Hemodialysis

What is hemodialysis and how does it work?

Hemodialysis is a treatment for kidney failure that uses a machine to filter your blood outside
your body. At the start of a hemodialysis treatment, a dialysis nurse or technician places two
needles into your arm. Once trained by the health care team, some people prefer to insert, or
put in, their own needles. A pump on the hemodialysis machine draws your blood through
one of the needles into a tube, a few ounces at a time. Your blood travels through the tube to
the filter, called a dialyzer. Inside the dialyzer, your blood flows through thin fibers that filter
out

wastes

extra salt

extra fluid

After the dialyzer filters your blood, a different tube carries your blood back to your body
through the second needle.

Hemodialysis

Hemodialysis can replace part of your kidney function. Hemodialysis is not a cure for kidney
failure; however, it can help you feel better and live longer.

You also may need to make changes to your diet, medicines, and liquid intake. Changes to
your diet and liquid intake and the number of medicines you need will all depend on the
amount of kidney function you have left and whether you receive treatments three times a
week or more often.

Equipment and Supplies

Hemodialysis requires several pieces of equipment and many supplies for each treatment. The
hemodialysis machine, dialyzer, dialysis solution, and needles are four of the most important
parts in hemodialysis treatments:

Hemodialysis machine. The hemodialysis machine at a dialysis center is about the

size of a microwave. Machines for home hemodialysis are small enough to sit on an
end table. The hemodialysis machine has three main jobs:

o pump blood and regulate blood flow through the dialyzer

o monitor blood pressure

 o control the rate of fluid removal from your body

Blood is removed from the body through one needle and propelled by a blood pump,
which is, essentially like a rolling pin on the outside of the tube. The blood passes
through the dialyzer and then is returned to the body through the other needle. Along
the way, there are blood pressure monitors and detectors to ensure the procedure is
safe. The blood, while it does pass outside of the body, remains inside the tubes or in
the dialyzer and does not actually go into the hemodialysis machine.

Dialyzer. The dialyzer is the artificial kidney. Blood enters at the top of the
dialyzer, in this case, and is forced into multiple, very thin, hollow fibers made of a
semi-permeable membrane. Each fiber is about the size of a human hair. As blood
passes through the hollow fibers, dialysis solution passes in the opposite direction on
the outside of the fibers. In the less than one second it takes for the blood to pass from
the top of the dialyzer to the bottom, waste products diffuse out of the blood and into
the dialysis solution.

Inside the dialyzer, your blood

flows through thin fibers that filter out wastes and extra salt and water.

Dialysis Solution. Also known as dialysate, dialysis solution contains water and
added substances that allow the safe removal of wastes and extra salt and fluid from
your blood during dialysis. Your doctor will prescribe a specific dialysis solution for
your treatments. If you have problems such as low blood pressure or muscle cramps
during your treatments, your doctor can prescribe a solution with a different balance
of chemicals. Your doctor might also adjust your solution if your blood tests show that
your blood has too much or too little of certain minerals, such as potassium or
calcium.

Needles. You, a nurse, or a technician will insert two needles into a vein, usually in
the arm, at the start of each hemodialysis treatment. One needle draws blood that goes
to the dialyzer, and the other needle returns the filtered blood to your body. When you
 first start hemodialysis treatments, the needle insertions may be one of the most
uncomfortable parts of the treatment. Most people get used to them after a few
treatments. If you find the needle insertions painful, you can put a numbing cream or
spray on your skin so you wont feel the needles.

Many people who have their treatments at a dialysis center have their needles inserted
by a nurse or technician; however, you may prefer to insert your own needles. Youll
need training on inserting needles properly to prevent infection and keep your vein
healthy. With a little practice, you can become good at inserting needles. Whether you
insert your own needles or have it done by a nurse or technician, you should learn
how to care for the area where the needles are inserted to prevent infection.

What is a vascular access?

A vascular access is an artificial connection between an artery and a vein where blood is
diverted toward the vein. The resulting high blood flow through the vein causes the vein to
expand and thicken. A vascular access lets high volumes of blood flow continuously during
hemodialysis treatments to filter the greatest possible amounts of blood per treatment. A
vascular access may be

long lastingmore durable

temporaryused for a short time

A long-lasting vascular access takes weeks to months to mature, or grow stronger, after the
procedure to create the access. Ideally, a working access is in place before your first
hemodialysis treatment. You should work closely with your nephrologista doctor who
specializes in kidney problemsand vascular surgeona surgeon who works with blood
vesselsto make sure the access is in place in plenty of time.

The veins in your arm are your lifeline, and it is important to protect them prior to starting
dialysis. If an arm vein is damaged by an IV line or by repeated blood draws, it may not be
suitable for the surgery described below. If you are approaching dialysis, remind health care
providers to draw blood and insert IV lines only in veins below your wrist.

Long-lasting Vascular Access

An arteriovenous (AV) fistula and an AV graft are the two types of long-lasting vascular
accesses.

AV fistula. A vascular surgeon creates an AV fistula by connecting an artery directly

to a vein. An artery is a blood vessel that carries blood from the heart to the rest of the
body. A vein is a blood vessel that carries blood from the body back to the heart. The
vascular surgeon usually places an AV fistula in a persons forearm or upper arm. An
AV fistula causes the vein to expand and thicken, providing easy, reliable access to
blood vessels. Doctors often recommend the AV fistula over the other types of access
because it

o provides adequate blood flow for dialysis

 o lasts a long time

o has a lower complication rate than other types of access

You may need to stay overnight in the hospital, or you may be able to go home after
the procedure. You will get local anesthesia to numb the area where the vascular
surgeon creates the AV fistula. Depending on your situation, you may get general
anesthesia, in which you are not awake during your procedure.

AV fistula in the forearm

AV graft. If your vascular surgeon cannot create an AV fistula because of problems

with your veins, you may need an AV graft instead. An AV graft is a connection from
an artery to a vein using a synthetic, or man-made, tube that is usually bent or looped.
You may need to stay overnight in the hospital, or you may be able to go home after
the procedure. You will get local anesthesia to numb the area where the vascular
surgeon creates the AV fistula. Depending on your situation, you may get general
anesthesia during your procedure.

You can use an AV graft soon after it is inserted. An AV graft is more likely to have
problems with infection and blood clots. The repeated formation of blood clots can
block the flow of blood through the AV graft and make it hard or impossible to do the
hemodialysis treatment.
 AV graft in the forearm

Temporary Vascular Access

If your kidney disease has progressed quickly, you may not have time to get a long-lasting
vascular access before starting hemodialysis. In this case, you may require a venous catheter
a small, soft tube inserted into a vein in your neck, chest, or leg near the groinas a
temporary access. A nephrologist or an interventional radiologista doctor who uses medical
imaging equipment to perform operationsperforms the placement of the venous catheter in
a hospital or an outpatient clinic. You will receive local anesthesia and sedation to keep you
calm and relaxed during your procedure.

The catheter splits in two after the tube exits your body. The two tubes have caps designed to
connect to the arterial line, which carries your blood to the dialyzer, and the venous line,
which carries blood from the dialyzer back to your body. Clamps on the tubes can be closed if
one of the lines is disconnected.

Although not encouraged, some people use a venous catheter for long-term access. When a
person needs a venous catheter for more than 3 weeks, the vascular surgeon will tunnel the
catheter under the skin, rather than insert it directly into the vein. A person will be more
comfortable and have fewer complications with a tunneled catheter than with a nontunneled
catheter.
 Venous catheter

More information is provided in the NIDDK health topic, Vascular Access for Hemodialysis.

Where can I do hemodialysis?

You can do hemodialysis at a dialysis center or at home. Each location has its pros and cons.

Hemodialysis at a Dialysis Center

Most people in the United States on hemodialysis have their treatments at a dialysis center. At
the dialysis center, nurses and patient care technicians do most of the tasks, such as setting up
the machine and inserting the needles. You will have a team of health care workers to help
you with various needs. In addition to the nurses and patient care technicians, your health
care team will include

your doctor

a dietitian

a social worker

If you choose treatments in a dialysis center, you will have a fixed time slot, usually three
times per week: Monday, Wednesday, and Friday or Tuesday, Thursday, and Saturday. If you
work or have children to care for, you will need to consider that when choosing a dialysis
schedule. Some dialysis centers offer nighttime treatments. This treatment occurs over a
longer period while you sleep 3 nights a week at the center. Getting longer overnight dialysis
treatments means
 fewer diet changes

a more normal liquid allowancehow much liquid you can drink

your days are free

Your doctor, nurse, or social worker can help you find a dialysis center that is convenient for
you. You have the right to choose the dialysis center where you will receive treatment. Your
doctor will give your medical information to the dialysis center you choose.

Most large cities have more than one dialysis center to choose from. You can visit the centers
to see which one best fits your needs. For example, you can ask about their rules for laptop
and cell phone use as well as for having visitors.

You may want the center to be close to your home to reduce your travel time. If you live in a
rural area, the closest dialysis center may be far from your home and require a lot of travel
time. If you would have a hard time getting to the dialysis center, you may want to consider
home dialysis treatments, such as home hemodialysis or peritoneal dialysis.

More information is provided in the NIDDK health topic, Peritoneal Dialysis.

To help you choose a dialysis center, the Dialysis Facility Compare website , gives quality
ratings for all U.S. dialysis centers. The website is maintained by Medicare, the Federal
Government health insurance agency that pays most of the costs of hemodialysis and the
other treatments for kidney failure. If you have supplemental insurance, your health plan may
also have a list of centers you can use.

Home Hemodialysis

If you choose to do your hemodialysis treatments at home, you will still need to choose a
dialysis center so you can learn how to perform the treatments and take care of the
equipment. You will get your hemodialysis machine from the dialysis center. You will also go
back to the center once a month for tests that will show how well your hemodialysis
treatments are working.

Home hemodialysis lets you do longer or more frequent dialysis, which comes closer to
replacing the work healthy kidneys do. Home hemodialysis lets you choose a schedule that
fits the way you live. You can do daily home hemodialysis 5 to 7 days per week for 2 to 3
hours at a time, and you set the schedule. You can do nightly home hemodialysis three to six
times per week while you sleep. Your doctor will determine how many treatments you need
each week for daily home hemodialysis or for nightly home hemodialysis.

Daily home hemodialysis or nightly home hemodialysis will let you have a more normal diet
and liquid allowance. You will also have fewer blood pressure medicines to take than you
would with a standard schedule in a dialysis center.

For home hemodialysis, you must first learn how to perform treatments at the dialysis center,
working with a dialysis nurse. You must learn how to
 insert your own needles

monitor your vital signs

set up and clean the hemodialysis machine

If these procedures are not done correctly, you could have serious problems.

Most dialysis centers require that you have a trained partner in your home during
hemodialysis treatments, so you must ask a family member or friend to go through training
with you. In addition to providing training and a hemodialysis machine that stays in your
home, the dialysis center also provides 24-hour support if you have a question or problem.
Some programs also monitor treatments over the Internet. Training often takes 3 to 8 weeks.

More information is provided in the NIDDK health topic, Home Hemodialysis.

Home hemodialysis

Dialysis Center and Home Hemodialysis Comparison

Chart
Use the following chart to help you choose between hemodialysis in a dialysis center and
home hemodialysis.

Dialysis Center and Home Hemodialysis Comparison Chart

Dialysis Center Home
Three treatments a week for 3 to
Flexible. Three to seven short or long
5 hours or more. Monday,
Schedule treatments per week at times that work
Wednesday, Friday or Tuesday,
best for you.
Thursday, Saturday.
Availability Available in most communities; Becoming more widely available as
 Dialysis Center and Home Hemodialysis Comparison Chart
Dialysis Center Home
may require travel in some rural
smaller equipment is developed
areas
The machine and 2 to 4 weeks worth of
The clinic has the machine and supplies are in the home. You may need
Machine/Supplies
supplies. minor changes to hook the machine to
electricity and water in your home.
The clinic teaches about
You and a partner must attend 3 to 8
Training treatments, diet, liquids,
weeks of home hemodialysis training.
medicines, lab tests, etc.
Strict limits on liquids,
Fewer limits on liquids or diet, based on
Diet and Liquids phosphorus, sodium, and
the amount of hemodialysis and lab tests
potassium
Less freedom on treatment days. You set the treatment schedule, fitting in
Level of Freedom May feel washed out and tired all prescribed treatments. Work and
for hours after each treatment. travel are much easier.
You and your partner must set up, run,
Center staff do hemodialysis
and clean the machine; check vital signs;
Amount of Work tasks. They can teach you to do
track the treatments and send in forms;
some tasks.
and order supplies.
Medicare covers three hemodialysis
Medicare and most other health
treatments a week and may cover more
Payment plans cover three hemodialysis
for medical reasons; other health plans
treatments a week.
may cover all hemodialysis treatments.

What problems could I have with hemodialysis?

You could have problems with your vascular access, which is the most common reason for
hospitalization for people on hemodialysis. Any type of vascular access may

become infected

have poor blood flow or blockage from a blood clot

These problems can keep your treatments from working. You may need to have more
procedures to replace or repair your access for it to work properly.

Rapid changes in your bodys water and chemical balance during treatment can cause other
problems as well. Muscle cramps and sudden hypotension a drop in blood pressureare
two common side effects. Hypotension can make you feel weak, dizzy, or sick to your
stomach. Your doctor can make changes to your dialysis solution prescription, which can treat
these problems.

You may need a few months to adjust to hemodialysis. You should always report problems to
your doctor and dialysis staff so they can treat your side effects quickly and easily. You can
prevent many side effects if you follow a proper diet, limit your salt and liquid intake, and
follow your doctors instructions for taking your medicines.
More information about problems that can occur with kidney failure is provided in the
NIDDK health topic, Kidney Failure: What to Expect.

What changes will I have to make when I start

hemodialysis?
One of the biggest changes you will have to make when you start hemodialysis treatments is
following a strict schedule. Also, adjusting to the effects of kidney failure and the time you
spend on dialysis can be hard. You may feel tired after treatments. You may need to make
changes in your work or home life, giving up some activities and responsibilities. Keeping
the same schedule you had when your kidneys worked can be hard now that your kidneys
have failed. Accepting these changes can be hard on you and your family. A mental health
counselor or social worker can answer your questions and help you cope .

How will I know my hemodialysis treatments are

working?
You will know your hemodialysis treatments are working by how you feel. Most people with
kidney failure feel better after starting dialysis treatments. Your appetite usually improves and
your energy levels increase. Hemodialysis reduces salt and fluid buildup, so you should have
less shortness of breath and swelling as well.

The key to making the most of your hemodialysis treatment is to keep to your ideal dry
weight. Your ideal dry weight is your weight when you do not have extra fluid in your body.
If you are careful about the salt in your diet and the hemodialysis is working, over time, you
should be able to reach your ideal dry weight at the end of every hemodialysis treatment.
When hemodialysis treatments are working and you keep to your ideal dry weight, your
blood pressure should be well-controlled.

In addition, blood tests can show how well your hemodialysis treatments are working. Once a
month, whether you are on home or dialysis center hemodialysis, your dialysis nurse will test
your blood using one of two types of lab tests:

Kt/V is a score given as a number. Experts recommend a minimum Kt/V of 1.2. A

single score below 1.2 should not worry you; however, your average Kt/V should
exceed 1.2.

urea reduction ratio (URR) is a score given as a percentage. Experts recommend a

minimum URR of 65 percent. A single score below 65 percent should not be of great
concern; however, your average URR should exceed 65 percent.

Both tests look at changes in one specific waste product, called blood urea nitrogen (BUN),
to gauge the overall level of waste products in your system. Your BUN is measured before
and after a dialysis treatment to see how much of it has been removed.

More information about these tests is provided in the NIDDK health topic, Hemodialysis
Dose and Adequacy.
What financial help is available to pay for hemodialysis?
U.S. citizens who have kidney failure are eligible to receive Medicare. Treatment for kidney
failure costs a lot; however, Medicare pays much of the cost, usually up to 80 percent. Often,
supplemental insurance pays the rest. For people who are not eligible for Medicare or who
still need help with the portion that Medicare does not cover, states have Medicaid programs
that provide funds for health care based on financial need. Your social worker can work with
you to locate resources for financial help.

More information is provided in the NIDDK health topic, Paying for Kidney Failure
Treatment.

Eating, Diet, and Nutrition

Eating the right foods can help you feel better when you are on hemodialysis. Talk with your
dialysis centers dietitian to find a hemodialysis meal plan that works for you. Your dietary
needs will depend on your treatment and other factors, such as your weight and activity level.
Staying healthy with kidney disease requires watching how much of the following are
included in your diet:

Protein is in many foods you eat. Protein is in foods from animals and plants. In
general, most diets include both animal and plant proteins. Protein provides the
building blocks that maintain and repair muscles, organs, and other parts of your
body. Most people on hemodialysis are encouraged to eat high-quality protein because
it maintains a healthy body. High-quality protein comes from meat, fish, and eggs.
However, many high-protein foods also contain phosphorus, which can weaken your
bones. Talk with your dietitian about ways to get the protein you need without getting
too much phosphorus.

Read more in the National Kidney Disease Education Program (NKDEP) fact sheet
Protein: Tips for People with Chronic Kidney Disease.

Phosphorus is a mineral that keeps your bones healthy and your blood vessels and
muscles working. Phosphorus is found naturally in foods rich in protein, and it is also
added to many processed foods. However, phosphorus can weaken your bones and
make your skin itch if you have too much. Hemodialysis may not remove enough
phosphorus, so you will probably need to limit or avoid high-phosphorus foods
especially those with phosphorus added to improve flavor or keep them from going
bad, such as lunch meats. You may also need to limit milk and cheese, dried beans,
peas, colas, nuts, and peanut butter. In addition, you may need to take a pill with
meals called a phosphate binder that keeps phosphorus in your food from entering
your bloodstream.

Read more in the NKDEP fact sheet Phosphorus: Tips for People with Chronic
Kidney Disease.

Fluid includes water and drinks such as fruit juice and milk; and water in foods such
as fruits, vegetables, ice cream, gelatin, soup, and ice pops. You need water for your
body to function properly; however, too much can cause swelling and make your
 heart work harder. Over time, too much fluid in your body can cause high blood
pressure and congestive heart failure. Fluid builds up in your body between
hemodialysis treatments, resulting in swelling in your ankles and hands. Limiting the
amount of liquid you have can help you prevent these problems. You can tell that you
have too much fluid in your body if your body weight goes too far above your dry
weight.

Sodium is a part of salt. Sodium is found in many canned, packaged, frozen, and fast
foods. Sodium is also found in many condiments, seasonings, and meats. Too much
sodium makes you thirsty, which makes you drink more liquid. Try to eat fresh foods
that are naturally lower in sodium, and look for products labeled low sodium,
especially in canned and frozen foods. Pay attention to the amount of sodium in
milligrams (mg) listed on the nutrition facts label of food products.

Read more in the NKDEP fact sheet Sodium: Tips for People with Chronic Kidney
Disease.

Potassium is a mineral that helps your nerves and muscles work the right way. People
with kidney failure who do not make enough urine can have a buildup of potassium in
their blood. Hemodialysis balances the potassium level in your blood by removing
extra potassium from your blood. Potassium levels that are too high or too low can
cause heart problems and, if severe enough, can lead to sudden death due to an
abnormal heartbeat. You can prevent your potassium level from going too high
between hemodialysis treatments by avoiding high-potassium foods, including
bananas, oranges, potatoes, and tomatoes.

Read more in the NKDEP fact sheet Potassium: Tips for People with Chronic Kidney
Disease.

Calories are units of energy. Calories in food give you the energy you need. Many
people on hemodialysis do not have a good appetite and do not get enough calories. If
you find it hard to eat, talk with your dialysis centers dietitian to find healthy ways to
add calories to your diet.

Supplements help provide some of the vitamins and minerals that may be missing
from your diet because you have to avoid many foods. Hemodialysis also removes
some vitamins from your body. Your doctor may prescribe a vitamin and mineral
supplement designed specifically for people with kidney failure. Never take vitamin
and mineral supplements that you can buy over the counter. They may be harmful to
you. Talk with your doctor before taking any medicines, including vitamin and
mineral supplements that are not prescribed for you.

You may have a hard time with changing your diet at first. However, eating the right foods
will help you feel better. You will have more strength and energy. More information is
provided in the NIDDK health topic, Eat Right to Feel Right on Hemodialysis.

Points to Remember
 Hemodialysis is a treatment for kidney failure that uses a machine to filter your blood
outside your body.

Hemodialysis is not a cure for kidney failure; however, it can help you feel better and
live longer.

Hemodialysis can replace part of your kidney function. You also may need to make
changes to your diet, medicines, and liquid intake.

A vascular access is an artificial connection between an artery and a vein where some
of the blood is diverted toward the vein. The resulting high blood flow through the
vein causes the vein to expand and thicken. A vascular access lets high volumes of
blood flow continuously during hemodialysis treatments to filter the greatest possible
amounts of blood per treatment.

A long-lasting vascular access takes weeks to months to mature, or grow stronger,

after the procedure to create the access. Ideally, a working durable access is in place
before your first hemodialysis treatment. You should work closely with your
nephrologista doctor who specializes in kidney problemsand vascular surgeon
a surgeon who works with blood vesselsto make sure the access is in place in
plenty of time.

Doctors often recommend the arteriovenous (AV) fistula over the other types of
access.

If you are approaching dialysis, remind heath care providers to draw blood and insert
IV lines only in veins below your wrist.

If you choose treatments in a dialysis center, you will have a fixed time slot, usually
three times per week: Monday, Wednesday, and Friday or Tuesday, Thursday, and
Saturday.

If you would have a hard time getting to the dialysis center, you may want to consider
home dialysis treatments such as home hemodialysis or peritoneal dialysis.

Home hemodialysis lets you do longer or more frequent dialysis, which comes closer
to replacing the work healthy kidneys do.

Blood tests can show how well your hemodialysis treatments are working.

Treatment for kidney failure costs a lot; however, Medicare pays much of the cost,
usually up to 80 percent. Often, supplemental insurance pays the rest. Your social
worker can work with you to locate resources for financial help.

Eating the right foods can help you feel better when you are on hemodialysis.

Clinical Trials
The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and other
components of the National Institutes of Health (NIH) conduct and support research into
many diseases and conditions.

What are clinical trials, and are they right for you?

Clinical trials are part of clinical research and at the heart of all medical advances. Clinical
trials look at new ways to prevent, detect, or treat disease. Researchers also use clinical trials
to look at other aspects of care, such as improving the quality of life for people with chronic
illnesses. Find out if clinical trials are right for you .