Tiffany Archibald 00:02
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. Deciding on what type of dialysis is best for you can be challenging. Listen to what Dr. Richie has to say about making a choice that best fits your needs. Hello, Dr. Richey, thank you, again for taking the time to sit here and go over some very important information. I think this topic is going to be one that is in depth is extremely important. We’re talking about the types of dialysis, what types of dialysis are best for each patient, and then we’ll go through an overview of the three different types of dialysis. Alright, so let’s begin with when is dialysis necessary?
Dr. Richey 00:58
That’s a very complicated question. So when patients are following with their nephrologist, they’re used to looking at what they call their kidney numbers. And that could be a number called a GFR, or creatinine level. And that’s really how we gauge how a patient’s kidney function is progressing. What I tell my patients is we start dialysis when your kidneys can no longer safely support you. Now, what I mean by that is, are we seeing things on their bloodwork that could potentially be life threatening. So for example, a very common indication to start dialysis would be a high potassium level, you know, our kidneys excrete potassium, and that keeps level down, which keeps us safe. But if a patient’s kidneys cannot excrete that, that potassium has to come out somehow, and so that’s one indication. Same thing with increased acid buildup in their bloodstream. Another common reason we start patients is because of what we call fluid overload. Our kidneys are the really the main way we get rid of extra fluid. And so if you’re swelling or have fluid buildup, and it’s making its way into your lungs, if the kidneys cannot get rid of that fluid, then it has to come out somehow. And that’s, again, another indication for dialysis. And then the last indication would just be how the patient feels. Chronic kidney disease and progressive kidney failure, you know, there comes a point when the patient just feels bad, you know, they can’t necessarily put their finger on it, but, you know, they have no energy, they lose their appetite. They just feel terrible. And, and that is a very common indication for initiation of dialysis.
Tiffany Archibald 02:49
Okay. And when you say feeling terrible, I know people these days are sluggish or work kind of overloads them but feeling terrible?
Dr. Richey 03:00
I think the most common thing I hear from patients is I can’t do the things I normally used to do. Even getting out of bed every day is difficult. I said weight loss is very common because patients stop eating, but when you see those particular things, to me, that’s an indication that, hey, we have this therapy that’s gonna help, we need to start it.
Tiffany Archibald 03:22
Okay. And so what are the types of dialysis?
Dr. Richey 03:25
So there are three main options for our patients. One is what we call in-center hemodialysis. Then we have home hemodialysis and then we have peritoneal dialysis. And these are all very different types of therapies. So, by far the most common one that we we have patients do is called in-center hemodialysis. We have these dialysis centers that people drive by them all the time. They’re standalone buildings or clinics and the sole purpose is for providing these dialysis treatments. Patients go in there, they get their dialysis. Outside of that, we have home dialysis. Home dialysis comes in two forms. Home hemodialysis, which is the same process as the patients who go to the center. We just train them and provide them with the equipment to do this at home. And then peritoneal dialysis, which is also home therapy, but it’s quite different than the hemodialysis. But again, that’s a home therapy that they can do. We train them. We give them all the equipment and everything and they can do it themselves.
Tiffany Archibald 04:36
Okay. And so what you said is peritoneal and home hemo are different. What is the major difference in those two?
Dr. Richey 04:46
So hemodialysis, hemo, meaning blood, essentially in hemodialysis, a patient has their blood run through a machine and that machine cleans it. It removes extra fluid and then the cleaned blood is then returned back to the patient. So, both the in-center hemodialysis and the home hemodialysis have kind of basically the same type of machines and the same treatment. Peritoneal dialysis is very different. So peritoneal dialysis, we utilize the patient’s own body to do the filtering. So, what we do is there’s a catheter that goes into the patient’s abdomen, and inside the abdomen, there’s what we call the peritoneum. It’s a membrane, you know, and we give them a special fluid, the fluid goes into their abdomen, and through that peritoneum, you get exchange of toxins and fluid removal, and then you empty that fluid out from the abdomen. So it’s a different way of kind of achieving the same thing.
Tiffany Archibald 05:53
Okay, and so you you mentioned, peritoneal it’s a it’s a certain access, right, we talk about the different accesses that we use for hemo and peritoneal.
Dr. Richey 06:07
Yeah, so hemodialysis, again, we have to have access to the patient’s blood. Unfortunately, we can’t use just like an IV, there has to be a special access. And so the most common access that we we want to use is either what we call an AV fistula, or an AV graft. AV means arteriovenous. And so what happens is, through a surgical procedure, an artery and a vein are sealed together. And so basically, you’re getting blood flow through the artery directly into the vein. And that usually doesn’t happen in the human body. And what that does is that gives us access to that high blood flow rate through a vein. And so what you end up getting is a couple of needles in that vein that gives us access to run the blood through the machine and then back into your body. And those accesses are the same whether you’re doing home hemodialysis or in-center. So for peritoneal dialysis, like I mentioned, you get a special catheter that goes inside your abdomen. It sits down kind of in your lower pelvis, on the inside, and then you have a certain small length of tubing that comes from under the skin outside where you can access it and put the fluid in and out.
Tiffany Archibald 07:25
Okay, all right. And so you talked about hemo dialysis and home hemo dialysis. Let’s get into that. What would qualify a patient to be able to do home hemodialysis?
Dr. Richey 07:40
I’d say most patients can do home hemodialysis, but I think what we look for, first of all, the patient has to be able to take part in their treatment. So if the patient is unable to do any of the training themselves, and we don’t really consider them good candidates. They have to have good vision. It’s suggested that they have good family support, and even sometimes we recommend they have a caregiver go through the training with them so they have backup. They need to have good vision, because you know, there are connections, they have to access their bloodstream, be able to work the machine, things like that. And then they have to have an appropriate space at home to do these treatments. And these are all things that we look at before we actually train someone.
Tiffany Archibald 08:32
Okay, so when you say appropriate space, walk a patient through that, is it like a, do a nurse come out or a medical professional come out and kind of take a look at the home environment? Or can you expand on that?
Dr. Richey 08:44
Yeah, the they do have a nurse come out. They do what we call a home visit. They come and not only do they make sure that you have the appropriate space, they’ll actually sit there with you and work through, okay, your machine goes here, your supplies go here. So that way, you know, when all these things come to your home, you know exactly where they’re going to go. You’re going to know exactly how this is going to be set up.
Tiffany Archibald 09:10
And so what will disqualify a patient from being a candidate for home hemo? I know you said a bad vision, not being involved in their care. Is there anything else that would disqualify them?
Dr. Richey 09:24
Well, if their home is not conducive, you know, again, some people just don’t have the space, there’s quite a bit of supplies and equipment that go with this. So that’s one thing. A lot of times just the amount of training that it requires. Some patients don’t have the time to do this training. And so sometimes that will prevent them from going forward with with this modality.
Tiffany Archibald 09:47
Okay. And so we kind of touched on the most common type of home dialysis, is it hemo or is it peritoneal?
Dr. Richey 09:54
The most common is peritoneal.
Tiffany Archibald 09:58
Why is that?
Dr. Richey 09:59
It’s considered an easier therapy to learn. So the home hemodialysis training can take anywhere from four to six weeks. Peritoneal dialysis, you’re looking looking at about seven to 10 days on average, to train to do that. It’s a very simple procedure. Really can train anybody to do that.
Tiffany Archibald 10:17
Okay. And so what is the typical hemodialysis schedule?
Dr. Richey 10:23
So if you’re talking about an in-center treatment, the in-center patients will dialyze three days a week, and that’s typically on a Monday, Wednesday, Friday, or a Tuesday, Thursday, Saturday schedule. And on average, I’d say most people dialyze about four hours per treatment.
Tiffany Archibald 10:42
So kind of getting off, not necessarily getting off topic, but do you see that a lot of individuals are unable to work? How does that affect their social life being committed to three days a week, you know, four hours a day? I mean, that’s 12 hours.
Dr. Richey 11:01
What we tell people is in-center hemodialysis is more than just the timeframe where you’re sitting in that chair receiving dialysis. So of course, there’s the travel time to and from the unit. But in-center hemodialysis can be somewhat difficult for patients to recover from afterwards. So a lot of patients after treatment will actually go home and sleep or rest because it’s a hard, it’s a rough treatment to go through. And you’re trying to fit, you know, two days worth of, I guess filtering or kidney function into a four hour treatment. And so, you know, it is very difficult for patients to maintain a normal work schedule. And a lot of times the day they dialyze you know, they just realize am I’m kind of going to be out of it the rest of the day.
Tiffany Archibald 11:51
Okay. And so and what is the typical schedule for a peritoneal dialysis?
Dr. Richey 11:57
Peritoneal dialysis is a seven day a week treatment. Alright, you do this every day. Now there’s different ways to do it. There’s a machine that can do this treatment for you while you sleep. Some patients are able to just do the peritoneal exchanges while they sleep. And then when they wake up in the morning, they can disconnect and go about their day normally. Other patients require treatments throughout the day as well. And that can be what we call manual exchanges, where they they put fluid in and then manually drain that fluid out. Or they can just put fluid in early in the morning and leave it there throughout the day and receive dialysis that way. The the most important thing to tell patients is it’s a seven day a week treatment. You know, there’s there’s no skipping days,
Tiffany Archibald 12:47
Okay, seven days a week, but then sleeping. But you mentioned a fluid exchange throughout the day. What timeframe is that fluid exchange?
Dr. Richey 12:58
So the fluid, when it goes in, it depends on the prescription, but it will stay inside their abdomen for anywhere from two to four hours before it is exchanged for a new set of fluid.
Tiffany Archibald 13:09
Obviously, dialysis is a medication in itself. But are there any additional medications that are in combination with dialysis? How does that work?
Dr. Richey 13:20
I would say most of our patients still require anti-hypertensive medications or medicines to lower their blood pressure. So that’s a very common medicine. We use what we call phosphorus binders. A big issue with our patients on dialysis is their bodies still retain a lot of phosphorus, which can cause a lot of long term complications with their bones and their blood vessels so we try to get that level down. And to do that we use these medications and they take them every time that they eat. That’ll help bind up phosphorus so that they don’t absorb it. Beyond that, most of our patients are also anemic. They have low blood counts, and so we give them medications typically, to help bring their blood counts up. So those are the most common ones. We also use vitamin D, but you know, other than that whatever medicines they’re on before, a lot of times they’re on the same regimen as they are after they start dialysis.
Tiffany Archibald 14:24
Okay, and so I know you talked about phosphorus and phosphorus binders, and you know, combining that with their diet. Are there any special diets or dietary restrictions for patients that do dialysis?
Dr. Richey 14:38
It is a fairly restrictive diet. So we ask our patients to monitor salt intake, phosphorus intake and protein intake. You know, now protein we want them to eat more of. Phosphorus and salt we want them to restrict that as much as possible. So that those are the main dietary issues that we deal with.
Tiffany Archibald 15:01
What are some examples for those that don’t know of foods that have high phosphorus?
Dr. Richey 15:07
High phosphorus, the most common would be dairy products. Dairy products, cheese, milk, ice cream, things like that are usually your highest phosphorus content.
Tiffany Archibald 15:16
And then I did have another question. So you talked about the trainings for home hemodialysis and home peritoneal dialysis. One was seven to 10 days, and one was four to six weeks. Why is there such a vast difference in the amount of time?
Dr. Richey 15:36
There’s more to learn as far as the home hemodialysis and one of the big differences is with home hemodialysis, you’re actually accessing these fistulas or grafts. And so, you know, putting a needle into one of these accesses there’s certainly a risk as far as bleeding. So we do a lot of training with patients, making sure they feel comfortable putting these needles in and accessing these, these fistulas and grafts. I think that takes up a lot of time. And then again, the machines a little bit more complicated. It just you have to learn all the bells and whistles on the machine, understand how to troubleshoot.
Tiffany Archibald 16:20
Okay, that’s it for the questions that I have. But I do want to just kind of have you summarize, because you’re the specialist in the dialysis. If you could give us three main points to have patients, or even professionals, that are listening to take away about dialysis.
Dr. Richey 16:38
So dialysis is a last resort. Right. We do it because we have no choice to do it. But you know, a lot of patients think of dialysis, as you know, they hear stories from family and friends about how terrible it is. And, you know, I think if what we try to get our patients to do is we want them to take their healthcare into their own hands. So we try to get patients to go into home dialysis more so these days. They tend to feel better. And you know, they get to be more involved in their care, you know, so we have an understanding that this is a therapy that, if they started, it’s because they have to start it but we still want people to be engaged and we want them to try to live as normal life as possible. And so going to home therapies, I think is something that most nephrologists now are really trying to stress you know, for the patient because it is just better for them.
Tiffany Archibald 17:33
Well, thank you again for being with us today to talk about the different types of dialysis so patients that are listening can understand what their options are when choosing this type of modality of treatment and you did an awesome job. 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.