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After reading the article you should be able to:

1. Describe basic hemodialysis principles.
2. Discuss nursing and medical management for a patient receiving hemodialysis.
3. Develop a plan of care that helps a patient receiving hemodialysis comply with treatment.

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By DEBORAH MARTCHEV, RN

DEBORAH MARTCHEV is nurse manager of the renal/progressive care unit and dialysis program at Regions Hospital in St. Paul, MN. The author has no financial relationships to disclose. Editor: JUDITH ASCH-GOODKIN. She has no financial relationships to disclose.

When the kidneys fail, hemodialysis may be the only way to prolong existence. Nurses can help patients cope with this arduous intervention and maintain quality of life.

More than 375,000 Americans are being treated for kidney failure, also known as end-stage renal disease (ESRD) or Stage 5 chronic kidney disease.¹ Approximately 275,000 of them receive dialysis.¹ Although peritoneal dialysis is an option, the most common modality in use today is hemodialysis. Usually, these patients are treated at chronic dialysis centers by dialysis technicians supervised by an RN certified in dialysis management.

But nurses outside of the specialty also care for patients with kidney failure who are receiving hemodialysis. Therefore, it's important that all nurses understand basic principles, be aware of how demanding the regimen is for patients, and be conversant with nursing interventions that can help patients achieve compliance.

Chronic kidney failure: The basics

Human kidneys have an enormous reserve capacity, so patients with kidney disease are often asymptomatic, even when their kidneys are functioning at only 25% of normal capacity. As kidney capacity continues to diminish, however, symptoms become more pronounced. Impending renal failure does send signals—weakness, irritability, lack of appetite, a metallic taste in the mouth—that the kidneys are shutting down and replacement of kidney function via dialysis or transplant has become urgent.^1,2 A more detailed presentation of the five "stages of kidney disease" appears in this article.

Patients with kidney failure are usually treated at free-standing hemodialysis centers three times a week, with each session lasting about three to five hours. Or, they may choose in-center nocturnal hemodialysis for six to eight hours per night, if the modality is offered. Either way, patients can continue receiving dialysis at the center indefinitely, or until they qualify for a kidney transplant. Some may decide to take home dialysis instead. This modality is receiving increasing attention as the numbers in need of treatment climb and the self-management paradigm becomes more widely accepted.

The primary purpose of dialysis is to replace the functions the patient's kidneys can no longer perform: removing waste products and excess fluids, and maintaining electrolyte balance.³ Ideally, during hemodialysis, blood is removed through an A/V fistula, a vascular access site surgically created in the patient's arm or leg. (The most common connects the radial artery and cephalic vein.) As an alternative, tunneled permanent catheters can be used for months or years in patients who do not have suitable blood vessels for an A/V fistula or arteriovenous graft, those whose hearts cannot tolerate the increased cardiac output needed for an A/V fistula, or those who have used up all available blood vessels in their arms and legs. Patients in acute renal failure may be dialyzed through temporary catheters, used for days or weeks, with the internal jugular as the preferred location. Special care must be taken, however, when utilizing temporary or permanent caths—these patients are at higher risk for infections and, worse case, sepsis.

During dialysis, blood is pumped through a dialyzer, a machine that functions as an artificial kidney. The dialyzer consists of a blood compartment and a dialysate compartment, separated by a semipermeable membrane that allows for the diffusion of solutes and the filtration of water. The dialysate—an electrolyte solution similar to plasma—is pumped around the blood compartment, and the blood is returned to the patient's circulation.

A nephrologist customizes the dialysis treatment, varying the components of the dialysate based on the patient's needs.⁴ For instance, to promote fluid removal, the specialist will increase the dialysate's sodium concentration to create a higher osmotic gradient within the bloodstream.³ The patient's weight, fluid and electrolyte status, and the type of vascular access are all factors in the treatment plan.

Patient's eye view of the procedure

Complying with a dialysis regimen demands a great deal of patience, commitment, and courage. A diagnosis of ESRD brings patients face-to-face with their own mortality. Beset by the myriad discomforts their illness entails, patients spend hours connected to a machine that keeps them alive but disrupts their work routines and family life.⁵ Some patients adjust fairly easily; they read, nap, or watch TV during dialysis. But others, especially younger patients used to an active, outdoor life, find sitting still for hours almost intolerable.

Being on dialysis imposes other restrictions, too. Patients must stick to a prescribed diet, avoiding foods rich in potassium and phosphorus; limit sodium and fluid intake and watch their weight; and take numerous medications daily to control hypertension, bind phosphorus, and counteract anemia, diabetes, cardiac disease, and other conditions that may accompany kidney failure.

On top of all that, transportation to and from treatment may be difficult to arrange and financial burdens may exist. While Medicare pays 80% of dialysis costs for most patients, and private health insurance or state medical assistance likely contributes funds, individuals could have co-pays for secondary insurance. Plus, Part D prescription coverage is rarely adequate for the high costs of oral medications. And individuals may need to limit their work hours, affecting take home pay, to accommodate appointments.

Some patients react to the dramatic change in lifestyle with depression or anger, asserting themselves by defying the routines, skipping or shortening treatments, or ignoring their fluid and dietary restrictions. Patients with underlying mental illness, personality disorders, or drug addiction may rebel with violent or aggressive behavior. The dialysis staff may become frustrated, demanding compliance in ways that feed into the patient's anger, exacerbating an already volatile situation.⁶ Joe Stevens' story, in this article, typifies the issues that often elicit noncompliance, and explores the nursing dilemmas these patients present.

When patients don't follow the dialysis regimen

Of all patients undergoing dialysis, about 20% shorten treatments and 6% skip some of their appointments.⁸ A study of noncompliant patients showed that most patients who shortened treatment had complained of discomfort during dialysis: they had cramps, back pain, nausea, or headache; needed to use the bathroom; or were cold. Those who missed treatments cited interference with other activities, such as physician appointments, business travel, and work or family commitments.⁸ Shortened or missed treatments are an issue because decreased time on dialysis can lead to adverse effects, including:⁵

Fluid overload. Patients who've missed more than a week of dialysis may show up in the ED with signs and symptoms of fluid overload, such as shortness of breath, anxiety, hypertension, and chest pain.⁴ Fluid overload may progress to pulmonary edema or congestive heart failure, requiring close monitoring in the ICU. Nursing care in the ED should include assessing for crackles and edema, checking vital signs, monitoring the EKG for changes, and reducing anxiety.⁴ Treatment consists of emergency dialysis to remove excess fluid and restore electrolyte balance.

Malnutrition. A significant number of hemodialysis patients suffer from malnutrition, either because they don't stick to their diet or because they don't feel like eating. Risk factors for malnutrition include metabolic acidosis, inadequate dialysis, other medical problems, nutrient loss during dialysis, and the rigors of the prescribed diet.³ Serum albumin levels are an accurate marker for nutritional status. In ESRD patients, levels less than 3.35 g/dL are strong predictors of morbidity and mortality.

Cardiac complications. Patients with chronic renal failure are at high risk for cardiovascular disease. That risk doubles for patients with hypertension or diabetes. Because imbalances in calcium and phosphorus metabolism can lead to calcification of the coronary arteries,⁵ patients should limit intake of meats and avoid prepared foods with phosphate additives.⁹ Each facility has a registered dietician who provides dietary support and often monitors outcomes such as calcium and phosphorus levels.

Hyperkalemia. This life-threatening condition can lead to cardiac arrhythmias and arrest. Defined as a serum potassium level greater than 5.5 mEq/L, hyperkalemia can result from missed dialysis treatments, dialysate solution overloaded with potassium, eating too much food rich in potassium, and tissue breakdown from surgery.^3,5

Signs of hyperkalemia include muscle and abdominal cramps, bradycardia, weakness, and peaked T waves on EKG.³ Patients with ESRD can often tolerate high potassium levels, but those who aren't accustomed to high levels may not. The rapid change in potassium level, rather than the high level per se, produces the symptoms.

Dialysis is the most effective way to correct hyperkalemia. If the patient cannot be dialyzed immediately, sodium bicarbonate or glucose and insulin, given intravenously, can drive the excess potassium into the cells. Sodium polystyrene sulfonate (Kayexalate), administered orally or as a retention enema, can also bring down potassium levels, as the potassium is excreted in the stool.

What nurses can do: Interventions that work

Nurses have more face-to-face time with dialysis patients than any other healthcare provider. They can use that time to educate patients and families, negotiate a treatment plan, and work with the care team to ascertain and overcome barriers to compliance.

Patient education is such an essential aspect of dialysis that it's included as an objective in the Surgeon General's Healthy People 2010.¹¹ Teaching sessions should be tailored to match the patient's learning style, language, and level of health literacy.¹² Educational materials at all reading levels are available on the World Wide Web through the National Kidney Foundation and the National Institutes of Health.

Nursing assessment during dialysis is vital and may reduce the likelihood of shortened sessions. Patients who are anxious or in pain, for example, may need medication to alleviate their symptoms. Dialysis staff should work to reduce friction between patients and staff by reconciling differences or shifting personnel, or by calling in a social worker or mental health professional. For other nursing considerations, see this article.

There are times when patient-staff disputes, noncompliance, or chronic absenteeism result in a patient's dismissal from a dialysis center. While the patient is not discharged until another facility is located, the new institution may be reluctant to admit a patient that is labeled "noncompliant" or "disruptive." For individuals without other options, emergency dialysis in an acute care facility is the ultimate safety net.

Refusing to treat dialysis patients amounts to a death sentence, a possibility that nurses should go to almost any lengths to avoid.⁶ Nursing interventions to avert this dire conclusion include individualizing treatment plans to meet patients' needs and preferences, engaging patients in formalized behavioral contracts, setting up family conferences, referring patients to support groups, and arranging for psychiatric and social work consultations.¹⁰ To ensure optimal outcomes, nurses who encounter chronic dialysis patients in other settings need to be in communication with the dialysis facility in order to coordinate care.

Should individuals choose to discontinue dialysis altogether, nurses must make sure these patients understand the consequences of their choices and arrange for palliative and supportive care.⁷ Social workers can assist with contacting regional renal networks that provide referrals to palliative care teams. These team members are trained to address patient concerns and ethical issues involved in a decision to discontinue dialysis. For a list of the 18 national ESRD networks, go to www.esrdnetworks.org.

The last word, but an important one

At one time, patients with ESRD were within weeks of death. Thanks to hemodialysis, that's no longer the case. It is one of the few treatments covered by Medicare for patients—of all ages—who are eligible to receive disability benefits through Social Security.^5,7 Widespread access to dialysis offers ESRD patients the promise of many more years of productive life. Nurses play an essential part in making that promise a reality.

REFERENCES

1. McFeeley, T. (2001). The price of access. Nashua, NJ: MDL Press.

2. Medical Education Institute. "Kidneys: How they work, how they fail, what you can do." 2003. www.kidneyschool.org/pdfs/KS-Module-01.pdf (8 Jan. 2008).

3. Medical Education Institute. "Core curriculum for the dialysis technician: A comprehensive review of hemodialysis, 3rd ed." 2006. www.meiresearch.org (8 Jan. 2008).

4. Swearingen, P. L. (2008). All-in-one care planning resource (2nd ed.). St. Louis, MO. Elsevier/Mosby.

5. Kallenbach, J., Gutch, C. F., et al. (2005). Review of hemodialysis for nurses and dialysis personnel (7th ed.). St. Louis, MO: Elsevier Mosby.

6. Smetenka, S. L. (2006). Who will protect the "disruptive" dialysis patient? Am J Law Med, 32(1), 53.

7. National Kidney Foundation. "Dialysis patients' Bill of Rights and Responsibilities." 2008. www.kidney.org (7 Jan. 2008).

8. Gordon, E., Leon, J., & Sehgal, A. (2003). Why are hemodialysis treatments shortened and skipped? Nephrology Nursing, 30(2), 209.

9. Murphy-Gutekunst, L., & Uribarri, J. (2005). Hidden phosphorus-enhanced meats. J Renal Nutrition, 15(4), E1.

10. Kammerer, J., Garry, G, et al. (2007), Adherence in patients on dialysis: Strategies for success. Nephrology Nursing Journal, 34(5), 479.

11. National Institutes of Health. "Healthy People 2010." (2008). www.healthypeople.gov (13 Jan. 2008).

12. End Stage Renal Disease Network of Texas. "Intensive intervention with the non-compliant patient." 2008. www.esrdnetwork.org/assets/pdf/conflict/Intensiveweb.pdf (13 Jan. 2008).

Stages of kidney disease

The single best index of kidney function, the glomerular filtration rate (GFR), is used to determine the stage of kidney disease, as shown below. The GFR is calculated on the basis of age, weight, serum creatinine, gender, and race. For an explanation of other lab values relevant to chronic kidney disease, go to www.kidney.org/kidneydisease/ckd/knowGFR.cfm.

Click here to view full-size graphic

Source: National Kidney Foundation. "About chronic kidney disease." 2008. www.kidney.org/professionals/KLS/aboutCKD.cfm (2 Jan. 2008).

Hemodialysis: Nursing considerations

Pre-dialysis care

Assess

• Weight: Determines amount of fluid to be removed during dialysis
• Vital signs: BP for hypotension and hypertension; temperature for sepsis; respiration for fluid overload
• Potassium level: Determines potassium level in dialysate (in the chronic setting, this is done monthly unless the patient is symptomatic)

Review medications

• Hold drugs that pass through the dialysis membrane, such as piperacillin/tazobactam (Zosyn), folic acid, and other water-soluble vitamins.
• Hold antihypertensive drugs, especially if systolic pressure is below 100, per physician order.

Review need for blood products

Check access site

• Assess fistula or graft for infection
• Assess circulation in distal portion of extremity
• Ausculate for bruit
• Palpate for thrill
• No IV or blood draws in that arm
• No BP in arm

During dialysis

Watch for

• Hypotension
• Muscle cramps
• Nausea and vomiting
• Headache
• Itching
• Less commonly: disequilibrium syndrome, hypersensitivity reaction, arrhythmia, cardiac tamponade, seizures, air embolism

Post-dialysis care

• Monitor BP; report hypotension or hypertension
• Watch for bleeding
• Check weight and compare (weight loss should be close to fluid removal goal set during treatment)
• Document unusual findings
• Assess access site for bruit, thrill, exudate, signs of infection, bleeding
• Give missed meds, if indicated

Sources: 1. Daugirdas, J. T., Blake, P. G., & Ing, T. S. (2007). Handbook of dialysis (4th ed.) Philadelphia: Lippincott Williams & Wilkins. 2. Swearingen, P. L. (2008). All-in-one care planning resource (2nd ed.). St. Louis, MO: Elsevier/Mosby.

The patient who won't comply

Joe Stevens is an African-American man with end-stage kidney disease, the result of years of untreated hypertension. His history includes chronic anemia, osteomyelitis, and drug abuse. A long-term dialysis patient, he's scheduled for treatment every Tuesday, Thursday, and Saturday but has missed several recent appointments.

Suppose it's 2:00 a.m. and Mr. Stevens arrives at your ED by ambulance. You recognize his familiar face; he appears whenever he skips several treatments at the dialysis center. With his spot at his current center in jeopardy due to his noncompliant behavior, his chances of receiving a kidney transplant are slim.

A high cost to all

When you evaluate Mr. Stevens, you find he's short of breath, complaining of chest pain, hypertensive, and tachycardic. His vital signs are: BP 263/106, heart rate 140, and respiration 32. His O₂ saturation is 91%, and he's visibly working hard to breathe. When you auscultate his chest, you hear scattered wheezing with crackles at the bases, indicating pulmonary edema. You administer oxygen by Ventimask and ask the respiratory therapist to bring over a BiPAP machine, in case the patient's breathing worsens. Mr. Stevens' potassium level is 7.0, which puts him at risk for lethal cardiac arrhythmias. You recognize that he needs emergency dialysis, and you page the on-call dialysis nurse at the request of the nephrologist.

After a few days in the medical intensive care unit, he moves to a med/surg floor. Finding a chronic facility that will accept him is difficult, and until that's done, Mr. Stevens remains in the hospital where his noncompliant, drug-seeking behavior poses a challenge for all involved. He'll require an interdisciplinary care conference—with his home unit, social worker, Network, and nephrologists—to address his complex needs, and the cost of his ED care and subsequent hospitalization is considerable.

No easy answers

As a matter of public policy, guaranteed by Act of Congress, all patients with ESRD are entitled to receive the care that keeps them alive.¹ Once Mr. Stevens' condition is stable, however, and a dialysis unit accepts him, he'll likely be back on the same merry-go-round—possibly ameliorated by treatment for the depression and fear that underlie his behavior. His actions place a financial burden on the healthcare system and utilize resources earmarked for more compliant patients. Is it time to consider denying dialysis to noncompliant patients like Mr. Stevens? Many believe it requires fewer resources to continue dialysis than to stop it and provide the necessary patient education and end-of-life care. Until formal criteria and guidelines are established to address this issue, tough decisions surrounding dialysis will remain.

Source: 1. Smetenka, S. L. (2006). Who will protect the "disruptive" dialysis patient? Am J Law Med, 32(1), 53.