How To Know What To Expect From Dialysis

Transcription

1 Discovering Dialysis a manual for kidney and dialysis patients Provided By: Kidney Foundation of the Greater Chattanooga Area Revised 2004

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3 A Manual for Kidney & Dialysis Patients courtesy of THE KIDNEY FOUNDATION OF THE GREATER CHATTANOOGA AREA 620 Cherokee Boulevard Suite 111 Chattanooga, TN

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5 Table of Contents Part 1 Clinic Information General Introduction... 2 A Typical Day On Dialysis... 3 Part 2 Kidney Disease The Normal Kidney... 7 Part 3 Renal Failure and Dialysis Causes of Kidney Failure Problems of Kidney Failure Common Questions Asked About Complications Part 3 Medical Needs Medications Lab Tests Blood Chemistries The Renal Diet Helpful Hints to Stay on your Diet Hepatitis Hepatitis Vaccine Vascular Access Common Questions About Vascular Access Part 4 Treatment Options Treatment Options Common Questions About Hemodialysis High Flux Dialysis and High Efficiency Dialysis Home Hemodialysis Continuous Ambulatory Peritoneal Dialysis (CAPD) Continuous Cycling Peritoneal Dialysis (CCPD) Transplantation Part 5 Social Services Social Work Services Common Questions About Social Work Services Other Facilities and Organizations of Interest to Kidney Patients Part 6 Definitions Glossary... 70

6 EMERGENCY CONTACT INFORMATION UNIT NAME: UNIT ADDRESS: UNIT PHONE NUMBER: HOSPITAL: HOSPITAL PHONE NUMBER: DIALYSIS DAYS: DIALYSIS TIME: DOCTOR: DOCTOR PHONE NUMBER: PRIMARY NURSE: PRIMARY NURSE PHONE NUMBER: SOCIAL WORKER: SOCIAL WORKER PHONE NUMBER: DIETITIAN: DIETITIAN PHONE NUMBER: 24-HOUR CALL NUMBER: OTHER INFORMATION AND INSTRUCTIONS:

7 PART I CLINIC INFORMATION page 1

8 General Information about the Dialysis Clinic Your dialysis treatments should not be skipped except in an emergency. Try not to schedule other appointments on the days you have dialysis. If you are not able to come for your appointment, call the Dialysis Clinic and talk to the nurse in charge. Bradley Dialysis Cleveland, TN Chattanooga Kidney Center Chattanooga, TN Dialysis Clinic, Inc. Third Street, Chattanooga, TN Dialysis Clinic, Inc. Lyerly St., Chattanooga, TN Dialysis Clinic, Inc. East Ridge, TN Dialysis Clinic, Inc. Hixson, TN Dialysis Clinic, Inc. Broad Street, Chattanooga, TN Dialysis Clinic, Inc. Dayton, TN Dialysis Clinic, Inc. Ft. Oglethorpe, GA Dialysis Clinic, Inc. Lafayette, GA Dialysis Clinic, Inc. Jasper, TN FMC Dialysis Clinic Athens, TN Woods Memorial Dialysis Etowah, TN Report for all your treatments ON TIME. Call if you will be more than one hour late. If you come late, you may not receive all of your prescribed treatment. If you are late on a regular basis, you will be scheduled for a conference with your doctor. Please leave children at home. They are not allowed in the treatment area. There is no place for them to stay while you are receiving dialysis. Dress in comfortable clothes. You will sit in a reclining chair for your treatment. You may bring a blanket, an extra pillow, and something to do (a book, handiwork, etc.) while you are here. Unless you have problems with nausea and vomiting, it s a good idea to eat something before coming to dialysis. You are not allowed to bring food or drinks into the clinic. No drugs are given out at the Dialysis Clinic. If you run out of a medicine, tell your nurse. He or she will have your doctor prescribe a refill. Only take medicines prescribed by your kidney doctor, even if they are over-the-counter drugs. Aspirin, milk of magnesia, and other common medicines can have harmful effects on kidney patients. The clinic will give you Medical ID tags or order them if you ask. Please make sure that the clinic has your correct address and telephone numbers. Let the clinic know immediately of any changes. This allows your doctor or nurse to contact you if any significant problems come up. When you come for your first dialysis treatment, bring ALL your medicines, including any medicines that you received when you were discharged from the hospital. These will be reviewed. If necessary, changes might be made. Your nurse will check your medicines every month, so bring ALL your medicines to the clinic the FIRST week of each month. Please do not bring expensive items to the clinic. If they become lost or stolen, the clinic is not responsible for them. page 2

9 A Typical Day on Dialysis You will receive detailed instructions during your first dialysis treatment. There are general steps to follow for each time you receive dialysis. We have listed the things you need to do each dialysis to familiarize you with the procedures of the clinic. You may want to come a little early on your first day to sign forms and meet the staff. 1. When you arrive at the clinic, wait in the lobby until the nurse calls you. 2. When you are called into the dialysis area, first go to the scales. The nurse or a technician will check and note your weight. 3. Find your name on the board and the number of the chair you are to sit in. 4. Get all necessary items (magazines) that you may need during dialysis. 5. When you get to your chair, make sure your name is correct on your artificial kidney. 6. If you have a graft, wash your arm or thigh with the Betadine scrub provided on the table next to your chair. 7. Several procedures will be carried out throughout the dialysis including: blood pressure reading pulse rate blood flow rates (how fast your blood is moving through the artificial kidney) machine adjustments 8. A nurse will take your blood pressure (sitting and standing), your pulse, and temperature and note them on your chart. 9. The nurse will place a cleansing solution on your graft or fistula and let it set for three minutes. 10. If you have a graft or a fistula, the nurse will insert two special needles into your arm. A medicine to numb your skin can be used, if you want. 11. Once the needles are inserted, the nurse will connect the blood lines to the needles and turn on a pump. The pump pulls blood from your body, sends it through the artificial kidney, and returns it to your body. page 3

10 12. The machine alarms and equipment are checked to insure your safety. Don t be frightened if you hear the machine beep. This is a necessary test. 13. The machine is adjusted for your fluid weight. 14. While you are dialyzing, two blood samples are removed from the blood lines to test how fast your blood clots. The results of this these tests determine how much medicine (Heparin) that you need to prevent clotting of your blood within the artificial kidney. 15. Near the end of dialysis (15 minutes to an hour before the end of the process), the heparin is turned off so your blood can return to its normal clotting time. This will keep you from bleeding too long after your dialysis. 16. If you have a fistula or graft, the blood line carrying the blood from the body is disconnected from the needle and the remaining blood in the machine is returned to you. The needles are then removed, and pressure is placed over both needle holes. If you are able to hold pressure on your needle sites, the nurse will instruct you on how to do this. Continue pressure on this area for 10 minutes or longer to make sure that all the bleeding is stopped. When the bleeding has stopped, band-aids or pressure dressings are placed over the two needle holes. 17. Your blood pressure, pulse and temperature will be taken and recorded on your chart. 18. Have your nurse weigh you again. 19. Put away your magazines and place your linens in the laundry hamper. Gather your belongings before you leave. page 4

11 PART 2 KIDNEY DISEASE page 5

12 The Normal Kidney To understand kidney failure, you need to know something about the kidneys and how they work. The urinary tract contains two kidneys, two ureters, a bladder, and one urethra. The kidneys are small. Each kidney is about the size of your fist. They are located in the middle of your back, on each side of your spine just below the ribs. When the blood enters the kidney, it is cleaned when it passes through lots of blood filters, known as nephrons. The waste materials filtered out of the kidney go through the ureters--tubes that connect the kidneys and the bladder. Urine is made in the kidneys and moves from the kidneys through the ureters to the bladder, where it is stored. When this waste (urine) reaches the bladder, it is stored and then sent out through the urethra, a tube that takes the urine from the bladder to outside of your body. Urine is constantly flowing from the ureters into the bladder. However, the urine goes out of your body from the bladder through the urethra only when you go to the bathroom. Any remaining urine is stored in your bladder. Since urine eventually leaves the body, it is a waste product. page 6

13 The kidney is usually only thought of as producing urine. Actually, the kidney performs many other extremely important functions. 1. Controls Blood Pressure The kidneys play an important role in controlling blood pressure. When blood pressure is high, the kidneys get rid of excess salt (sodium) and water. When blood pressure is low, the kidney saves salt and water. The kidney also produces a hormone called renin. Renin affects a protein in your bloodstream, which helps raise blood pressure. 2. Helps Produce Red Blood Cells Another function of the kidneys is to control the formation of red blood cells, which are usually produced in bone marrow. The kidneys produce erythropoietin that helps to produce red blood cells by stimulating the bone marrow. 3. Helps in Absorbing Calcium The kidneys also activate vitamin D, which is produced in the skin based on what you eat in your diet and from sunlight. This vitamin is changed by the liver and by the kidneys. When changed, vitamin D helps your body absorb calcium, which is important to prevent your bones from becoming soft. The kidneys are vital organs that play many roles. When kidney failure occurs, your body s systems are disturbed, causing many changes. page 7

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15 PART 3 RENAL FAILURE & DIALYSIS page 9

16 Causes of Kidney Failure There are many causes for kidney failure: high blood pressure, diabetes, hereditary disease, drug abuse and infection. A few of the more common ones are outlined in this booklet. COMMON CAUSES OF KIDNEY FAILURE Uncontrolled High Blood Pressure Drug Abuse Infection Hereditary Polycystic Kidneys There are two main types of kidney failure: acute and chronic. Acute failure usually happens suddenly and often is reversible. In comparison, chronic renal failure develops over a longer period of time, is usually not reversible. This means the kidneys will never regain their function with chronic renal failure. Acute renal failure can happen because of a trauma (such as a wound or an injury), disease, ingestion of poison or drugs, shock, or infection. As a result of this trauma, the kidney is temporarily damaged and stops producing urine. Poisons build up in the bloodstream, which causes page 10

17 the person to become confused or unconscious, and overloaded with fluids. Often the patient is placed on a special diet, fluid restrictions and temporary dialysis. After a few weeks, the patient s kidney function usually returns to normal. Chronic renal failure usually requires dialysis treatment for the rest of a patient s life. The most common causes of chronic renal failure are: chronic glomerulonephritis, pyelonephritis, polycystic kidney disease, diabetic renal failure, and hypertensive nephrosclerosis. Chronic glomerulonephritis Glomerulonephritis, which has several causes, is an inflammation of the glomeruli-small structures in the kidneys. The inflammation interferes with how your urine is cleaned or filtered. As the disease develops, scar tissue replaces the inflamed areas and causes the blood circulation to slow down. The nephron is starved of its blood and withers. Chronic pyelonephritis Pyelonephritis is an inflammation of the kidney that affects the tubules of the nephron and eventually the glomerulus. The infection causes the kidney to lose its ability to produce urine. The cause of the infection may be from the bloodstream or the bladder. Polycystic kidney disease Cysts on the tubules is called polycystic kidney disease. The tubules don t develop properly and the cysts begin to grow. Over time, the cysts get bigger and put pressure on the tissues close to them. This pressure can affect the job of the normal nephrons. The kidneys soon stop producing enough urine to get rid of the body s waste. Diabetic renal failure Diabetic renal failure happens when diabetes causes the renal arteries to scar. This interferes with the proper filtration of urine. Hypertensive nephrosclerosis This type of renal failure happens when a patient has high blood pressure over a long period of time. This causes the blood vessels of the kidney to scar. When enough of the blood vessels are scarred, the kidneys can no longer filter enough of the body s waste. There are other causes of kidney failure and the above descriptions are by no means inclusive. For more information about your type of kidney failure, talk with your doctor. page 11

18 Problems of Kidney Failure When kidney failure begins, you may see a number of signs and symptoms. Some of these are alarming and baffling. Some of these problems are discussed here. We hope this will relieve any of your concerns and increase your understanding of your condition. As kidney failure progresses, the amount of urine you pass will probably go down. Because the kidneys no longer filter as much fluid, the extra fluid remains in your bloodstream and tissues. The increase in fluid in the bloodstream leads to high blood pressure and puts an increased workload on your heart. An increased workload on the heart can cause an irregular heart rate and congestive heart failure. After dialysis is started and the fluid is removed, your blood pressure may drop. Your doctor may be able to decrease the blood pressure medicines you take. Symptoms of congestive heart failure also improve with dialysis. Kidney failure may also affect your heart by causing pericarditis, a swelling and redness of the sac around the heart. Pericarditis can cause chest pain and weakness. Once dialysis is started, pericarditis should get better. Occasionally, dialysis patients receiving regular kidney treatments will get pericarditis. Usually increasing dialysis treats this condition. Kidney failure can also cause shortness of breath and pulmonary edema (swelling of the lungs), because of extra fluid in the bloodstream and lungs. This should go away once regular dialysis treatments are started, but it may come back if you drink too many liquids between treatments. Most kidney patients have low blood counts (anemia) due to three main reasons. 1. A decrease in a hormone that helps the body to produce red blood cells. This hormone is called erythropoietin. 2. A decrease in how long the red blood cells live. 3. Loss of blood while on dialysis. If your blood count stays low and causes you problems, your doctor may order a blood transfusion. But, transfusions are avoided, if possible, because of the following reasons. 1. Transfusions may transmit hepatitis. 2. Although it has not been proven, a high number of transfusions may interfere with a future transplant. However, they may also be beneficial to transplant patients. page 12

19 3. Transfusions may prevent your body from making blood for itself. Kidney failure also affects the stomach and G.I. tract in various ways: 1. Nausea and vomiting, 2. A decrease in appetite, 3. Weight loss, 4. Mouth and stomach ulcers. These symptoms are caused by the build-up of waste (poisons) in the blood. These symptoms improve with regular dialysis, but may occur off and on while you are on dialysis or in between your treatments. Sometimes your feet may tingle or feel numb because your nerves are damaged. This is called neuropathy (nerve damage used by kidney failure). These symptoms should get better with dialysis. When nerve damage occurs, you may feel tried, drowsy, or excited. Or you may have headaches, poor memory, confusion, seizures, or a coma. These symptoms should improve when dialysis treatments start. Itching is a common problem of dialysis patients. It usually is worse when the waste products in the blood are very high. When phosphorus is high, itching may be much worse, and the doctor will probably increase your binders. It s important to take the binders correctly because a high phosphorus level results in low calcium. When calcium is low, the bones become weak and break easily. Other minor problems caused by renal failure include muscle cramps, arthritis, and blurred vision. Psychological problems may include decreased ability to concentrate, depression, and difficulty sleeping. Other problems may also occur. If you have any questions about these or other problems, ask your doctor or nurse about them. page 13

20 Common Questions Asked About Complications 1. What if I don t feel like coming for my treatments? If you think you are too sick to come for your dialysis treatment, it may be that you need the treatment so much that you are beginning to be sick with uremia. Do not miss a treatment because you feel sick. Call your nurse or doctor, and tell them about your symptoms. They may want you to have an emergency treatment. If you must miss a treatment because of work, call your nurse as soon as possible. This way the necessary laboratory tests can be done to make sure your blood levels are still safe and another treatment time can be set up. 2. Why do kidney patients continue to have nausea and vomiting after they have been on dialysis for some time? Usually, nausea and vomiting improve after dialysis is started. However, some patients still have occasional attacks of nausea and vomiting between treatments. This happens sometimes because the kidney machine cannot keep their blood chemistries at normal levels by only working 9-12 hours a week. Many patients have nausea and vomiting while they are on dialysis because their blood pressure falls suddenly or because their blood urea nitrogen (BUN) level drops quickly. A drop in the BUN can also cause headaches. You can minimize these symptoms by following your diet closely so that the BUN is not high at the beginning of dialysis. 3. Is constipation a problem for dialysis patients? Yes. This is because vegetables and other sources of roughage are limited in the diet. Physical activity is usually reduced and binders (such as Phos-Lo, used to control your phosphate levels) can also cause constipation. If you are constipated, your doctor can prescribe a mild laxative. 4. Does blurred vision happen very often? Yes, it is quite common before your first dialysis is performed. It may also happen near the end of a dialysis treatment, especially if the level of waste products in your blood were high at the beginning of your treatment. Vision usually clears up after the first several dialysis treatments. page 14

21 5. Is it unusual to have problems falling asleep? Not at all. Many patients with kidney failure have difficulty going to sleep. If this bothers you, mention it to your doctor, who can prescribe a mild sedative. 6. What can I do for the itching? Regular dialysis. Take your binders regularly. Use skin lotions. Ask your doctor about medicines to relieve the itching. 7. Is there a reason why I might feel tired at times? Most patients with kidney failure are anemic even after they start dialysis. Being anemic means their red blood cell count is a lot lower than normal. This low blood count can make a patient feel tired. 8. Will my sex life change? Many patients on dialysis notice that their interest in and enjoyment of sex is decreased. 9. Can anything be done about this change in my sex life? In some cases, hormone treatments will improve the situation. Like all other problems, mention any difficulty you have to your nurse or doctor so that proper treatment can be started. 10. Can a woman dialysis patient have a baby? A few such cases have happened. Most women do not ovulate while they are on dialysis, so it is unlikely they can get pregnant. To be safe, we recommend that you continue to use your usual means of birth control. We recommend that female dialysis patients do not try to have children. 11. Can a male dialysis patient still father children? The sperm count is low in many male dialysis patients, and some have difficulty with impotence (inability to have intercourse). However, many male dialysis patients do father children. page 15

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23 PART 3 MEDICAL NEEDS page 17

24 Medications All kidney patients have to take some medicines. Most patients have to take vitamins and iron pills. Some patients also need medicines to meet their specific needs. Because your pills are based on what you need, take only the medicines prescribed for you by your kidney doctor. If another doctor prescribes a medicine for you, check with your kidney doctor. Never take pills that belong to your family, friends, or other patients. Kidney patients should never take overthe-counter drugs without the asking their doctor first. These medicines may contain harmful ingredients. Follow all of the directions for each medicine. Each has a special purpose to meet your special needs. Problems may occur if you don't take them as prescribed. Learn the names of all your medicines and why you are taking them. This can help you, and your doctor and nurses. You must bring ALL of your medicines to the dialysis clinic during the first week of each month. The nurse will check each medicine and review the correct dosage and schedule with you. If you have not started on dialysis at the outpatient clinic, please bring your medicines with you on your first clinic visit. The nurses will write down your medicines on your chart and make sure you are taking them correctly. Kidney patients often ask the following questions about medications. 1. How long will I need to take medications? You will have to take some of the medicines as long as you are on dialysis. All patients take certain medicines, and some patients take additional medicines to meet their specific needs. 2. What happens if I don't take the medicine? We will explain the purpose of each medicine and the effects of not taking them. In some cases, not taking your medicines can destroy your bones and cause heart failure. In other cases, you could become very anemic and weak. If you find that a certain drug bothers you in any way, do not stop it. Instead, tell your nurses and doctors. Your doctor may be able to prescribe another drug that works better for you. 3. Why must I take a binder? You must take a binder to protect your bones from becoming weak and to avoid getting calcium deposits in your heart and other vital organs. These are very serious problems. Take the binder page 18

25 with your meals, so it mixes with your food and prevents the phosphorus in the food from being absorbed. 4. Why must I take vitamins? Vitamins are limited in the renal diet for kidney patients. Many vitamins are removed during dialysis. All dialysis patients take vitamins. 5. Why must I take iron? Some blood is lost during each dialysis. Iron tablets will replace the iron lost during the treatment process. page 19

26 Medications MEDICATIONS THAT MOST PATIENTS TAKE Medicine Reason Special Instructions Controls how much Take with meals and with phosphorus is absorbed snacks (except a fruit snack). from foods. Phosphorus Binders Phos-Lo (calcium acetate) Os-Cal 500 (calcium carbonate) Tums carbonate Tums E-X carbonate Magnebind 400 Renagel 800 mg Renagel 400 mg Too much phosphorus can cause kidney-related bone disease. Do not skip dosages. Don t take iron at the same time. Iron supplements Ferrous sulfate Ferrous fummerate (various brands) Niferex-150 Nu-Iron 105 (polysaccharide-iron complexes) Vitamins Nephrocap Nephrovite (These vitamins are specially designed for patients with kidney disease). Prevents iron deficiency. Helps build blood, replaces the iron lost with blood in the dialyzer and when blood samples are drawn. Replaces the water-soluble vitamins C and B-complex that can be lost during the dialysis treatment. Take between meals. Do not take at the same time as phosphorus binders. If stomach upset occurs, you may need to change the type of iron you take. Polysaccharide-iron complexes are usually tolerated best. Take any time. page 20

27 MEDICATIONS THAT SOME PATIENTS TAKE Medicine Reason Special Instructions Possible Side Effects Blood pressure medicine Controls blood pressure when proper control of sodium and water does not bring blood pressure down. If blood pressure is low for you, do not take blood pressure medicine. Tiredness, weakness dizziness, lightheadedness. Digoxin or Lanoxin Increases the force of the heart when it contracts, increases cardiac output. Take your pulse before taking digoxin. Do not take digoxin unless your pulse rate is 60 or higher. Weakness, hypotension, nausea and vomiting, diarrhea, slow heart rate. Itching Medicines Benadryl Temaril Atarax Decreases the amount of itching. Take as prescribed. Drowsiness, dry mouth, dizziness. Stool softeners Metamucil Dulcolax Pericolace Sorbitol Prevents constipation. Take as needed, usually one every day. Diarrhea. Pain reliever Tylenol Darvon Relieves pain. Should be used only when necessary. Taking too much may result in dependence. Hormones Male hormones Nandrolone To raise hematocrit (blood count) Take as prescribed. Slightly increased risk of forming blood clots. WARNINGS DO NOT take any medicines not approved by your kidney doctor. Antibiotics are not given for colds. Some antibiotics cannot be used for people whose kidneys have failed. Over-the-counter drugs can be dangerous. Never take new medicines of any kind that are not prescribed by your kidney doctor. Never take home remedies unless approved by your doctor. DO NOT change your dosages on your own. Some medications can be habit forming. Take only as directed. When having prescriptions filled, never allow the pharmacist to substitute a drug without first talking to your physician. page 21

28 HELPFUL HINTS ABOUT MEDICATIONS Learn the name of each medicine you take, the dose you should take, and its purpose. Ask your nurses or doctors whenever you have questions about your medicines. Get all of your medicines at one drug store. The pharmacist will get to know you and your medications and help you when you need it. Carry an updated list of your medications with you at all times. This is very important in emergencies. Establish a routine. Pick specific times to take your medications. page 22

29 Your Numbers -- Lab Tests (Blood Chemistries) You will have lab work checked once a month in the dialysis clinic. This lab work is referred to as your panel. The results of the lab work are called your numbers. The nurse or dietitian will review results with you each month and explain them to you. Numbers Are done monthly. Tell if your diet is in order or if you are well dialyzed. You will be especially interested in a few of the numbers that the doctors and nurses will check closely. They might need to adjust your diet or dialysis to improve some of your lab test results. The following tests will be covered in more detail: A. Potassium B. BUN (blood urea nitrogen) C. Phosphorus D. Hemoglobin and Hematocrit POTASSIUM Potassium is a particle in your cells and bloodstream. It is important to the function of your cells, muscles, and heart. Most kidney patients have a high potassium level before dialysis because almost all foods contain potassium, and the kidneys can't get rid of the excess. Potassium can collect in your bloodstream and make your heart beat irregularly or even stop. Some foods that are high in potassium are: oranges, bananas, chocolate, and potatoes. Many high protein foods are also high in potassium and must be limited. Some foods must be totally eliminated due to their high potassium content. The dietitian will tell you more about how much potassium you can have in your diet and what foods to eat and not to eat. BUN (Blood Urea Nitrogen) BUN stands for blood urea nitrogen. Urea is the waste product that comes when your body processes protein from what you eat. How much urea is in the blood is measured by the BUN test. page 23

30 When you are off your diet, the BUN will usually be higher. If you follow your diet and dialyze the right amount of time, your BUN should stay in a satisfactory range. PHOSPHORUS Phosphorus is usually excreted by the kidneys. Due to kidney failure, phosphorus builds up in the blood and causes the calcium to drop. This leads to a breakdown of the bones. Phosphorus can be controlled with adequate dialysis and medicine (binders) that bind the phosphorus so that it will be excreted by your bowels. When your phosphorus goes up, the doctor will probably increase your binders. HEMOGLOBIN AND HEMATOCRIT Kidney patients are usually anemic, so we will keep a close check on your hemoglobin and hematocrit. These two tests measure the amount of oxygen and the number of red blood cells in your blood. If your blood count gets too low, your doctor may order a blood transfusion for you. He may want you to take iron pills or iron shots to build up your blood count. If you should need a blood transfusion, you will get it while you are on the kidney machine. There are other tests that are checked with your monthly panel. If you have questions about any of your lab work, ask your doctor or nurse. YOU WILL BE ENCOURAGED TO PARTICIPATE IN THE REVIEW OF YOUR NUMBERS. page 24

31 Blood Chemistries (This guide was put together by the staff of Good Samaritan Hospital Chronic Dialysis Center, Bay Shore, New York) Blood Chemistry Normal Values Accepted Normals For Dialysis Patients Causes of Abnormal Levels (Refers to increases in, unless otherwise noted) Glucose mg/dL mg/dL Diabetes, persistent uremia. Will be slightly higher within 1-3 hours after eating a meal. Signs and Symptoms of Abnormal Values Excessive thirst BUN 10-26mg/dL Depends on how much protein you eat. Eating too much protein-containing food. Or could indicate the need for more dialysis time, higher blood flow of a larger dialyzer. Fatigue, nausea, insomnia, dry and itching skin, taste and smell affected, urine-like body odor and breath. CO 2 Bicarb 21-30mEq/L Not less than Eating too much protein, creating a more acid blood and lowering C0 2 Sodium (Na) mEq/L mEq/L Eating too much salt, e.g., potato chips, ham, pickles. Rapid breathing, shortness of breath Thirst. Leads to drinking more fluid, causing fluid weight gain, elevated blood pressure and shortness of breath. Chloride (CL) mEq/L mEq/L Same as Sodium Same as Sodium Creatinine Below 1.2mg/dL Varies with how much muscle mass you have. Should remain about the same as at start of dialysis from treatment to treatment. Only the most muscular of patients should have values in the upper range. Inadequate dialysis time or addition of muscle Non-specific symptoms associated with inadequate dialysis. Potassium (K) meq/l Few symptoms below 7.0 in dialysis patients Eating too many foods high in potassium Extreme weakness that can lead to a heart attack (cardiac arrest). page 25

32 Blood Chemistry Normal Values Calcium (Ca) mg/dl Accepted Normals For Dialysis Patients Should be near upper range if normal to prevent overactive parathyroid glands. Causes of Abnormal Levels (Refers to increases in, unless otherwise noted) Low calcium: eating too much high phosphorus food. Not taking phosphate binders. Calcium will go down if phosphorus goes up. Signs and Symptoms of Abnormal Values Low: Muscle twitching and cramping, seizures, varying degrees of depression, hair loss, cataracts and conjunctivitis. High calcium: Medications such as Rocaltrol may cause sharp increase. Check blood regularly. Parathyroid gland removal may be indicated. High: Muscle weakness, fatigue, constipation, abdominal cramps, nausea, vomiting, loss of appetite, coma. Phosphorus (Phosphate) (PO 4 ) Calciumphosphate product (Ca XPO 4 ) Magnesium (mg) Hematocrit (Hct) Enzymes mgldl High: Not taking phosphate binders, eating highphosphorus foods, e.g., milk, cheese, organ meats, beans. Low: Taking too much phosphate binder. Multiply calcium and phosphorus blood values should not exceed mg/dl mg/dl Elevations due to taking phosphate binders containing magnesium or other medications such as milk of magnesia or citrate of magnesium % [% of total blood volume made up by red cells] Check normal for your lab. Will be lower varies with patient Check with your doctor. Decreased production of red blood cells, blood loss during or after dialysis, shortened survival of red cells. Check with your doctor. High: Causes elevated parathyroid hormone by lowering calcium. High and low: Breaking of bones without specific injury (spontaneous fractures), continuous bone pain especially hips, knees and ankles, heels. High: calcification of blood vessels including coronary arteries. Decreased mental function ranging from drowsiness to, in severe cases, coma. Decreased tendon reflex leading to paralysis. Nausea and vomiting, hypotension due to dilation of blood vessels. Fatigue, shortness of breath, chest pain on exertion (if underlying heart disease is present). Check with your doctor. page 26

33 Blood Chemistry Normal Values Accepted Normal For Dialysis Patients Causes of Abnormal Levels (Refers to increases in, unless otherwise noted) SGOT U/mL U/mL Hepatitis Some medicines SGPT 7-33 U/mL 7-33 U/mL Hepatitis Some medicines Signs and Symptoms of Abnormal Values None, or nausea, vomiting, abdominal cramping, fatigue if severe liver damage. None, or nausea, vomiting, abdominal cramping, fatigue if severe liver damage. Alkaline Phosphatase IU/L IU/L Comes from bone or liver From bone: A marker for how bad parathyroid-caused bone disease might be. From liver: Marker for diseases involving the liver or gall bladder. Painful joints, weakened bones that could lead to severe pain and or deterioration requiring surgery (hyperparathyroidism). Parathyroid Hormone (PTH) Check normals for your lab Long-term imbalances of calcium and phosphorus. Same as evaluated phosphorous. A brief explanation of other tests that are drawn monthly or quarterly. Blood Normal Values Reason For Test Chemistry Australian Negative Test for serum hepatitis (Hepatitis B) Antigen Hepatitis Antibody Negative Antibody test to determine if you have ever had hepatitis. Past episodes of hepatitis would give a positive result. If you have ever had a vaccine for hepatitis B, then you could also have a positive result. Total Protein 6-8 gm/dl Observed for abnormally low levels due to intake of protein foods. Albumin Above 4 Measure of nutritional adequacy. gm/dl Red Blood Cells (RBCs) 4-6 millionlmm3 Test for anemia due to decreased RBC production when there is little or no kidney function. Ferritin ng/ml A measure of stored iron. Total Bilirubin mg/dl Elevated level indicates liver damage, e.g., hepatitis, or obstruction of bile ducts. page 27

34 The Renal Diet Managing your diet is an important part of the overall treatment of kidney disease. A special diet is usually prescribed for renal patients to reduce the production of wastes (and the effects) on your body. You will be on a special diet as long as you are on dialysis. When the wrong foods or too much of the right foods are eaten, waste products can build up in the blood and cause nausea, vomiting, itching, and weakness. Headaches, shortness of breath, or swelling of the legs may occur also. These may be present some of the time in all patients. Many occur most of the time in patients who do not follow their dietary and fluid restrictions. The kidney machine cannot do as much work in three to four hours, two to three times a week, as your kidneys did working 24-hours a day. You must reduce how hard the artificial kidney must work by following a diet restricted in protein, sodium, potassium, and certain other nutrients. The dietitian will carefully explain your diet to you. Following it is essential to your care because the diet helps reduce production of wastes in the body. Specific waste products that accumulate in the blood include excessive amounts of nitrogen (BUN), phosphorus, sodium, potassium and fluids. Monthly lab values show which waste products may be high in the blood and indicate how well you are following your diet. Although there are some similarities among patients diets, each diet is set up specifically for you. Your diet is made for your particular needs and the type of dialysis you are receiving. You may have different diet restrictions or allowances from other patients. You must be responsible for controlling your own diet. A dietitian will help you with what you should eat, how you can prepare meals on the special diet, and will explain how blood chemistries are affected by sticking to your diet. However, it is up to you to actually eat the correct amount and types of foods. No one can do this but you. page 28

35 HELPFUL HINTS TO STAY ON YOUR DIET Learn about kidney disease so that the importance of the diet is clear. Talk with your dietitian. It is easier to follow a diet if you understand it. It is your responsibility to ask questions about your diet. Get your family or close friends involved in learning about your diet. They can help and support you if you need it. You should be honest about food that you like or dislike. Your dietitian can help with recipes and can adjust your diet so it includes food that you like. Learn what foods to avoid, the proper amounts of foods you can eat, and how to measure food portions. You should not adjust or change your diet without first talking with your dietitian. Don t compare your diets with other patients. Your size, weight, and diagnosis determine which foods your can eat and how much you can eat. Below is a list of questions that may help you. Remember: Talk with your dietitian if you have any questions. 1. How much will I be able to drink on my diet? If you have no urine output, you will be able to consume only 500-1,000 cc of fluid a day. If your kidneys still produce urine, you can drink 500cc plus the amount your kidneys produce. The doctor and dietitian will discuss your fluid intake with you. 2. I have been told to limit how much fluid I drink. How can I avoid being thirsty? Excess salt is the main cause of thirst. You can limit how thirsty you are by limiting how much salt you eat. Patients who do not eat too much salt (sodium) are not thirsty, even if they are only allowed to drink 500-1,000 cc of fluid a day. Sweets also may make you thirsty if you are a diabetic. 3. I just can t eat food without salt. What can I do? Patients say that it takes two to three months to get used to eating food without salt. After that, food with salt tastes strange to them, just as salt-free food did at first. There are many page 29

36 other spices that you can use to add flavor to food. Talk with your dietitian about spices that might be good to use. 4. What is high-quality protein? High-quality protein is protein of animal origin. It is called high quality because it has a higher percentage of the components that are necessary to build strong muscles and other tissue. High-quality protein produces fewer waste products than does low quality protein, which is derived from vegetables sources such as beans, corn, and peas. page 30

37 Hepatitis Hepatitis is a big danger to all dialysis and transplant patients, and for those who are in close contact with them, such as family members and staff who work in the dialysis unit. We do not want to cause excessive concern about this, but we want to see that you are fully informed about the dangers of hepatitis and about the measures that you can take to prevent spreading it. Hepatitis is a virus infection of the liver. In most cases, it causes an acute illness that gradually clears up in two to three weeks or a month or two. In some cases more often in dialysis patients hepatitis can lead to a chronic infection that can seriously damage the liver. It is important that you try to prevent the spread of hepatitis. The form of hepatitis most commonly seen in dialysis units is called serum hepatitis because it was once believed that it could only be spread by the transfer of blood or blood products from one person to another (for example, by blood transfusions). Now we know that this form of hepatitis can be spread by other means but it occurs less easily than by contact with the blood. To identify patients and/or staff who have been infected with hepatitis, we do a blood test each month known as the Australian antigen test. The Australian antigen is a factor that can be found in the blood of patients who have had serum hepatitis. A positive test for this factor does not mean that the patient has a serious case of hepatitis, but it does mean that he or she has been infected with the virus at some time and could possibly spread the infection to someone else. Once an individual has had hepatitis, he or she cannot be infected with the same type of hepatitis again, but may carry the virus and possibly can transmit it to others several years after the initial infection. Most kidney patients who develop hepatitis have mild cases. The most common symptom is being more tired than usual. Other symptoms are: skin rash; pain in the hands or joints; yellow color of the whites of the eyes or skin; dark yellow urine (almost brown) or light colored stools; loss of appetite; and nausea, vomiting or diarrhea. To protect patients as well as staff, the following safeguards against contracting hepatitis will be followed at the clinic. 1. Contact with the blood of potentially infected patients should be avoided. Because the test for Australian antigen is not 100 % perfect, we regard all blood as being potentially infected with the hepatitis virus. Our personnel wear disposable gloves when working page 31

38 with dialysis patients. This reduces the chance that blood will enter a small cut on their hands or fingers, or be spread to other patients. 2. Use care when you handle used needles. This means discarding them in proper containers and seeing that no one is carelessly stabbed with a used needle. 3. Avoid blood transfusions unless they are very necessary. Blood Assurance tests every unit of blood for Australian antigen, but this testing is not 100 % perfect. Transfusions should be kept to a minimum. 4. Use care when cleaning up or getting rid of vomit, urine, stool and other secretions from all patients, particularly those who are known to have a positive Australian antigen test. 5. Patients who are known to be positive for Australian antigen will be isolated from those who are negative. They will dialyze on a special machine set aside for only positive patients. We hope that all patients and visitors will understand the need for regulations that help increase safety of all patients, visitors, and staff. Please understand that staff members are exposed to hepatitis every working day, and that some rules are necessary to see that they, as well as the patients, are protected from an accidental hepatitis infection. For this reason, patients should follow the policies given to them. You also can take the following precautions at home to protect yourself and your family from becoming Australian antigen positive. 1. Wash dishes and eating utensils thoroughly with hot water and plenty of soap. 2. Wash pans or sheets contaminated by blood, vomit, or diarrhea, etc., thoroughly in hot water and with plenty of soap before using them again. 3. Do not share razors, clippers, and personal articles used by a person who is positive for hepatitis. 4. Practicing personal cleanliness will decrease the chances of spreading hepatitis. 5. If you are positive for hepatitis, tell others who may come in contact with your blood (e.g., dentists, barbers). A positive Australian antigen is no cause for alarm. If you have a positive antigen, or if you have questions about hepatitis, talk to the nurses and your doctor. They will explain more about how important this problem is and the meaning of the tests that are done. page 32

39 Hepatitis Vaccine There is a vaccine that can help prevent you from getting hepatitis. Your doctor may order this vaccine for you. The vaccine makes your body produce antibodies that kill the hepatitis virus. The vaccine is a total of four injections at different times; one shot at the beginning, one shot after one month, another after two months, and another shot six months from the first. After all the shots are completed, your blood will be checked to see if you have the antibodies. The medicine does not produce antibodies in everyone and if you are a kidney patient, you have a greater chance of not developing antibodies. If you do not develop antibodies, your doctor will order another series of shots for you. If you have more questions about this medicine or if you want to get it, talk with your doctor or nurse. page 33

40 Vascular Access To start you on dialysis, you need a vascular access to your blood. This is a way of getting your blood from your body, through the artificial kidney, and back into your body. You need to have special surgery to create an access. Your doctor will determine the type of access that is best for you. The most common accesses are listed below. A-V Fistula Gortex Graft Dialysis Catheter Each type of access has advantages and disadvantages. One will probably suit your needs better than the others. You may hear doctors and nurses refer to arteries and veins. Arteries are blood vessels that carry blood from your heart to all parts of your body. Veins are blood vessels that carry blood back to your heart. Veins are usually closer to the skin than arteries are. During dialysis, you will hear the nurses using the words arterial and venous. An arterial needle in a fistula or graft leads the blood away from the heart just as an artery does. A venous needle takes blood toward the heart, as does a vein. A-V FISTULA A fistula is a direct surgical connection between an artery and a vein that allows blood to flow directly from the artery into the vein. Because of this fast flow of blood, the vein gradually gets larger and becomes stronger and tougher. This allows the nurses to easily insert large needles to remove blood from your body, pass it through the artificial kidney and return it to your body. An ordinary vein would not be strong enough for this, since it would not provide the amount of flow needed for efficient dialysis. A fistula is created by first numbing your skin with a local anesthetic (similar to what the dentist uses). The surgeon makes a small cut (usually about one inch long) over the artery and the vein at the wrist. The surgeon then attaches the vein to the side of the artery and closes the incision. Nothing is actually placed in your arm except the stitches that hold the vein to the side of the artery. page 34

41 GORTEX GRAFT The Gortex graft is a man-made graft like plastic. The graft can be placed under the skin as a substitute for your own blood vessels. The graft is connected to an artery at one end and to a vein at the other, so that blood flows constantly from the artery into a vein. After the area has healed, needles can be placed in the graft just like in a normal fistula. One advantage of a graft is that it may be used soon after dialysis. The graft can be used after a day or two, but we prefer to let it heal for at least two weeks. DIALYSIS CATHETER When you first start on dialysis you may need to have a catheter placed. This is a temporary access that involves putting a small catheter below your collarbone into the large blood vessel going to your heart. The catheter is stitched in place and stays there until your permanent access is ready to use. After the nurses start using your graft or fistula, the catheter can be removed. Sometimes, these catheters may still clot or kink, or get infected, and it may be necessary to replace the catheter. page 35

42 Common Questions About Vascular Access 1. After the access is created, what will happen to the rest of my hand? The rest of your hand has plenty of blood supply from other arteries, so nothing will happen to it. Some patients get numb over the thumb. This usually goes away in two to three weeks. 2. Can I use that arm? After the incision heals--usually in 7-10 days--you can use the arm freely. You can do anything with your fistula arm that you could do before the surgery. We suggest that you exercise your fistula arm often. 3. What happens if I cut my arm? If you should cut the fistula vein or the graft, it will bleed more than a normal vein. Putting pressure over the cut will control this bleeding. 4. When can the fistula be used? It can be used after five or six weeks. The vein can sometimes be used within a week, but we prefer letting it develop for a longer period. 5. When can a graft be used? Usually after two to four weeks. 6. What can I do to help the fistula vein develop more rapidly? After the incision heals, you will be given a rubber tourniquet. The vein will develop faster if you put the tourniquet on for three to four minutes several times a day. While the tourniquet is on exercise the arm by squeezing a rubber ball or by lifting a moderately heavy weight. 7. How is the access used? One needle is placed in the vein to remove blood from your body, and a second needle is used to return the blood to your body. The arterial needle takes blood away from your heart. The venous needle returns blood toward your heart. page 36