ameliorates the symptoms of kidney disease.” (White, 2014, p.75) The patient will go through many lifestyle fluctuations including dietary and fluid restrictions to accommodate their illness. The changes in diet include but not limited to maintaining iron and protein levels. This has an impact on their personal well-being, leading to anxiety and depression, hindering coping, and appropriate alterations. Depression is the most common psychological issue linked to dialysis. “Depressed patients are found to be three-times as likely to be noncompliant with treatment recommendations as nondepressed patients.” (Finnegan, 2013) Treatment can greatly affect the way the individual perceives their body. For example, “procedures to create a point of access for dialysis via a fistula, neck line, or catheter can all change the appearance of the body.” (Finnegan, 2013) Some patients may also have erectile dysfunction putting a stress on their personal life. This can affect their relationship with their significate other. Many patients become increasingly tired causing them to spend more time sleeping and missing out on a lot of quality time with loved ones and important thing happening in their life.There are important risks and benefits that must be assessed when deciding between the two different types of dialysis. The peritoneal approach is different because it doesn’t use a machine to remove the excess water and waste. The abdomen houses many small blood vessels that are very capable of filtering the blood when the particle concentration outside the vessels is higher than inside. In order, to create this concentration gradient a tube is place in the wall of the abdomen where the fluid can be passed through. The fluid is then placed inside for a few hours, so the water and waste can leave the blood vessels and accumulate so it can be removed from the abdomen and replaced. This process can be preformed in home, work or even while traveling. The benefits with this type of dialysis is convenience, normal diet, less fluid restrictions, and more likely to still feel healthy. With this being said the patient must be willing to have tube placed in abdomen and understand that infection can occur and result in a peritoneal scar. In order to be eligible, you must have some remaining kidney function and it will require regular testing. Over time, this form of dialysis will become less effective at separation of waste/fluid and require you to switch to hemodialysis. On the contrary hemodialysis is done in a facility with well trained staff, so, they can be monitored during the treatment. This process is usually performed three times a week and can last up to 4 hours. It is very important for these individuals to be steady with appointments and agreement process. Having extended breaks in dialysis treatment can cause them to have severe sickness and the outcome could result in death. Many individuals like being able to have help when needed and like being able to associate with others that are going through this same process. Hemodialysis has some cons such as time, more limitations on fluids, more medication necessities, and a greater risk for adverse side effects. There are many medications that can be used to treat individuals on dialysis. Some of the medication is blood pressure tablet because high blood pressure is very common with individuals with kidney disease. Then for those with heart failure these medications may be prescribed: ramipril, enalapril, perindopril, losartan, candesartan, and irbesartan. Diuretics may be given because it helps reduce fluid retention. Warfarin the blood thinner may help aide in the dialysis line or fistula. Tinzaparin also will help with making sure the blood passes easily through the dialysis machine it commonly known heparin. Phosphate binders help reduce the phosphate in your blood and should be taken around the time of meals. Kidney failure prevents your body from making vitamin D in its usual way so Alfa-calcidol/one alpha may need to be taken to help balance the calcium levels and regulate the parathyroid hormones that will help maintain strong and healthy bones. For those individuals that need a parathyroidectomy but unable to have one, cinacalcet can be prescribed. Healthy kidneys make a hormone called erythropoietin that help in making of the red blood cells in bone marrow. Erythropoietin Simulating agents (ESA) can be used to aide in production of red blood cells. It is very common for dialysis patients to need extra iron because it helps the bone marrow and ESA to produce red blood cells. At the end of each treatment an antimicrobial lock is used to help stop infection and blood clots from forming in the line. The lines are initially flushed with sterile saline and then the antimicrobial solution is added slowly into each tube. Other medications used include: Sodium bicarbonate, allopurinol, quinine sulphate, pain killers and over the counter medications. When choosing OTC medication its important to check with the physician to assure it is ok to take while going through the treatment. Renal damage may be acute or chronic both can have problems with medications. If any kidney damage is suspected there should be a renal function test done before prescribing any drug. Some reasons for impairment are failure to metabolize and excrete a drug. Drugs that are excreted through the kidney need to have lower doses in patients with end-stage kidney disease. Patients with a GFR of 50ml/ minute usually don’t require any dosage adjustment. Drugs that need to be monitored include many antibiotics, histamine H2-receptor antagonists, digoxin, anticonvulsants and non-steroidal anti-inflammatory drugs (NSAIDs). Prescribing any medication that raises potassium levels is possibly very dangerous. Products with a large sodium content, may result in retaining fluid. Nephrotoxic drugs such as NSAIDs may result in AKI. Some drugs that cause diarrhea or vomiting can cause AKI due to volume reduction. There are labs that can help determine if a patient has toxicity. The BUN shows the amount of nitrogen that is in the body in forms of waste this is called urea which the kidneys filtered. Having extra urea may lead to uremia. The serum Creatinine happens after the break down of creatine to make energy for the muscles. If the kidneys start to show lower function they will start to have difficulty filtering creatinine on a regular basis. Nephrotoxicity is the most common problem and happens by introduction to medication or toxins that can cause damage to the kidney. When this takes place, your kidneys will not be able to excrete the waste in the urine, causing an elevated potassium and magnesium levels. This can be temporary and be caused by dehydration. If found early, it can prevent permanent kidney problems. “CKD diagnosis did not seem to reduce significantly the prescription of nephrotoxic drugs, which may increase the risk of preventable renal function deterioration.” (Ngrasciotta, 2014)Depending on what dialysis’s that they are taking will determine the diet and fluid restrictions. If they are on hemodialysis they should eat more high protein foods and lower the intake of salt, potassium, and phosphorus foods. The doctor will give you the amount of fluid restrictions, that will include coffee, tea and water. If they are on peritoneal dialysis there is not as many restrictions and usually no fluid restrictions, but phosphorus levels should be watched. Now if they are not on dialysis it is recommended to include grains, fruits and vegetables in their diet, but limit the amount of whole grains and certain fruits and vegetables high in phosphorus or potassium. They should be told to limit processed foods and high salt food. The most significant thing is limiting fluid intake. The doctor may put the patient on some enhancement medication. “A significant number of dietary restrictions are imposed traditionally and uniform on maintenance dialysis patients, whereas there is very little data to support their benefits.” (Kalantar-Zadeh, 2015). You must watch your fluid intake, since the kidneys cannot get rid of the excess fluid through the urination process. One way to limit thirst, is to limit your salt intake. Choosing foods that are lower in potassium and phosphorous will be vital to helping the patients stay on tract.
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