Hemodialysis (HD) is a process of cleaning waste and poisonous toxins from the body when the kidney fails. It is a life saving procedure. Many times when patients are advised that they will need dialysis their first reaction is negative. This is usually due to fear and false information that they have received during their lifetime. Most patients can be in a state of denial. They can be very apprehensive about the whole process due to lack of correct knowledge. After learning about the details of the process, they become more receptive. They understand that this procedure can extend their life span and will make them feel better so that they can enjoy their life and can even work if they want with some adjustments.
Hemodialysis is usually performed three times a week, three to four hours each time. Patients also get to know others on dialysis resulting in a healthy support group. Dialysis nurses are able to enforce the teaching from physicians about details involved in the process. Dieticians make them aware of healthy food habits needed to follow in a dialysis patient’s daily diet. Restrictions regarding fluid control, sodium and potassium intake, as well as phosphorus are very important. A social worker may review their financial information, alleviate their fear about payment, coordinate with other organisations about cheaper medications and help them in many different ways.
PERCEPTION OF STRESS
One study in Japan identified various factors involved in perception of stress in patient undergoing HD. The most stressful factor for those patients was restriction of water followed by length of treatment. A stepwise analysis revealed that mental state was the most influencing factor followed by the support from the family, satisfaction with dialysis staff and the quality of explanation received by family at the outset. Therefore it is clear that perception of stress on the patient’s part can by reduced by dialysis staff having thorough understanding of the patient’s mental status.
PREPARARATION FOR DIALYSIS
It is usually recommended that patients have construction of an arteriovenous fistula (AV Fistula) placement in their non-dominant arm when their kidney function goes down below 25 %. AV Fistula is needed for patients on permanent dialysis for maximum blood flow and reduction in chance of infection. After placement of AV Fistula, it needs at least three months to heal, develop and mature before it can be used for dialysis of the patient. Unfortunately, patients are very resistant to placement of the fistula and prefer to wait until the last minute. Placement of a temporary catheter can be traumatic to a patient and create an unnecessary emergency. This usually increases the cost, risk of infection, and is inconvenient to the patient. It is true that early placement of fistula is associated with improved health status and quality of life.
RATIONING OF DIALYSIS
We in the US still are fortunate that rationing of dialysis is not practised here. In many parts of the world rationing is practised based on age, medical condition and financial situation. In Canada, due to expense of dialysis and limited budget, there is no incentive to accept patients for treatment. Those who suffer while receiving dialysis are offered the choice of stopping treatment. Stopping dialysis is now the second most common cause of death in Canada and third in the US dialysis population.
EARLY VS LATE REFERRAL
Some of these problems can be alleviated by early referral (Stage 3: Kidney function between 30-60%) of cases to nephrologists for close follow-up. National Institute of Health has recommended patients to be referred when serum Creatinine is 1.5 in male and 2 in female. Recent medical evidence suggests that proper management of chronic kidney disease in the early stages can prevent death from cardiovascular disease, delay the need for dialysis and improve the patient’s health at the onset of dialysis. Late referral is one of the main reasons for high mortality and poor outcome.
There were many patients who have anaemia for a long time but are not aware that it can be caused by kidney failure itself. Anaemia starts to appear in patients when kidney function goes down below 60%. Timely management of anaemia has shown not only to decrease the hospitalisation for congestive heart failure by 80% but also improved exercise capacity and quality of life.
There are many issues and concerns faced by the patients and doctors alike. Nephrologists are always ready to provide aggressive care which can improve their patient’s health, prevent hospitalisation and delay the need of dialysis. Teachings provided by Nephrologists and nursing staff can go a long way in alleviating the stress and result in better compliance with dialysis.
[Dr. Anis Ansari, MD is Board certified Nephrologist and Medical Associate, Clinton, Iowa, USA]