Information on access options can be found at www.kidney.org, www.aakp.org, or www.esrd.ipro.org.
Aterio-venous Fistula (AVF)
The fistula is the gold standard for vascular access and should be considered first for every patient needing hemodialysis. This type of access is placed in any of the body locations listed below, by a vascular surgeon. It is a connection between an artery and a vein to create a large blood vessel to provide a high volume of blood flow so that your hemodialysis treatment will be efficient and effective. It also allows for repeated needle insertions. Although you may have had a catheter placed for an immediate treatment, The Regional Dialysis Center supports the “Fistula First” program.
The “Buttonhole” technique and self cannulation are also part our program. Please ask your nurse about these techniques and “Fistula First”.
Locations: Forearm, upper arm
Advantages: Lasts many years
Less chance of infection
Higher blood flow rates
Fewer complications
Graft
A graft is another access that is inserted by a vascular surgeon. It a synthetic tube placed under the skin in any of the locations listed below. It can be straight or in a loop. This type also allows for needle insertions for high blood flow.
Locations: Forearm, upper arm, thigh (deleted straight or loop here)
Advantages: Can be used two weeks after placement
For use when a fistula does not work
For patients with special health issues
Catheter (Perm-Cath)
This is a temporary access that is placed by doctors in our Special Procedures Unit. A dialysis catheter is placed under the skin and into a large vein that leads to your heart. It has two lumens, one to deliver blood from the patient to the filter and the other one returns blood from the filter to the patient.
Locations: Neck (jugular vein), groin (femoral vein), or chest (subclavian vein) — should be avoided
Advantages:
Only used in an emergency or for temporary access
Can be used when other access types are maturing
Disadvantages:
Infection
Clotting
Lower blood flow rates
Vessel damage
Designed for short-term use only
Care of Your Vascular Access
Proper care of your vascular access must be followed to ensure your safety and prevent infections.
Post-Dialysis Fistula or Graft Care
When the needles are removed from the fistula, while wearing a glove, the patient holds pressure over the needle sites to stop the bleeding.
Pressure should be adequate to stop the bleeding but not stop the blood flow through the access.
Pressure should be held for at least 10-15 minutes and released gradually.
The sites will be covered with bandages, which should remain on the sites until the next day.
Occasionally, you may experience leaking from the venipuncture sites after dialysis. If bleeding occurs, apply direct pressure to the site.
It is recommended you carry some 4 x 4 bandages in your purse or car, and have some at home to enable you to hold pressure on the sites to stop the bleeding.
Pressure should be held just as it is done post dialysis.
Notify the physician or dialysis center if bleeding occurs at home.
Care of the Fistula or Graft at Home
It is important to keep the fistula clean. By keeping the skin in the area of your A-V fistula clean, you can substantially reduce the risk of infection. Wash your fistula daily with soap and water.
On a daily basis:
Check your fistula for signs of infection such as redness, swelling, soreness, or drainage.
Check your fistula for proper function, making sure you feel a pulse or thrill along the length of your fistula or vein to which your graft is attached. To do this, place your fingertips over your access.
Wash your fistula site.
You may shower and bath normally.
Do not:
Restrict blood flow through your A-V access for long periods. Be careful when lifting and carrying objects that press against it.
Sleep on your A-V access.
Use your A-V access for the administration of any drug or medication without professional renal medical assistance.
Wear tight jewelry over your A-V access.
Allow lab draws or IV insertions in the arm of the A-V fistula.
Allow your blood pressure to be monitored using this arm.
When to call the doctor:
Absence of thrill (buzzing sensation) in arm.
Pain or swelling in arm.
When signs or symptoms of infection occur. I.e.: drainage, tenderness, redness, warm to touch.
If any substantial bleeding occurs from fistula at home.
Treatment of hematoma or clotted access
Hematoma
A hematoma is bruising of the skin around your fistula caused by blood leaking into the tissue. Ice the area for 24 hours 15 minutes on 15 minutes off. Apply moist, warm compresses after 24 hours. Check your access for thrill.
Thrombosed Access (also called a clotted access)
Removal of clot in the fistula or graft is necessary before the access can be used for the purpose of dialysis. This is done in the Special Procedures Unit and must be done as soon as possible once the clotted access is noted.
Care of the Perm-Cath at home
Check the exit site for signs of infection, such as drainage, swelling, redness, and soreness.
Keep a dry dressing over the port ends.
You may shower with your physician’s okay.
Cover your dressing before showering using plastic wrap or baggies. You may also use catheter shields, which are available online. Ask your provider for more details.
If the bandage covering the catheter exit site becomes wet, replace it with a clean, dry one.
When to call the doctor:
If drainage, pain, swelling or redness is noted around the catheter exit site.
If fever is more than 100 degrees.
If the catheter comes out at home, place direct pressure on the skin site with the palm of your hand or any clean towel or washcloth.
Do Not:
Pull or tug on the catheter.
Remove any sutures that are holding the catheter in place. This must be done by the nephrologist.
Allow usage of the catheter by anyone for IV or lab draws.
Remove any caps or unclamp any clamps on the catheter.
Treatment Options
The Dialysis Center at Faxton-St. Luke’s Healthcare provides care for those with chronic and acute renal failure. The center offers several treatment options, including outpatient hemodialysis, home hemodialysis, and peritoneal dialysis. Not all patients are candidates for each method. Treatment depends on the patient’s physical condition, emotional condition, and family. Options can be discussed with the patient’s nephrologist.
Hemodialysis
Hemodialysis is a process where a small amount of blood (just over a cup) is removed from the body and sent through an artificial kidney. The artificial kidney has a cellophane-like membrane, and is bathed in a solution called dialysate. The blood is cleansed of waste products and excess fluid. The blood is then returned to the patient. Dialysis is not only the removal of fluid, but also the removal of waste. This includes electrolytes, especially potassium, which, in excess, can cause cardiac arrhythmias. Hemodialysis is usually performed three times a week, for three to five hours at our outpatient hemodialysis center located at the Faxton Campus.
Home Hemodialysis
If a patient is physically stable and mentally fit, the patient and his or her partner can be trained for home dialysis. Training may take 3 to 5 weeks to complete. The patient and partner are responsible for all aspects of the treatment including water testing, insertion of needles or accessing a catheter, and monitoring vital signs and machine operation. For more information on home dialysis, contact your primary nurse. The physician has final approval on whether this treatment is right for you. The Regional Dialysis Centers offers NxStage home hemodialysis.
Peritoneal Dialysis
Peritoneal dialysis removes waste products and excess fluid from the blood, but in a way different from hemodialysis. A membrane that surrounds all of our organs is called a peritoneal membrane. This membrane acts like an artificial filter that filters out waste products and excess fluid. In peritoneal dialysis, a catheter is surgically placed in the abdomen and dialysate is instilled into the abdomen and left for a number of hours. After a prescribed amount of time, the dialysate is drained out of the abdomen. It is a slower dialysis method and must be done several times during the day, every day. Sterility is vital during peritoneal dialysis connections.
There are two types of home peritoneal dialysis:
CAPD (Continuous Ambulatory Peritoneal Dialysis) is a manual method of doing exchanges. The patient connects a fill and drain bag to the catheter, performs the exchange, and disconnects the tubing from the catheter. Exchanges must be done four to five times per day during waking hours. Precautions must be taken to assure sterile connections to the catheter.
CCPD (Continuous Cycling Peritoneal Dialysis) is a method of doing exchanges with a machine called a cycler. The patient connects his catheter to the cycler, at midday or late afternoon, which automatically drains and fills the abdomen once. The patient disconnects himself and is free until bedtime. At bedtime, the patient reconnects himself to the cycler and the cycler automatically drains and fills the abdomen four to five more times during the night while the patient sleeps eight to 10 hours. Sterility is vital during the dialysis connections.
Ask your renal team for more information on these dialysis treatment options.
Transplantation
Renal transplantation is the placement of a kidney from another person (donor) into the patient with renal failure. It involves major, but low-risk, surgery. The donated kidney can perform all the functions that the patient’s damaged kidneys are unable to do.
The patient with a functioning donated kidney no longer requires dialysis treatments, because the kidney works more effectively than dialysis. The patient who receives a transplant generally feels better and has more energy. Many restrictions are lifted after transplantation, including food and liquid restrictions.
A strict medication regimen must be adhered to prevent rejection of the transplanted kidney. However, if rejection does occur, the patient may have to return to dialysis.
Once your physician gives you medical approval, arrangements can be made with the transplant hospital for information and evaluation.
Any questions about these treatment options can be asked of your primary nurse or physician.
Nocturnal Dialysis
This is a type of hemodialysis where you receive your dialysis treatments while you are sleeping at night for 6-8 hours. This can be done in dialysis center or at home via a monitoring system with a dialysis unit. The initial requirements are the same as home dialysis. Nocturnal dialysis is not currently offered at Faxton-St. Luke’s Healthcare.
No Treatment
Dialysis is your choice. You have the right to refuse dialysis, or there may come a time when you feel that dialysis is no longer an option and you want to discontinue your treatments. If this occurs, it is important to discuss your feelings with your loved ones and your health care team. Your doctor and primary nurse can advise you about the type of care you may need once a decision has been made. Your social worker is also available to make arrangements for end-of-life care. More information is available at www.kidney.org.
Dialysis Medication
Q. Do you know why you get Aranesp?
A. Normal functioning kidneys produce a hormone called erythropoietin, which tells the bone marrow to produce red blood cells. Red blood cells carry oxygen throughout the body. Diseased or damaged kidneys do not produce as much erythropoietin so the bone marrow makes fewer new red blood cells, a condition called anemia.
Q. What does anemia feel like?
A. If you have anemia, you may feel weak, tired and may lack energy most of the time. Even mild exercise may bring on fatigue, difficulty breathing and sometimes chest pain. Although dialysis makes up for the loss of some kidney function, it cannot correct anemia.
Q. What is Aranesp?
A. Aranesp is a drug that works just like the erythropoietin produced by the body. Aranesp stimulates the bone marrow to produce red blood cells at a more normal level.
Q. When is Aranesp given?
A. Aranesp is given once a week at the end of your dialysis session into the blood tubing during the rinse back of your blood.
The amount of Aranesp you receive is based on a blood test called hemoglobin. You will continue to get monthly hemoglobin tests to see if you are staying within the target range. Adjustments will be made according to your results.
Venofer/ iron sucrose
Q. Why do I get Iron?
A. To make red blood cells, your body needs iron as well as Aranesp. Chronic kidney failure patients on dialysis have a special need for iron. This is because you lose a little blood (which contains iron) during hemodialysis treatments.
You may also have other problems that cause you to lose blood, or that make it difficult for your body to store or release iron.
Q. When is Iron given?
A. Lab tests are done every three months to check your iron levels.
Iron is given during dialysis.
Depending on your iron levels you will receive iron every treatment for 10 treatments in a row and then once every two weeks or you may start out getting iron once every two weeks.
Hectoral/ doxercalciferol
Q. What is doxercalciferol?
A. Doxercalciferol is a form of vitamin D hormone replacement therapy.
Q. Why do you need doxercalciferol?
A. Kidneys are responsible for normal calcium balance. Normal calcium balance helps make bones strong and keeps them healthy. The healthy kidney makes a special form of Vitamin D called calcitriol.
When you have kidney disease, your kidneys stop making calcitriol. Without calcitriol, you cannot absorb enough calcium from your diet. The body begins to “rob” calcium from your bones. This makes your bones grow weak.
Also, without calcitriol, the glands in your neck (parathyroid glands) will make too much PTH- parathyroid hormone; this will cause even more calcium to be taken from your bones and increases bone disease.
If the PTH is not controlled, your doctor’s only choice may be to recommend that your parathyroid glands be surgically removed.
Doxercalciferol is given to restore PTH to safe levels and normalize calcium levels.
Q. When is Doxercalciferol given?
A. Lab tests are done every three months to determine how much doxercalciferol you require. It is administered every treatment at the end of your dialysis session into the blood tubing during the rinse back of your blood.
