Preparing for Hemodialysis

In order to undergo this type of dialysis, a patient first has an operation performed on the
arm, allowing blood vessels to enlarge so that needles can easily be inserted into them to
connect them to the dialysis machine. There are two types of surgery that may be done:
Fistula - Creation of a "fistula," in which two of the person's own blood vessels, an artery and
a vein (in the lower or upper arm), are connected together through a small opening. Blood
flow from the artery is partly diverted to the vein, causing the latter to enlarge and develop
thicker walls over the next few weeks to months. The thickened vein forms a conduit that
allows placement of needles for efficient dialysis.
Graft - Construction of a "graft," in which a synthetic blood vessel, usually made of Gore-tex
(the same material as is used for making ski wear), is inserted into the arm (or occasionally
the leg), connecting two blood vessels and creating an easily accessible "blood vessel" that
can be punctured by needles for dialysis.

Choosing Between a Fistula and a Graft

The first alternative, fistula construction, is the preferred type of surgery, since it uses only a
person's own blood vessels. Graft construction is performed in people who start with small
veins, or veins that are not visible on the surface of their arm. In either case, the operation is
considered to be minor surgery and is performed on an outpatient basis, usually at least 2 to
3 months before dialysis is anticipated to be needed.
Sometimes the kidneys fail quickly and dialysis needs to be started on an emergency basis,
so there is not time for the patient to undergo surgery and await maturation of the fistula or
graft. In this case, an IV catheter (the size of a large IV line) can be placed in a vein just
beneath the right or left collarbone and can be used immediately for dialysis. Such a
catheter can remain in place and be used for weeks or even months if needed, until surgery
can be done to construct a fistula or graft.

What Happens During Hemodialysis

During the actual procedure of dialysis, the patient usually sits in a lounge chair or lies in a
bed, and the arm with the fistula or graft is cleaned with an antibacterial solution. Two
needles are then inserted, one to carry blood to the dialysis machine, and one to return it to
the body. In cases where the patient has an intravenous dialysis catheter as described just
above, the catheter is hooked up via tubing to the dialysis machine. The patient's blood
flows continuously through the machine, a little at a time, and is cleaned and processed by
the dialysis filter. During the procedure, excess fluid can be removed from the person's body
as well, allowing swelling in the legs and elsewhere to gradually be reduced.

Chronic Renal Failure-Describe

what causes/contributes to CRF

90% nephrons destroyed Renal Insufficiency - 75 % nephrons

destroyed. Decreased renal reserve - 50% of nephrons destroyed L&B, 2004, 775
Causes
1. Diabetes Mellitus

2. Hypertension
3. Glomerulonephritis
4. Polycystic Kidney Disease
Symptoms of Chronic Failure

Fixed urine specific gravity 1.010

Apathy, weakness, fatigue
Proteinuria, hematuria,
Inability to concentrate urine (polyuria, nocturia, Na+ & H20 retention
K increases cause muscle weakness, paresthesia, ECG changes (peaked t waves and
wide QRS) Phos increases & --Ca+ decreases due to impaired activation of Vit D
Metabolic acidosis with Respirations increasing= deep Kussmaul
Hypertension - edema - CHF
Pericarditis
Erythropoietin -decreases--, decreased--HCT, -decreased Folate, -decreased--Iron,
shortened RBC life Anorexia, N/V
Uremic fetor urine breath
Impaired clotting

Lab Diagnosis
Chronic Renal Failure

Specific gravity 1.010

Urine culture
BUN 20-50 mild--- tlOO poor prognosis
Creatinine above 4.0 & symptomatic N, V, anorexia
Hematocrit 20-30%

Treatment for Chronic renal failure

Phosphate Binders
Vitamin D supplement
Epoetin
Folic Acid
Iron
Hypertension meds -Frequently ACE Inhibitors Assess vascular access for bruit
--Notify MD if absent No longer need to avoid nephrotoxins

Functions of the Kidneys

The kidneys are important to many functions, mainly to regulate water fluid levels and to
remove waste products from the blood. The kidneys also produce hormones (renin and
angiotensin) that regulate how much sodium the body keeps and how well the blood vessels
expand and contract thus regulating blood pressure. Healthy kidneys also produce a
hormone (erythropoietin EPO) which stimulates the production of red blood cells. Without
this, anemia develops. Another hormone produced by the kidneys is Calcitriol, which is
needed to maintain correct levels of calcium, phosphates, and vitamin D. Without these,
renal bone disease can develop.
End-Stage Renal Disease: Nutritional Considerations
Nutrition-related concerns include maintenance of acceptable weight and serum proteins
(eg, albumin), prevention of renal osteodystrophy, and reduction of cardiovascular risk.

Weight Maintenance and Protein Requirements

Protein needs are higher in patients with ESRD due to losses that occur during dialysis. The
recommended dietary protein intake for clinically stable maintenance hemodialysis patients
is 1.2 g/kg body weight/d, and 1.2 -1.3 g/kg body weight/d for individuals on peritoneal
dialysis, 50% of which should come from sources high in biological value. 9
Nutritional status should be assessed, and every patient with ESRD should receive a diet
plan. ESRD patients on dialysis may spontaneously reduce protein and calorie intake as a
result of uremic toxins, elevations in leptin and other cytokines, and delayed gastric
emptying.10 The average energy intake of patients with ESRD is lower than the
recommended 30 to 35 kcal/kg,11 and 50% of patients reveal evidence of malnutrition.12
To prevent malnutrition-related morbidity and mortality, ESRD patients on dialysis should
have periodic nutrition screening, consisting of laboratory measures (eg, albumin),
comparison of initial weight with both usual body weight and percent of ideal body weight,
subjective global assessment, and dietary interviews with review of food diaries. Nutrition
counseling should be intensive initially and provided every 1 or 2 months thereafter. If
nutrient intake appears inadequate, malnutrition is apparent, or adverse events or illnesses
threaten nutritional status, counseling should be increased. If protein-calorie needs cannot
be met with the usual diet, patients should be offered dietary supplements or, if necessary,
tube feeding or parenteral nutrition to approximate protein and calorie requirements. 9
Sodium and Potassium Balance
ESRD patients should avoid high-sodium diets. Hypertension in dialysis patients is largely
attributed to positive sodium balance and volume expansion. 13 While many patients on
dialysis can effectively control blood pressure without drugs on a low-sodium (2 g) diet and a
low-sodium (130 mmol) dialysate,14 current practice is such that almost 70% of dialysis
patients require antihypertensive medications. Although many patients may not achieve a
therapeutic degree of sodium restriction, those who do can effectively control blood pressure
and reverse left ventricular hypertrophy.15
A high-potassium diet is normally desirable to control blood pressure and reduce risk for
stroke; however, individuals with ESRD on hemodialysis cannot tolerate this diet because
they are unable to excrete potassium. Therefore, ESRD patients may need to avoid such
foods as bananas, melon, legumes, potatoes, tomatoes, pumpkin, winter squash, sweet
potato, spinach, orange juice, milk, and bran cereal to prevent life-threatening
hyperkalemia-induced arrhythmia. Evidence indicates that the vast majority of patients
comply with potassium restriction.1 In patients on peritoneal dialysis, hyperkalemia is
significantly less likely and hypokalemia has been reported in some patients, at times
requiring an increase in potassium-containing foods and even potassium supplementation. 16
Fluid Restriction
It is essential that ESRD patients restrict their fluid intake. Without adherence to a specified
fluid allowance, patients are more likely to have poorly controlled blood pressure 17 and risk
congestive heart failure. The typical fluid allowance for patients on dialysis is 700 to 1000
mL/day, plus urine output.

Phosphorus
Elevated blood phosphorus concentrations are associated with increased mortality in ESRD
patients,12 and increase the risk for cardiovascular events, at least in part by contributing to
vascular calcification.18 Excess phosphorus also causes secondary hyperparathyroidism,
triggering the release of calcium from the bone matrix, and osteodystrophy. 12 Management
of hyperphosphatemia and renal osteodystrophy has improved with phosphate binders,
particularly sevelamer hydrochloride (Renagel), which also helps prevent hypercalcemiarelated vascular calcification.19 However, certain factors continue to confound adequate
control of phosphorus levels. These include covert phosphate intake from processed
foods,20treatment with high doses of vitamin D analogues, and the high protein needs of
ESRD patients. Protein intake over 50 grams/day causes positive phosphate balance, in spite
of phosphate binder therapy.12,21
Micronutrient Supplements
Micronutrient supplements are essential for ESRD patients. Individuals on dialysis commonly
suffer from deficiencies of vitamin C, folate, vitamin B6, calcium, vitamin D, iron, zinc, and
possibly selenium, which can contribute to an antioxidant-deficient state. 22 The National
Kidney Foundation clinical practice guidelines for nutrition in chronic renal failure suggest
that patients achieve 100% of the Dietary Reference Intakes (DRI) for vitamins A, C, E, K,
thiamin (B1), riboflavin (B2), pyridoxine (B6), vitamin B12, and folic acid, as well as 100% of
the DRI for copper and zinc.9 As a result of restricted intake of many foods and losses of
water-soluble vitamins during dialysis, patients are usually given specially formulated
vitamins. Intravenous forms of vitamin D analogues and iron are typically given to patients.
While oral iron supplements may not be needed, oral vitamin D (ergocalciferol) may be
beneficial.
Certain other dietary supplements may be helpful. Supplementation with L-carnitine has
been approved by the U.S. Food and Drug Administration to treat carnitine depletion in
dialysis patients. In small studies L-carnitine has also been found to improve lipid
metabolism, protein nutrition, antioxidant status, and anemia.23 However, some large studies
have not confirmed these findings. Therefore, inadequate evidence exists to support the
routine use of carnitine in patients who do not reveal signs of deficiency. 24 Both vitamin C
(250 mg/d) and vitamin E (400 IU/d) have proven effective in some patients for treating
painful muscle cramps, and they provide a less toxic alternative to quinine
therapy.25,26However, additional clinical trials are required before these can be used as
standard therapy.
Saturated Fat and Cholesterol
Dialysis patients should follow a diet low in saturated fat and cholesterol. These patients are
considered the group at greatest risk for development of coronary artery disease. They often
have increases in serum triglycerides and low high-density lipoprotein (HDL)
cholesterol.27 Although they must eat a relatively high-calorie diet to spare protein, patients
on dialysis should avoid foods that raise triglycerides and cholesterol concentrations
(see Hyperlipidemia).