Tiffany Archibald 00:01
Let’s Talk About Kidneys takes a deep dive into the chronic kidney disease patient journey. We’re here to inspire meaningful conversations and to help people living with CKD gain a full understanding of their disease. Dialysis is a life saving procedure that takes over many functions of the kidneys. It can be accessed both in dialysis centers and in your own home. Today, we are going to learn more about the types of dialysis that can be done in your own home. Welcome Dr. McDonald, how are you today?
Dr. McDonald 00:34
I’m doing well and thank you for having me and hello to all the podcasters out there.
Tiffany Archibald 00:38
Yes, we are so thrilled to have you today. We know you will bring a wealth of knowledge to this topic today. So I think the best thing to do is to kind of jump right in. We’re going to be talking about dialysis and the different types of modalities. What are the different dialysis treatments done at home versus the in-center dialysis treatments?
Dr. McDonald 01:00
Well, basically, I’m going to start with in-center, and in-center to make it very clear, is that the patient goes to an outpatient dialysis center, hopefully close to their home. They go in, they sit down at a chair there in the chair for about three and a half to four hours. Now, when we talk about home dialysis, there’s a couple of types. One is home hemodialysis, just like in-center, but you’re doing it at home. And there’s also peritoneal dialysis through the belly, which is also done at home.
Tiffany Archibald 01:31
Okay, so before we go into the different types, first of all, they have to make the decision if they’re going to do dialysis, and then which decision needs to be made on which modality.
Dr. McDonald 01:45
Correct and just really talking about whether or not the patient will do dialysis is worthy of a whole nother podcast, because there’s so many decisions that come into play in terms of life decisions, life or death decisions, so to speak. So when patients go into deciding which type of dialysis, as a doctor, we want the patient to choose something that fits their lifestyle. And you know, everybody is different. Everybody is into something. So some people are very content to do things at home. Some people are like, oh, home is the last place I want to be, I want to be with my friends with people that I like, I want to be in-center where the nurses are there to help me. So it really depends on the patient, how they look at their life and their lifestyle.
Dr. McDonald 02:29
Okay, and so can you cover what are some of the advantages of doing home hemodialysis?
Dr. McDonald 02:36
Well, the biggest thing about home is that, first of all, you’re in your home. And most of us look at our home as sanctuary. So you have a special area in your house. The dialysis machine is about the size of a nightstand. And as we go further in technology, they’re getting smaller and smaller. They’re very easy to set up. Everything is kind of self contained. You open it and push it in. And after you’ve plugged it into the wall, you flip a switch. So the technology of the machine is pretty straightforward. And so once you hook yourself onto the machine, you’re there for three and a half or four hours at a time. You’re able to interact with your children, your friends, you’re able to watch TV, take a nap, get online, whatever you’d like to do. So a lot of people like being at home, because it’s just very comfortable and natural for them.
Tiffany Archibald 03:30
Okay, so you did just cover some of the advantages. But can you talk about some of the disadvantages of doing home hemodialysis?
Dr. McDonald 03:38
Of course, I’ve had some patients that, to them, their health care, like most of us, is very private. So they don’t like to be at home because people come by. Even some of their close relatives, even their adult children, they don’t like them to see them in this position. And some of it is even tied up that sometimes when we’re ill people have this misconception that they’re weak. And so they think, oh, people are going to see this. I’ve even had patients say they don’t even like the delivery van was supplies to be seen at their home. So like I said, it all depends on the patient and how they look at themselves.
Dr. McDonald 04:15
Okay, so privacy is definitely key to that personal decision.
Dr. McDonald 04:22
Privacy is key, but also when you talk about home dialysis, there’s a certain amount of a, for instance, the patients have to be comfortable sticking themselves with a needle or, as we say in doctor language, cannulating their access. They have to be comfortable doing that. They have to be comfortable with maybe the buzzers that go off on the machine. So there’s certain things that you know, some people are very comfortable with and others are not.
Tiffany Archibald 04:47
Okay. And so we covered hemodialysis. Can we talk about some advantages of peritoneal dialysis?
Dr. McDonald 04:54
Well, with peritoneal dialysis, it’s very portable. For those that aren’t clear There’s a catheter that’s into your abdomen that’s inserted into your abdomen in surgery. The catheter comes out of the abdomen and under sterile technique, and that meaning gloves and a mask, the exchanges, the tubing is connected to tubing that exits the belly, the fluid goes in, it takes about 15 or 20 minutes for the fluid to be instilled. It sits there for about eight hours. During that eight hour period, you can go out, you can go to the store, go to school, go to work. Come back after about eight hours, using your gloves and your mask, connect again and drain the fluid out of your abdomen. So peritoneal dialysis is, it’s not as technologically advanced, say, as the hemodialysis, there’s no machine necessarily involved. But it’s also easy, for instance, if you’re traveling. You can throw the exchanges in the trunk of your car. If you’re flying, you can put them in a suitcase. We give patients a letter for TSA. They’re able to take it on the plane. It’s pretty easy to deal with. There’s also something we can talk about at a later time called a cycler, which is a small machine that can be used at night in place of doing those manual exchanges that I described.
Tiffany Archibald 06:18
Okay. And so you gave a lot of the listeners some advantages. And you know, I could see someone who has an active lifestyle, you just painted a perfect picture of how the advantages of peritoneal and the convenience of it. So are there any disadvantages? Or where do you feel patients say are things that are troubling, or that caused them a lot of frustration with doing the peritoneal dialysis?
Dr. McDonald 06:45
Well, like anything in life, there’s always something. And with peritoneal dialysis, some people find it to be a stumbling block, that they have to use gloves and a mask. Now that we’ve been through COVID masks aren’t as taboo as they used to be. But for some people, they don’t like that. Other people, for instance, believe it or not, I’ve had patients that have like 15 cats and dogs in the house and there are just too many germs floating around for them to do it safely. I’ve had patients that just are pretty, they’re not comfortable checking their own blood pressure, making decisions about the strength of the solution. Like I said, everybody’s different and so there’s pluses and minuses. With peritoneal because that catheter exits the belly, we have to be very careful about infection. So that’s kind of a downside for some of the people on peritoneal dialysis. When we contrast to hemodialysis, some of the things sometimes blood pressure can fall, other issues, so there’s pluses and minuses to everything.
Tiffany Archibald 07:49
And so if you have to think about a patient that has been super successful with home hemodialysis, can you give me an example? And also a successful patient that does peritoneal?
Dr. McDonald 08:01
Well, what I like to tell my patients is the key to what you’re asking me is successful. And what I find these days, not just with patients and dialysis, but I think all of us in today’s society, there’s a term that’s going around now called calling people out of their name, which is not nice. But when I hear patients say, oh, I’m so stupid, I can’t do this, or, you know, gosh, you know, I’m so ugly, that’s calling yourself out of your name. So you have to have confidence, you have to believe in yourself. And if you’re constantly cutting yourself down, you’re not going to be good at anything. So with all of my patients, I like to give them that confidence and say, hey, you can do this. A lot of times, I’ll tell patients, if you remember, when you started, when you learn how to drive, you may have been 14 or 15 or 16. And I can remember, you know, just driving and the indicator, and the mirror, and the radio, you know, when you’re a teenager. All of these things, you know, it seems overwhelming. But now when you get in the car and you drive, you don’t think anything about these things. And the same is true for instance of the home dialysis modalities. With peritoneal dialysis, once you get the system down, mask, glove, you’re in a room, everything’s quiet, you drain your the fluid out of your belly, you put it back in, or with home dialysis, with peritoneal on the cycler, getting towards bedtime, you hook up to the cycler, you go to bed, sometimes the alarms go off, you know what to do. Then you’re comfortable. When it comes to hemodialysis, home hemo, it’s the same thing. Once you learn and get your systems down, it’s very comfortable. And I just want to mention too to the listeners, when you do peritoneal dialysis, there’s at least a five to seven day training period, one on one with a nurse. And then all of our patients we tell them, you know, somebody’s always available for a phone call, even in the middle of the night. The nurse or the doctor. With home hemo dialysis, because of the technology associated with the machine, there’s a six week one on one training program with a nurse and it sounds like, oh, my God, six weeks. But if you think about it, you have to learn how to cleanse your access, how to place your needles, how to set up the machine. We’d like there to be another family member or an adult that’s with you. They don’t have to be there for the duration of the six weeks, but they can come in and learn the high points. So for instance, if you don’t feel well, or something’s going on, they can assist the patient.
Tiffany Archibald 10:41
Okay. And so that’s one of the questions that a lot of patients will have, because it’s a community. Even though earlier, you talked about some patients and their privacy, there has to be family members that are trained or informed, because if there’s a worst case scenario. So talk to us a little bit about the training that family members receive.
Dr. McDonald 11:05
Well, with peritoneal dialysis, we like to have the patient and if there is an adult with them, also usually a spouse. Because that way, that person can give support to the patient. Sometimes the patients are kind of, you know, they don’t feel well, they’re starting dialysis, they’re a little weak. They’re going to need help lifting some of the exchanges, or maybe putting the dressing on their abdomen, things like that. So it’s nice to have that extra person there. With hemodialysis, it’s the same thing. You know, for instance, the patient is in their chair hooked to the machine, for about three and a half, four hours, the family member may need to bring them dinner. I may need to get something for them or may need to help them troubleshoot the machine. So we like to have somebody there. On the other hand, one of the things we see particularly with home hemo dialysis is caretaker burnout. And we see that not just with dialysis, but other chronic illnesses and the caretakers, but sometimes it can and I’ve seen situations where it’s almost more stressful for the caretaker than it is for the patient. So that way we like the caretaker to realize that, you know, we understand what you’re going through. The nurses sometimes we’ll even orchestrate what we call a break sometimes. So the caretaker almost gets a vacation, where we’ll bring the patient in-center or, with peritoneal dialysis, will bring them to the peritoneal office. Let them sit there and dialyze during the day, so the caretaker can get a breather. And so you really have to have your hand on the pulse of the relationship between the patient and your caretaker.
Tiffany Archibald 12:47
Okay, so one thing I think we should kind of circle back on, let’s break down the timeframe for home hemodialysis, and then we’ll talk about the timeframe for peritoneal dialysis that’s done at home. So let’s talk about home hemo. How long is the training? And then once you are trained, how long is that process to dialyze?
Dr. McDonald 13:13
Well, let’s just back up to let’s say before the patient starts dialysis. You’re going to your doctor’s office, you’ve had the training, that you know you’re approaching dialysis. A lot of these patients have also applied for transplant and they’re waiting for transplant. So what we will do is arrange for access, and that’s usually a couple of months, two to three months prior to starting dialysis. Once all the labs are in the access is felt to be ready to be used. We usually have the patient dialyze in-center just for a week or two to make sure everything goes well. Then they will go transition to a training period. Usually it’s an office associated with the outpatient hemo unit, where they will start their one on one training with the nurse. During that time, when they start, the technician and the nurse will go to the patient’s home to make sure the home is set up properly, finding the right spot, making sure the electrical outlet is working properly. They have access to a water supply. So once all of that looks good, there’s a green light, then the patient starts their training for hemodialysis at home. And generally that’s a six week period, sometimes a little bit less, sometimes a little bit more. They start on their own and like they said, it’s not like we train you and throw you out to the wolves. The nurses are there for support, and the doctors are there also. Even after doing home hemo you need to come in to the office to see the doctor once a month and at that time we look at the labs, examine you, all of those things. So even though you’re doing dialysis at home, you do go to see your physician at least once a month. Now with peritoneal dialysis, it’s this same situation, when we know in the office, the patient’s ready to start, they get their catheter inserted. And usually we like at least two weeks for that catheter to be planted by the surgeon before it’s used. Once it’s inserted by the surgeon, we’ll have the patient once a week go to the peritoneal center to flush the catheter to make sure it’s working properly. After about two weeks, then they can start their training. Once their training is finished, the same situation, they do their exchanges at home. Call for any questions. The nurse and the technician have already gone out to the home to make sure everything is okay. Because believe it or not, this is home dialysis, some of our patients don’t have a home. We got to see what’s going on. So once they do their training their dialyzing successfully at home, they still need to come in once a month to get labs drawn and once a month to see the doctor.
Tiffany Archibald 15:53
Okay. All right. I know you’ve mentioned that the equipment is fairly small. Is there anything that goes on in the home environment evaluation that will prevent a patient from being a candidate for either type of home dialysis?
Dr. McDonald 16:14
Believe it or not, one of the things that we’ve seen, and as I said, we take for granted, we have people these days that we’re living in, like those public storage places. So that’s not a home. So we can’t do home dialysis when you don’t have a home. And unfortunately, with the way things are now housing, etc. sometimes that happens, or we have people that are essentially homeless. So obviously, you can’t do home dialysis. We like to look at the home for peritoneal dialysis or home hemo to make sure it’s clean. Because we’ve all seen the show on TV called hoarders. There are some people that it’s just not going to work. So those are the contraindications that are definite. Sometimes we’ll go look at a home and say, listen, you’ve got to clean these things up. You’ve got to have a better area. Clean out an area in your home so we have a place for the supplies and/or the hemo dialysis machine.
Tiffany Archibald 17:12
Okay. And so if a patient started home hemo or home peritoneal and then for whatever reason they decide, or the medical professionals decide, that it’s no longer a viable option. Can you walk us through that? And how that transfers them back to? I’ll let you go ahead.
Dr. McDonald 17:35
Well, again, remember that we like to tell patients this is supposed to fit your lifestyle. You’re not locked in. That though there are some medical situations where, for instance, you’re on hemo dialysis, you can’t go to peritoneal or vice versa. Those are minimal. But for the most part, we like patients, we like to say, hey, are you comfortable? Is this working for you? If it isn’t, you’ve got to communicate this to your healthcare team. Because you’re not locked in. We like to give you options. And a lot of times, you know, just think about it, we might go by that red car off the lot. After a week, you can’t stand it. So you have to do something different. So we like patients to understand, you do have the ability to change your mind.
Tiffany Archibald 18:18
I think that’s a great point to just kind of take a breather, and for anyone that’s listening in, you know, feel overwhelmed or think that dialysis is just very complicated. I think you’ve done a good job of just kind of painting the picture and basically making that point that if home hemo or home peritoneal tool doesn’t work out, they still have that support of in-center. And so with that support, is there 24 hour support? Like what if something happens overnight? I know someone listening may have that type of questions. So can you discuss that?
Dr. McDonald 18:56
Sure. And again, everybody has these insecurities. And we all worry about things like that. With home hemodialysis, you know you have this machine that’s pretty sophisticated. And a lot of times what will happen at night is the buzzers will go off, you’ll go through your troubleshooting. There is an 800 number that the patients can call for help with that and there’s someone available 24 hours a day. In addition to that, if there’s a medical issue, my blood pressure is low, something’s wrong, the nurse and the doctor are also on call. So you’re not out there by yourself, so to speak. That’s true of peritoneal dialysis. It’s also true of hemo dialysis.
Dr. McDonald 19:37
No, not at all. Now, of course, there’s extremes and I’ve mentioned the extreme of having so many pets. And we’ve all seen that on TV. We do have patients that might have a couple of dogs, couple of cats, that’s very common. With peritoneal dialysis and hemodialysis, a lot of times we like patients to be in a room, so we can close the door if we have to. With our hemodialysis patients, you know, they’re sitting in a chair for several hours. So it’s nice if Fido can, you know, kind of come in. And we all know, you know, our animals are like our kids, you know, some of our kids need to sit down. Other kids are just fine, they can sit there and behave themselves. I’ve had cats try to eat through a catheter, and you know, but those kinds of pets, they need to stay out of the room and let the good pets in. But for the most part, people can have their pets, you just have to make sure that they’re not violating the sterile field.
Tiffany Archibald 19:37
Okay, so we were discussing earlier about having too many animals and how that can kind of taint the home environment. So what if someone has, say a small or large dog or maybe a dog and a cat? For those people that are listening and can’t even imagine their lives? Sometimes animals are support care animals, you know, they provide people that peace.
Tiffany Archibald 21:02
Okay. And so we covered a lot today. And I know listeners are given a wealth of information. If you could leave us with maybe one or two key points for the listeners to take about dialysis home or in-center, what would that be?
Dr. McDonald 21:20
You know, I think it’s a general comment, I would say, you can do whatever you put your mind to. If you want to do this, you can do this. And we as your healthcare team are going to be there to support you. So at the beginning, it’s overwhelming for everyone, so don’t let that stop you from taking good care of yourself because we want you to be successful. This is about your life. It’s a chronic condition. You have to live with it. You don’t let it live for you.
Tiffany Archibald 21:53
I love that. I think we should end on that because that is a great quote for the listeners to kind of resonate within them. And if home hemo, home peritoneal or in-center dialysis is something that they’re interested in and they can listen to this podcast and let us know if they have any questions.
Dr. McDonald 22:13
Okay, well thank you so much.
Tiffany Archibald 22:16
Oh, it definitely is definitely is. Thanks for tuning in today learn more about Dallas Nephrology Associates at www.dneph.com. And if you found the information valuable, be sure to share with those who are impacted by chronic kidney disease.