Dialysis treatment makes it possible to live for years or even decades with advanced kidney disease. There are various forms of dialysis. For many people, dialysis in a dialysis center is a good option. Others prefer to choose a procedure that they can use at home.
For many people with terminal kidney failure, a kidney transplant is the best treatment. But it is not always possible. In this case, and also while waiting for a donor kidney, kidney replacement therapy using dialysis is necessary.
The most important forms of dialysis are hemodialysis and peritoneal dialysis. Which form of dialysis is suitable depends on medical factors. However, since everyday treatment differs considerably, personal wishes also play an important role in the choice. It is therefore advisable to familiarize yourself with the different forms of dialysis and to find out together with your family and doctor which one suits you best.
Dialysis makes it possible to live with the disease for many years. How well this is achieved depends primarily on whether and which accompanying illnesses exist, whether the dialysis therapy was well prepared and how well it is possible to cope with dialysis, the necessary medication and dietary rules over the long term.
What does hemodialysis offer?
Hemodialysis is the most frequently used dialysis method in countries like Germany and also in the United States is widely used. In this procedure, the blood is cleaned in a machine using dialysis fluid through tubes outside the body. Dialysis is normally performed three times a week. One treatment usually lasts about four to five hours.
Hemodialysis usually takes place in a dialysis center, but it is also possible to perform it at home (home hemodialysis). The costs of home dialysis are covered by health insurance companies in the same way as those of a dialysis center. Specialists at the center ensure that everything runs smoothly. This gives many a feeling of security and is an advantage for people who feel unable to use this treatment at home.
Home hemodialysis, on the other hand, allows more independence and flexibility. You are not tied to the times of the dialysis center and save yourself the trip there. However, home hemodialysis is not possible without training at a dialysis center and the support of a relative who is also trained. There must also be sufficient space at home for the dialysis machine and the necessary accessories. It is unclear whether the life expectancy of people with chronic kidney disease differs if they receive hemodialysis at home or at a dialysis center – suitable studies have not yet been conducted.
People who want to travel can receive “guest” or “holiday” dialysis at another dialysis center. This also makes it possible to go on vacation abroad: for dialysis at the place of vacation, timely registration is usually sufficient.
What are the disadvantages of hemodialysis?
Some people feel “dependent on the machine”. In addition, the long treatment and sometimes travel times can be stressful and make it difficult to keep in touch with friends and family. Moreover, the fixed treatment appointments at the center are often during the day during the week – but this is difficult to organize for people who want to stay at work. Most larger centers, therefore, offer so-called “evening shifts”.
Hemodialysis only works if there is adequate access to the bloodstream. Since superficial veins are not suitable for this, a small operation is necessary several weeks to months before hemodialysis begins. If possible, a vein and an artery are connected to each other in the forearm. This “short circuit” (arteriovenous fistula or shunt) creates a slightly larger blood vessel into which cannulas can be placed during each dialysis treatment.
The procedure must be performed sometime before dialysis begins because the fistula needs time to fully develop. An arteriovenous fistula is the best approach for hemodialysis because it is the least complicated. But it can also be a burden: some people are always reminded of their illness and dependence on dialysis. For some people, it can even be a reason to opt for peritoneal dialysis. Access is also the cause of typical complications of hemodialysis: the new blood vessel can become inflamed, for example, or be blocked by a blood clot. If an arteriovenous fistula is not possible, hemodialysis can also be carried out using a catheter that is inserted into a large vein near the heart via a neck access.
Hemodialysis is usually free of complications. In rare cases, symptoms such as a drop in blood pressure or seizures can occur during the time spent on the dialysis machine. In addition, blood clotting during dialysis must be suppressed with a drug.
What does peritoneal dialysis offer?
In peritoneal dialysis, the blood is not cleaned outside the body, but with the help of a dialysis fluid in the abdominal cavity. Patients receive a special abdominal catheter for this purpose: About two liters of dialysis fluid are introduced into the abdominal cavity through this catheter, drained after some time and exchanged for new dialysis fluid. This form of dialysis can be performed independently at home.
There are basically two different procedures for peritoneal dialysis. The standard procedure is continuous ambulatory peritoneal dialysis – CAPD for short or simply called “bag change”. Here, the fluid is changed manually three to four times a day, so no machine is needed. However, intensive training by specialist staff is necessary to learn how to use the catheter hygienically. In CAPD, the abdomen is always “filled”.
Those who do not want to change the fluid during the day or – for example, at work – do not have the opportunity to do so, can use a so-called automated peritoneal dialysis (APD) every night. To do this, the catheter is connected to a device (cycler) that regularly changes the dialysis fluid.
Which of the two methods is suitable for peritoneal dialysis also depends on the properties of the peritoneum: some people are more likely to undergo CAPD, others APD.
Peritoneal dialysis also requires certain dietary and drinking requirements. However, they are a little less strict than for hemodialysis.
Those who can no longer cope with peritoneal dialysis can switch to hemodialysis (or vice versa).
What are the disadvantages of peritoneal dialysis?
For the permanent catheter into the abdominal cavity a surgical intervention is necessary, as with hemodialysis. The catheter is also associated with the most common complications of peritoneal dialysis:
If bacteria enter the peritoneal cavity, they can cause peritonitis.
The tip of the tube in the abdominal cavity can cause painful irritation of the mucous membranes.
If the opening of the tube becomes stuck or the tube kicks off, dialysis is difficult or impossible.
The outlet of the tube in the abdominal wall can become inflamed.
To remove excess water from the body, most dialysis fluids contain sugar. Experts believe that over time the sugar can enter the bloodstream and promote obesity. In the case of diabetes mellitus, sometimes the blood sugar-lowering therapy has to be adjusted.
What is hemofiltration?
In the so-called haemofiltration, the blood is fed through tubes into a machine and cleaned there. No dialysis fluid is required: instead, water and degradation products are pressed out of the blood under pressure. When this method is combined with hemodialysis, it is called hemodiafiltration. Neither method plays a major role in the treatment of people with chronic kidney disease in this country. There are also not enough good studies that prove that they are better than standard dialysis.
Can one decide against dialysis?
With the exception of kidney transplantation, there is no alternative to dialysis, which makes it possible to live permanently without sufficiently functioning kidneys. Nevertheless, some people with kidney failure decide against it – for example, because of their advanced age and existing concomitant diseases. This decision means letting their life come to an end. This decision is often difficult for relatives and friends to accept – so it is important to discuss it with them beforehand. In addition, the support of family, relatives and friends will be particularly important in the coming weeks or months.
People who decide against dialysis can continue the therapy with medication and, despite kidney failure, may live for several weeks or months. Palliative treatment is then important at the end of life. It can alleviate pain and other complaints and is intended to maintain as much quality of life as possible. This includes, for example, relaxing or abandoning dietary rules altogether.