DIALYSIS

In medicine, dialysis (from Greek "dialusis", meaning dissolution, "dia", meaning

through, and "lysis", meaning loosening) is primarily used to provide an artificial
replacement for lost kidney function in people with renal failure. Dialysis may be used for
those with an acute disturbance in kidney function (acute kidney injury, previously acute
renal failure) or for those with progressive but chronically worsening kidney functiona state
known as chronic kidney disease stage 5 (previously chronic renal failure or end-stage
kidney disease). The latter form may develop over months or years, but in contrast to acute
kidney injury is not usually reversible, and dialysis is regarded as a "holding measure" until
a renal transplant can be performed, or sometimes as the only supportive measure in those
for whom a transplant would be inappropriate.

The kidneys have important roles in maintaining health. When healthy, the kidneys
maintain the body's internal equilibrium of water and minerals (sodium, potassium, chloride,
calcium, phosphorus, magnesium, sulfate). Those acidic metabolism end products that the
body cannot get rid of via respiration are also excreted through the kidneys. The kidneys
also function as a part of the endocrine system producing erythropoietin and calcitriol.
Erythropoietin is involved in the production of red blood cells and calcitriol plays a role in
bone formation. Dialysis is an imperfect treatment to replace kidney function because it
does not correct the endocrine functions of the kidney. Dialysis treatments replace some of
these functions through diffusion (waste removal) and ultrafiltration (fluid removal).

HISTORY

Dr. Willem Kolff, a Dutch physician, constructed the first working dialyzer in 1943
during the Nazi occupation of the Netherlands. Due to the scarcity of available resources,
Kolff had to improvise and build the initial machine using sausage skins, drinks cans,
a washing machine and various other items which were available at the time. Over the
following two years, Kolff used his machine to treat 16 patients who suffered from acute
kidney failure, but the results were unsuccessful. Then, in 1945, a 67-year-old woman
in uremic coma regained consciousness following 11 hours of hemodialysis with the dialyzer,
and lived for another seven years before dying of an unrelated condition. She was the first-
ever patient successfully treated with dialysis.

PRINCIPLE

Dialysis works on the principles of the diffusion of solutes and ultrafiltration of fluid
across a semi-permeable membrane. Diffusion describes a property of substances in water.
Substances in water tend to move from an area of high concentration to an area of low
concentration. Blood flows by one side of a semi-permeable membrane, and a dialysate, or
special dialysis fluid, flows by the opposite side. A semipermeable membrane is a thin layer
of material that contains various sized holes, or pores. Smaller solutes and fluid pass
through the membrane, but the membrane blocks the passage of larger substances (for
example, red blood cells, large proteins).

The two main types of dialysis, Hemodialysis and Peritoneal dialysis, remove wastes
and excess water from the blood in different ways.[1] Hemodialysis removes wastes and
water by circulating blood outside the body through an external filter, called a dialyzer, that
contains a semipermeable membrane. The blood flows in one direction and
the dialysate flows in the opposite. The counter-current flow of the blood and dialysate
maximizes the concentration gradient of solutes between the blood and dialysate, which
helps to remove more urea andcreatinine from the blood. The concentrations of solutes (for
example potassium, phosphorus, and urea) are undesirably high in the blood, but low or
absent in the dialysis solution and constant replacement of the dialysate ensures that the
concentration of undesired solutes is kept low on this side of the membrane. The dialysis
solution has levels of minerals like potassium and calcium that are similar to their natural
concentration in healthy blood. For another solute, bicarbonate, dialysis solution level is set
at a slightly higher level than in normal blood, to encourage diffusion of bicarbonate into the
blood, to act as a pH buffer to neutralize the metabolic acidosis that is often present in these
patients. The levels of the components of dialysate are typically prescribed by a
nephrologist according to the needs of the individual patient.

In peritoneal dialysis, wastes and water are removed from the blood inside the body
using the peritoneal membrane of the peritoneum as a natural semipermeable membrane.
Wastes and excess water move from the blood, across the peritoneal membrane, and into a
special dialysis solution, called dialysate, in the abdominal cavity which has a composition
similar to the fluid portion of blood.

TYPES

There are two primary types of dialysis and another two types in addition, they are
namely hemodialysis , peritoneal dialysis, and thirdly investigational type and
finally intestinal dialysis.

Hemodialysis

In hemodialysis, the patient's blood is then pumped through the blood compartment
of a dialyzer, exposing it to a partially permeable membrane. The dialyzer is composed of
thousands of tiny synthetic hollow fibers. The fiber wall acts as the semipermeable
membrane. Blood flows through the fibers, dialysis solution flows around the outside the
fibers, and water and wastes move between these two solutions.[6] The cleansed blood is
then returned via the circuit back to the body. Ultrafiltration occurs by increasing the
hydrostatic pressure across the dialyzer membrane. This usually is done by applying a
negative pressure to the dialysate compartment of the dialyzer. This pressure gradient
causes water and dissolved solutes to move from blood to dialysate, and allows the removal
of several litres of excess fluid during a typical 3 to 5 hour treatment. In the US,
hemodialysis treatments are typically given in a dialysis center three times per week (due in
the US to Medicare reimbursement rules); however, as of 2007 over 2,500 people in the US
are dialyzing at home more frequently for various treatment lengths. Studies have
demonstrated the clinical benefits of dialyzing 5 to 7 times a week, for 6 to 8 hours. This
type of hemodialysis is usually called "nocturnal daily hemodialysis", which a study has
shown a significant improve in both small and large molecular weight clearance and
decrease the requirement of taking phosphate binders. These frequent long treatments are
often done at home while sleeping, but home dialysis is a flexible modality and schedules
can be changed day to day, week to week. In general, studies have shown that both
increased treatment length and frequency are clinically beneficial.

Peritoneal dialysis

In peritoneal dialysis, a sterile solution containing glucose is run through a tube into
the peritoneal cavity, the abdominal body cavity around the intestine, where the peritoneal
membrane acts as a semipermeable membrane.The peritoneal membrane or peritoneum is
a layer of tissue containing blood vessels that lines and surrounds the peritoneal, or
abdominal, cavity and the internal abdominal organs (stomach, spleen, liver, and
intestines). The dialysate is left there for a period of time to absorb waste products, and
then it is drained out through the tube and discarded. This cycle or "exchange" is normally
repeated 4-5 times during the day, (sometimes more often overnight with an automated
system). Each time the dialysate fills and empties from the abdomen is called one exchange.
A dwell time means that the time of dialysate stay in patient's abdominal cavity - wastes,
chemicals and extra fluid move from patient's blood to the dialysate across the peritoneum.
A drain process is the process after the dwell time, the dialysate full with waste products and
extra fluid is drained out of patient's blood. Ultrafiltration occurs via osmosis; the dialysis
solution used contains a high concentration of glucose, and the resulting osmotic pressure
causes fluid to move from the blood into the dialysate. As a result, more fluid is drained than
was instilled. Peritoneal dialysis is less efficient than hemodialysis, but because it is carried
out for a longer period of time the net effect in terms of removal of waste products and of
salt and water are similar to hemodialysis. Peritoneal dialysis is carried out at home by the
patient. Although support is helpful, it is not essential. It does free patients from the routine
of having to go to a dialysis clinic on a fixed schedule multiple times per week, and it can be
done while travelling with a minimum of specialized equipment.
Hemofiltration

Hemofiltration is a similar treatment to hemodialysis, but it makes use of a different

principle. The blood is pumped through a dialyzer or "hemofilter" as in dialysis, but no
dialysate is used. A pressure gradient is applied; as a result, water moves across the very
permeable membrane rapidly, "dragging" along with it many dissolved substances,
importantly ones with large molecular weights, which are cleared less well by hemodialysis.
Salts and water lost from the blood during this process are replaced with a "substitution
fluid" that is infused into the extracorporeal circuit during the treatment. Hemodiafiltration is
a term used to describe several methods of combining hemodialysis and hemofiltration in
one process.

Intestinal dialysis

In intestinal dialysis, the diet is supplemented with soluble fibres such as acacia fibre,
which is digested by bacteria in the colon. This bacterial growth increases the amount of
nitrogen that is eliminated in fecal waste. An alternative approach utilizes the ingestion of 1
to 1.5 liters of non-absorbable solutions of polyethylene glycol or mannitol every fourth hour.

STARTING INDICATIONS

The decision to initiate dialysis or hemofiltration in patients with renal failure depends on
several factors. These can be divided into acute or chronic indications.

Indications for dialysis in the patient with acute kidney injury are:
1. Metabolic acidosis in situations where correction with sodium bicarbonate is
impractical or may result in fluid overload.
2. Electrolyte abnormality, such as severe hyperkalemia, especially when
combined with AKI.
3. Intoxication, that is, acute poisoning with a dialysable drug, such as lithium, or
aspirin.
4. Fluid overload not expected to respond to treatment with diuretics.
5. Complications of uremia, such as pericarditis, encephalopathy,
or gastrointestinal bleeding.
Chronic indications for dialysis:
1. Symptomatic renal failure
2. Low glomerular filtration rate (GFR) (RRT often recommended to commence at
a GFR of less than 10-15 mls/min/1.73m2). In diabetics dialysis is started earlier.
3. Difficulty in medically controlling fluid overload, serum potassium, and/or
serum phosphorus when the GFR is very low
 HEMODIALYSIS

In medicine, hemodialysis (also haemodialysis) is a method for removing waste

products such as creatinine and urea, as well as free water from the blood when
the kidneys are in renal failure. Hemodialysis is one of three renal replacement
therapies (the other two being renal transplant; peritoneal dialysis).

Hemodialysis can be an outpatient or inpatient therapy. Routine hemodialysis is

conducted in a dialysis outpatient facility, either a purpose built room in a hospital or a
dedicated, stand alone clinic. Less frequently hemodialysis is done at home. Dialysis
treatments in a clinic are initiated and managed by specialized staff made up of nurses and
technicians; dialysis treatments at home can be self initiated and managed or done jointly
with the assistance of a trained helper who is usually a family member.

PRINCIPLE

The principle of hemodialysis is the same as other methods of dialysis; it

involves diffusion of solutes across a semipermeable membrane. Hemodialysis
utilizes counter current flow, where the dialysate is flowing in the opposite direction to blood
flow in the extracorporeal circuit. Counter-current flow maintains the concentration gradient
across the membrane at a maximum and increases the efficiency of the dialysis.

Fluid removal (ultrafiltration) is achieved by altering the hydrostatic pressure of the

dialysate compartment, causing free water and some dissolved solutes to move across the
membrane along a created pressure gradient.

The dialysis solution that is used is a sterilized solution of mineral ions. Urea and
other waste products, potassium, and phosphatediffuse into the dialysis solution. However,
concentrations of sodium and chloride are similar to those of normal plasma to prevent
loss.Sodium bicarbonate is added in a higher concentration than plasma to correct blood
acidity. A small amount of glucose is also commonly used.
Note that this is a different process to the related technique of hemofiltration.

PRESCRIPTION

A prescription for dialysis by a nephrologist (a medical kidney specialist) will specify

various parameters for a dialysis treatment. These include frequency (how many treatments
per week), length of each treatment, and the blood and dialysis solution flow rates, as well
as the size of the dialyzer. The composition of the dialysis solution is also sometimes
adjusted in terms of its sodium and potassium and bicarbonate levels. In general, the larger
the body size of an individual, the more dialysis he/she will need. In the North
America and UK, 3-4 hour treatments (sometimes up to 5 hours for larger patients) given 3
times a week are typical. Twice-a-week sessions are limited to patients who have a
substantial residual kidney function. Four sessions per week are often prescribed for larger
patients, as well as patients who have trouble with fluid overload. Finally, there is growing
interest in short daily home hemodialysis, which is 1.5 - 4 hr sessions given 5-7 times per
week, usually at home. There also is interest in nocturnal dialysis, which involves dialyzing a
patient, usually at home, for 810 hours per night, 3-6 nights per week. Nocturnal in-center
dialysis, 3-4 times per week is also offered at a handful of dialysis units in the United States.
SIDE EFFECTS AND COMPLICATIONS

Hemodialysis often involves fluid removal (through ultrafiltration), because most

patients with renal failure pass little or no urine. Side effects caused by removing too much
fluid and/or removing fluid too rapidly include low blood pressure, fatigue, chest pains, leg-
cramps, nausea and headaches. These symptoms can occur during the treatment and can
persist post treatment; they are sometimes collectively referred to as the dialysis hangover
or dialysis washout. The severity of these symptoms is usually proportionate to the amount
and speed of fluid removal. However, the impact of a given amount or rate of fluid removal
can vary greatly from person to person and day to day. These side effects can be avoided
and/or their severity lessened by limiting fluid intake between treatments or increasing the
dose of dialysis e.g. dialyzing more often or longer per treatment than the standard three
times a week, 34 hours per treatment schedule.

Since hemodialysis requires access to the circulatory system, patients undergoing

hemodialysis may expose their circulatory system to microbes, which can lead to sepsis, an
infection affecting the heart valves (endocarditis) or an infection affecting the bones
(osteomyelitis). The risk of infection varies depending on the type of access used (see
below). Bleeding may also occur, again the risk varies depending on the type of access used.
Infections can be minimized by strictly adhering to infection control best practices.
Heparin is the most commonly used anticoagulant in hemodialysis, as it is generally well
tolerated and can be quickly reversed with protamine sulfate. Heparin allergy can
infrequently be a problem and can cause a low platelet count. In such patients, alternative
anticoagulants can be used. In patients at high risk of bleeding, dialysis can be done without
anticoagulation.

First Use Syndrome is a rare but severe anaphylactic reaction to the artificial kidney.
Its symptoms include sneezing, wheezing, shortness of breath, back pain, chest pain, or
sudden death. It can be caused by residual sterilant in the artificial kidney or the material of
the membrane itself. In recent years, the incidence of First Use Syndrome has decreased,
due to an increased use of gamma irradiation, steam sterilization, or electron-beam
radiation instead of chemical sterilants, and the development of new semipermeable
membranes of higherbiocompatibility. New methods of processing previously acceptable
components of dialysis must always been considered. For example, in 2008, a series of first-
use type or reactions, including deaths occurred due to heparin contaminated during the
manufacturing process with oversulfated chondroitin sulfate.

Longterm complications of hemodialysis include amyloidosis, neuropathy and various

forms of heart disease. Increasing the frequency and length of treatments have been shown
to improve fluid overload and enlargement of the heart that is commonly seen in such
patients.

ACCESS

In hemodialysis, three primary methods are used to gain access to the blood: an
intravenous catheter, an arteriovenous (AV) fistula and a synthetic graft. The type of access
is influenced by factors such as the expected time course of a patient's renal failure and the
condition of his or her vasculature. Patients may have multiple accesses, usually because an
AV fistula or graft is maturing and a catheter is still being used. The creation of all these
three major types of vascular accesses requires surgery.

Catheter
 Catheter access, sometimes called a CVC (Central Venous Catheter), consists of a
plastic catheter with two lumens (or occasionally two separate catheters) which is inserted
into a large vein (usually the vena cava, via the internal jugular vein or the femoral vein) to
allow large flows of blood to be withdrawn from one lumen, to enter the dialysis circuit, and
to be returned via the other lumen. However, blood flow is almost always less than that of a
well functioning fistula or graft.

Catheters are usually found in two general varieties, tunnelled and non-tunnelled.

Non-tunnelled catheter access is for short-term access (up to about 10 days, but
often for one dialysis session only), and the catheter emerges from the skin at the site of
entry into the vein.

Tunnelled catheter access involves a longer catheter, which is tunnelled under the
skin from the point of insertion in the vein to an exit site some distance away. It is usually
placed in the internal jugular vein in the neck and the exit site is usually on the chest wall.
The tunnel acts as a barrier to invading microbes, and as such, tunnelled catheters are
designed for short- to medium-term access (weeks to months only), because infection is still
a frequent problem.

Aside from infection, venous stenosis is another serious problem with catheter
access. The catheter is a foreign body in the vein and often provokes an inflammatory
reaction in the vein wall. This results in scarring and narrowing of the vein, often to the point
of occlusion. This can cause problems with severe venous congestion in the area drained by
the vein and may also render the vein, and the veins drained by it, useless for creating a
fistula or graft at a later date. Patients on long-term hemodialysis can literally 'run out' of
access, so this can be a fatal problem.

Catheter access is usually used for rapid access for immediate dialysis, for tunnelled
access in patients who are deemed likely to recover from acute renal failure, and for
patients withend-stage renal failure who are either waiting for alternative access to mature
or who are unable to have alternative access.
Catheter access is often popular with patients, because attachment to the dialysis machine
doesn't require needles. However, the serious risks of catheter access noted above mean
that such access should be contemplated only as a long-term solution in the most desperate
access situation.

AV fistula

A radiocephalic fistula.

AV (arteriovenous) fistulas are recognized as the preferred access method. To create

a fistula, a vascular surgeon joins an artery and a veintogether through anastomosis. Since
this bypasses the capillaries, blood flows rapidly through the fistula. One can feel this by
placing one's finger over a mature fistula. This is called feeling for "thrill" and produces a
distinct 'buzzing' feeling over the fistula. One can also listen through astethoscope for the
sound of the blood "whooshing" through the fistula, a sound called bruit.

Fistulas are usually created in the nondominant arm and may be situated on the
hand (the 'snuffbox' fistula'), the forearm (usually aradiocephalic fistula, or so-called
Brescia-Cimino fistula, in which the radial artery is anastomosed to the cephalic vein), or the
elbow (usually a brachiocephalic fistula, where the brachial artery is anastomosed to
the cephalic vein). A fistula will take a number of weeks to mature, on average perhaps 46
weeks. During treatment, two needles are inserted into the fistula, one to draw blood and
one to return it.
 The advantages of the AV fistula use are lower infection rates, because no foreign
material is involved in their formation, higher blood flow rates (which translates to more
effective dialysis), and a lower incidence of thrombosis. The complications are few, but if a
fistula has a very high blood flow and the vasculature that supplies the rest of the limb is
poor, a steal syndrome can occur, where blood entering the limb is drawn into the fistula
and returned to the general circulation without entering the limb's capillaries. This results in
cold extremities of that limb, cramping pains, and, if severe, tissue damage. One long-term
complication of an AV fistula can be the development of an aneurysm, a bulging in the wall
of the vein where it is weakened by the repeated insertion of needles over time. To a large
extent the risk of developing an aneurysm can be reduced by careful needling technique.
Aneurysms may necessitate corrective surgery and may shorten the useful life of a fistula.
To prevent damage to the fistula and aneurysm or pseudoaneurysm formation, it is
recommended that the needle be inserted at different points in a rotating fashion. Another
approach is to cannulate the fistula with a blunted needle, in exactly the same place. This is
called a 'buttonhole' approach. Often two or three buttonhole places are available on a given
fistula. This also can prolong fistula life and help prevent damage to the fistula.

AV graft

AV (arteriovenous) grafts are much like fistulas in most respects, except that an
artificial vessel is used to join the artery and vein. The graft usually is made of a synthetic
material, often PTFE, but sometimes chemically treated, sterilized veins from animals are
used. Grafts are inserted when the patient's native vasculature does not permit a fistula.
They mature faster than fistulas, and may be ready for use several weeks after formation
(some newer grafts may be used even sooner). However, AV grafts are at high risk to
develop narrowing, especially in the vein just downstream from where the graft has been
sewn to the vein. Narrowing often leads to clotting or thrombosis. As foreign material, they
are at greater risk for becoming infected. More options for sites to place a graft are
available, because the graft can be made quite long. Thus a graft can be placed in the thigh
or even the neck (the 'necklace graft').

TYPES

There are three types of hemodialysis: conventional hemodialysis, daily hemodialysis, and
nocturnal hemodialysis.

Conventional hemodialysis

The procedure of conventional hemodialysis are: patients attached to a dialysis

machine; the function of a dialysis machine is to push blood to circulate through the
patients body and machine, at the same time, monitor temperature, blood pressure and
time of the procedure; if patient is using fistula or graft, two huge-gate needles on patients
side: one brings wastes- full blood from patients body to the dialyzer, while another needle
carries clean blood back to the body; it is offered three times a week and 3 or 4 hours per
session. Patients are required to follow their rigid schedule.

Daily hemodialysis

The procedure of daily hemodialysis is similar to the conventional hemodialysis

except it is performed six days a week and about 2 hours per session.
Nocturnal hemodialysis

The procedure of nocturnal hemodialysis is similar to conventional hemodialysis

except it is performed six nights a week and six-ten hours per session while the patient
sleeps.[15]

ADVANTAGES AND DISADVANTAGES

Advantages

Low mortality rate

Better control of blood pressure and abdominal cramps
Less diet restriction
Better solute clearance effect for the daily hemodialysis: better tolerance and fewer
complications with more frequent dialysis

Disadvantages

Restricts independence, as people undergoing this procedure cannot travel around

because of supplies availability
Requires reliable technology such as high water quality and electricity
Requires more supplies like dialysis machines
The procedure is complicated and requires that care givers have more knowledge
Requires time to set up and clean dialysis machines, and expense with machines and
associated staff[17]

EQUIPMENT

The hemodialysis machine pumps the patient's blood and the dialysate through the
dialyzer. The newest dialysis machines on the market are highly computerized and
continuously monitor an array of safety-critical parameters, including blood and dialysate
flow rates; dialysis solution conductivity, temperature, and pH; and analysis of the dialysate
for evidence of blood leakage or presence of air. Any reading that is out of normal range
triggers an audible alarm to alert the patient-care technician who is monitoring the patient.
Manufacturers of dialysis machines include companies such as Fresenius, Gambro, Baxter,
B. Braun, NxStage and Bellco.

Water system

An extensive water purification system is absolutely critical for hemodialysis. Since

dialysis patients are exposed to vast quantities of water, which is mixed with dialysate
concentrate to form the dialysate, even trace mineral contaminants or
bacterial endotoxins can filter into the patient's blood. Because the damaged kidneys cannot
perform their intended function of removing impurities, ions introduced into the bloodstream
via water can build up to hazardous levels, causing numerous symptoms or death.
Aluminum, chloramine, fluoride, copper, and zinc, as well as bacterial fragments and
endotoxins, have all caused problems in this regard.

For this reason, water used in hemodialysis is carefully purified before use. Initially it
is filtered and temperature-adjusted and its pH is corrected by adding an acid or base. Then
it is softened. Next the water is run through a tank containing activated charcoal
to adsorb organic contaminants. Primary purification is then done by forcing water through a
membrane with very tiny pores, a so-called reverse osmosis membrane. This lets the water
pass, but holds back even very small solutes such as electrolytes. Final removal of leftover
electrolytes is done by passing the water through a tank with ion-exchange resins, which
remove any leftover anions or cations and replace them with hydroxyl and hydrogen
molecules, respectively, leaving ultrapure water.
Even this degree of water purification may be insufficient. The trend lately is to pass this
final purified water (after mixing with dialysate concentrate) through a dialyzer membrane.
This provides another layer of protection by removing impurities, especially those of
bacterial origin, that may have accumulated in the water after its passage through the
original water purification system.

Once purified water is mixed with dialysate concentrate, its conductivity increases,
since water that contains charged ions conducts electricity. During dialysis, the conductivity
of dialysis solution is continuously monitored to ensure that the water and dialysate
concentrate are being mixed in the proper proportions. Both excessively concentrated
dialysis solution and excessively dilute solution can cause severe clinical problems.

Dialyzer

The dialyzer is the piece of equipment that actually filters the blood. Almost all
dialyzers in use today are of the hollow-fiber variety. A cylindrical bundle of hollow fibers,
whose walls are composed of semi-permeable membrane, is anchored at each end into
potting compound (a sort of glue). This assembly is then put into a clear plastic cylindrical
shell with four openings. One opening or blood port at each end of the cylinder
communicates with each end of the bundle of hollow fibers. This forms the "blood
compartment" of the dialyzer. Two other ports are cut into the side of the cylinder. These
communicate with the space around the hollow fibers, the "dialysate compartment." Blood is
pumped via the blood ports through this bundle of very thin capillary-like tubes, and the
dialysate is pumped through the space surrounding the fibers. Pressure gradients are
applied when necessary to move fluid from the blood to the dialysate compartment.

Membrane and flux

Dialyzer membranes come with different pore sizes. Those with smaller pore size are
called "low-flux" and those with larger pore sizes are called "high-flux." Some larger
molecules, such as beta-2-microglobulin, are not removed at all with low-flux dialyzers;
lately, the trend has been to use high-flux dialyzers. However, such dialyzers require newer
dialysis machines and high-quality dialysis solution to control the rate of fluid removal
properly and to prevent backflow of dialysis solution impurities into the patient through the
membrane.

Dialyzer membranes used to be made primarily of cellulose (derived from cotton

linter). The surface of such membranes was not very biocompatible, because exposed
hydroxyl groups would activate complement in the blood passing by the membrane.
Therefore, the basic, "unsubstituted" cellulose membrane was modified. One change was to
cover these hydroxyl groups with acetate groups (cellulose acetate); another was to mix in
some compounds that would inhibit complement activation at the membrane surface
(modified cellulose). The original "unsubstituted cellulose" membranes are no longer in wide
use, whereas cellulose acetate and modified cellulose dialyzers are still used. Cellulosic
membranes can be made in either low-flux or high-flux configuration, depending on their
pore size.

Another group of membranes is made from synthetic materials, using polymers such
as polyarylethersulfone, polyamide, polyvinylpyrrolidone, polycarbonate, and
polyacrylonitrile. These synthetic membranes activate complement to a lesser degree than
unsubstituted cellulose membranes. Synthetic membranes can be made in either low- or
high-flux configuration, but most are high-flux.
Nanotechnology is being used in some of the most recent high-flux membranes to create a
uniform pore size. The goal of high-flux membranes is to pass relatively large molecules
such as beta-2-microglobulin (MW 11,600 daltons), but not to pass albumin (MW ~66,400
daltons). Every membrane has pores in a range of sizes. As pore size increases, some high-
flux dialyzers begin to let albumin pass out of the blood into the dialysate. This is thought to
be undesirable, although one school of thought holds that removing some albumin may be
beneficial in terms of removing protein-bound uremic toxins.

Membrane flux and outcome

Whether using a high-flux dialyzer improves patient outcomes is somewhat controversial,
but several important studies have suggested that it has clinical benefits. The NIH-funded
HEMO trial compared survival and hospitalizations in patients randomized to dialysis with
either low-flux or high-flux membranes. Although the primary outcome (all-cause mortality)
did not reach statistical significance in the group randomized to use high-flux membranes,
several secondary outcomes were better in the high-flux group [18][19]. A recent Cochrane
analysis concluded that benefit of membrane choice on outcomes has not yet been
demonstrated [20]. A collaborative randomized trial from Europe, the MPO (Membrane
Permeabilities Outcomes) study, [21] comparing mortality in patients just starting dialysis
using either high-flux or low-flux membranes, found a nonsignificant trend to improved
survival in those using high-flux membranes, and a survival benefit in patients with lower
serum albumin levels or in diabetics.

Membrane flux and beta-2-microglobulin amyloidosis

High-flux dialysis membranes and/or intermittent on-line hemodiafiltration (IHDF) may also
be beneficial in reducing complications of beta-2-microglobulin accumulation. Because beta-
2-microglobulin is a large molecule, with a molecular weight of about 11,600 daltons, it does
not pass at all through low-flux dialysis membranes. Beta-2-M is removed with high-flux
dialysis, but is removed even more efficiently with IHDF. After several years (usually at least
5-7), patients on hemodialysis begin to develop complications from beta-2-M accumulation,
including carpal tunnel syndrome, bone cysts, and deposits of this amyloid in joints and
other tissues. Beta-2-M amyloidosis can cause very serious complications, including a
spondylarthropathy, and often is associated with shoulder joint problems. Observational
studies from Europe and Japan have suggested that using high-flux membranes in dialysis
mode, or IHDF, reduces beta-2-M complications in comparison to regular dialysis using a
low-flux membrane.

Dialyzer size and efficiency

Dialyzers come in many different sizes. A larger dialyzer with a larger membrane area (A)
will usually remove more solutes than a smaller dialyzer, especially at high blood flow rates.
This also depends on the membrane permeability coefficient K0 for the solute in question.
So dialyzer efficiency is usually expressed as the K0A - the product of permeability
coefficient and area. Most dialyzers have membrane surface areas of 0.8 to 2.2 square
meters, and values of K0A ranging from about 500 to 1500 mL/min. K0A, expressed in
mL/min, can be thought of as the maximum clearance of a dialyzer at very high blood and
dialysate flow rates.

Reuse of dialyzers
The dialyzer may either be discarded after each treatment or be reused. Reuse requires an
extensive procedure of high-level disinfection. Reused dialyzers are not shared between
patients. There was an initial controversy about whether reusing dialyzers worsened patient
outcomes. The consensus today is that reuse of dialyzers, done carefully and properly,
produces similar outcomes to single use of dialyzers.
NURSING CARE FOR HEMODIALYSIS PATIENT

Hemodialysis Vascular Access: Assess the fistula/graft and arm before, after each
dialysis or every shift: the access flow, complications Assess the complication of central
venous catheter: the tip placement, exit site, complications document and notify appropriate
health care provider regarding any concerns. educates the patient with appropriate cleaning
of fistula/graft and exit site; with recognizing and reporting signs and symptoms of infection
and complication.

Hemodialysis adequacy: Assesses patient constantly for signs and symptoms of

inadequate dialysis. Assesses possible causes of inadequate dialysis. Educations patients
the importance of receiving adequate dialysis.

Hemodialysis treatment and complications: Performs head to toe physical assessment

before, during and after hemodialysis regarding complications and accesss security.
Confirm and deliver dialysis prescription after review most update lab results. Address any
concerns of the patient and educate patient when recognizing the learning gap.

Medication management and infection control practice: Collaborate with the patient
to develop a medication regimen. Follow infection control guidelines as per unit protocol.

PERITONEAL DIALYSIS

Peritoneal dialysis (PD) is a treatment for patients with severe chronic kidney
failure. The process uses the patient's peritoneum in the abdomen as a membrane across
which fluids and dissolved substances (electrolytes, urea, glucose, albumin and other small
molecules) are exchanged from the blood. Fluid is introduced through a permanent tube in
the abdomen and flushed out either every night while the patient sleeps (automatic
peritoneal dialysis) or via regular exchanges throughout the day (continuous ambulatory
peritoneal dialysis). PD is used as an alternative to hemodialysis though it is far less
common. It has comparable risks and expenses, with the primary advantage being the
ability to undertake treatment without visiting a medical facility. The primary complication
with PD is a risk of infection due to the presence of a permanent tube in the abdomen.

BEST PRACTICES

Best practices for peritoneal dialysis state that before peritoneal dialysis should be
implemented, the patient's understanding of the process and support systems should be
assessed, with education on how to care for the catheter and to address any gaps in
understanding that may exist. The patient should receive ongoing monitoring to ensure
adequate dialysis, and be regularly assessed for complications. Finally, the patient should be
educated on the importance of infection control and an appropriate medical regimen
established with their cooperation.

METHOD

The abdomen is cleaned in preparation for surgery, and a catheter is surgically

inserted with one end in the abdomen and the other protruding from the skin. Before each
infusion the area must be cleaned, and flow into and out of the abdomen tested. A large
volume of fluid is introduced to the abdomen over the next ten to fifteen minutes.[2] The
total volume is referred to as a dwell[3] while the fluid itself is referred to as dialysate. The
dwell can be as much as 2.5 litres, and medication can also be added to the fluid
immediately before infusion.[2] The dwell remains in the abdomen and waste products
diffuse across the peritoneum from the underlying blood vessels. After a variable period of
time depending on the treatment (usually 4-6 hours[2]), the fluid is removed and replaced
with fresh fluid. This can occur automatically while the patient is sleeping (automated
peritoneal dialysis, APD), or during the day by keeping two litres of fluid in the abdomen at
all times, exchanging the fluids four to six times per day (continuous ambulatory peritoneal
dialysis, CAPD).
The fluid used typically contains sodium, chloride, lactate or bicarbonate and a high
percentage of glucose to ensure hyperosmolarity. The amount of dialysis that occurs
depends on the volume of the dwell, the regularity of the exchange and the concentration of
the fluid. APD cycles between 3 and 10 dwells per night, while CAPD involves four dwells per
day of 2-2.5 litres per dwell, with each remaining in the abdomen for 4-8 hours. The viscera
accounts for roughly four-fifths of the total surface area of the membrane, but the parietal
peritoneum is the more important of the two portions for PD. Two complementary models
explain dialysis across the membrane the three pore model (in which molecules are
exchanged across membranes which filter molecules, either proteins, electrolytes or water,
based on the size of the pore) and the distributed model (which emphasizes the role
of capillaries and the solution's ability to increase the number of active capillaries involved
in PD). The high concentration of glucose drives the exchange of fluid from the blood with
glucose from the peritoneum. The solute flows from the peritoneal cavity to the organs, and
thence into the lymphatic system. Individuals differ in the amount of fluid absorbed through
the lymphatic vessels, though it is not understood why. The ability to exchange fluids
between the peritoneum and blood supply can be classified as high, low or intermediate.
High transporters tend to diffuse substances well (easily exchanging small molecules
between blood and the dialysis fluid, with somewhat improved results frequent, short-
duration dwells such as with APD) while low transporters filter fluids better (transporting
fluids across the membrane into the blood more quickly with somewhat better results with
long-term, high-volume dwells such) though in practice either type of transporter can
generally be managed through the appropriate use of either APD or CAPD.

Though there are several different shapes and sizes of catheters that can be used,
different insertion sites, number of cuffs in the catheter and immobilization, there is no
evidence to show any advantages in terms of morbidity, mortality or number of infections,
though the quality of information is not yet sufficient to allow for firm conclusions.

COMPLICATIONS

The volume of dialysate removed and weight of the patient are normally monitored;
if more than 500ml of fluid are retained or a litre of fluid is lost across three consecutive
treatments, the patient's physician is generally notified. Excessive loss of fluid can result
in hypovolemic shock or hypotension while excessive fluid retention can result
in hypertension and edema. Also monitored is the color of the fluid removed: normally it is
pink-tinged for the initial four cycles and clear or pale yellow afterwards. The presence of
pink or bloody effluent suggests bleeding inside the abdomen while feces indicate
a perforated bowel and cloudy fluid suggests infection. The patient may also experience
pain or discomfort if the dialysate is too acidic, too cold or introduced too quickly, while
diffuse pain with cloudy discharge may indicate an infection. Severe pain in
the rectum or perineum can be the result of an improperly placed catheter. The dwell can
also increase pressure on the diaphragm causing impaired breathing, and constipation can
interfere with the ability of fluid to flow through the catheter.

A potentially fatal complication estimated to occur in roughly 2.5% of patients is is

encapsulating peritoneal sclerosis, in which the bowels become obstructed due to the
growth of a thick layer of fibrin within the peritoneum.
RISK AND BENEFITS

PD is less efficient at removing wastes from the body than hemodialysis, and the
presence of the tube presents a risk of peritonitis due to the potential to introduce bacteria
to the abdomen;[3] peritonitis is best treated through the direct infusion of antibiotics into
the peritoneum with no advantage for other frequently used treatments such as routine
peritoneal lavage or use of urokinase. The tube site can also become infected; the use
of prophylactic nasal mupirocin can reduce the number of tube site infections, but does not
help with peritonitis. Infections can be as frequent as once every 15 months (0.8 episodes
per patient year). Compared to hemodialysis, PD allows greater patient mobility, produces
fewer swings in symptoms due to its continuous nature, and phosphate compounds are
better removed, but large amounts of albumin are removed which requires constant
monitoring of nutritional status. The costs and benefits of hemodialysis and PD are roughly
the same - PD equipment is cheaper but the costs associated with peritonitis are higher.
There is insufficient research to adequately compare the risks and benefits between CAPD
and APD; a Cochrane Review of three small clinical trials found no difference in clinically
important outcomes (i.e. morbidity or mortality) for patients with end stage renal disease,
nor was there any advantage in preserving the functionality of the kidneys. The results
suggested APD may have psychosocial advantages for younger patients and those who are
employed or pursuing an education.

Other complications include hypotension (due to excess fluid exchange and sodium
removal), low back pain and hernia or leaking fluid due to high pressure within the
abdomen. PD may also be used for patients with cardiac instability as it does not result in
rapid and significant alterations to body fluids, and for patients with insulin-
dependent diabetes mellitus due to the inability to control blood sugar levels through the
catheter. Hypertriglyceridemia and obesity are also concerns due to the large volume of
glucose in the fluid, which can add as many as 1200 calories to the diet per day. Of the
three types of connection and fluid exchange systems (standard, twin-bag and y-set; the
latter two involving two bags and only one connection to the catheter, the y-set uses a
single y-shaped connection between the bags involving emptying, flushing out then filling
the peritoneum through the same connection) the twin-bag and y-set systems were found
superior to conventional systems at preventing peritonitis.

RENAL FAILURE

Renal failure or kidney failure (formerly called renal insufficiency or chronic

renal insufficiency) describes a medical condition in which the kidneys fail to adequately
filter toxins and waste products from the blood. The two forms are acute (acute kidney
injury) and chronic (chronic kidney disease); a number of other diseases or health problems
may cause either form of renal failure to occur.
Biochemically, renal failure is typically detected by an elevated serum creatinine level. In
the science of physiology, renal failure is described as a decrease in the glomerular filtration
rate. Problems frequently encountered in kidney malfunction include abnormal fluid levels in
the body, deranged acid levels, abnormal levels
of potassium, calcium, phosphate, hematuria (blood in the urine) and (in the longer
term)anemia. Long-term kidney problems have significant repercussions on other diseases,
such as cardiovascular disease.

CLASSIFICATION
 Renal failure can be divided into two categories: acute kidney injury or chronic kidney
disease. The type of renal failure is determined by the trend in the serum creatinine. Other
factors which may help differentiate acute kidney injury from chronic kidney disease
include anemia and the kidney size on ultrasound. Chronic kidney disease generally leads to
anemia and small kidney size.

Acute kidney injury

Acute kidney injury (AKI), previously called acute renal failure (ARF), is a rapidly
progressive loss of renal function, generally characterized
by oliguria (decreased urine production, quantified as less than 400 mL per day in adults,
[1] less than 0.5 mL/kg/h in children or less than 1 mL/kg/h in infants); body water and body
fluids disturbances; and electrolytederangement. AKI can result from a variety of causes,
generally classified as prerenal, intrinsic, and postrenal. An underlying cause must be
identified and treated to arrest the progress, and dialysis may be necessary to bridge the
time gap required for treating these fundamental causes.

Chronic kidney disease

Chronic kidney disease (CKD) can develop slowly and initially, show few symptoms.
CKD can be the long term consequence of irreversible acute disease or part of a disease
progression.

Acute-on-chronic renal failure

Acute kidney injuries can be present on top of chronic kidney disease, a condition
called acute-on-chronic renal failure (AoCRF). The acute part of AoCRF may be reversible,
and the goal of treatment, as with AKI, is to return the patient to baseline renal function,
typically measured by serum creatinine. Like AKI, AoCRF can be difficult to distinguish from
chronic kidney disease if the patient has not been monitored by a physician and no baseline
(i.e., past) blood work is available for comparison.

SYMPTOMS

Symptoms can vary from person to person. Someone in early stage kidney disease
may not feel sick or notice symptoms as they occur. When kidneys fail to filter properly,
waste accumulates in the blood and the body, a condition called azotemia. Very low levels of
azotaemia may produce few, if any, symptoms. If the disease progresses, symptoms
become noticeable (if the failure is of sufficient degree to cause symptoms). Renal failure
accompanied by noticeable symptoms is termed uraemia.

Symptoms of kidney failure include:

High levels of urea in the blood, which can result in:
Vomiting and/or diarrhea, which may lead to dehydration
Nausea
Weight loss
Nocturnal urination
Foamy or bubbly urine
More frequent urination, or in greater amounts than usual, with pale urine
Less frequent urination, or in smaller amounts than usual, with dark coloured urine
Blood in the urine
Pressure, or difficulty urinating
A build up of phosphates in the blood that diseased kidneys cannot filter out may
cause:
Itching
 Bone damage
Muscle cramps (caused by low levels of calcium which can cause hypocalcaemia)
A build up of potassium in the blood that diseased kidneys cannot filter out
(called hyperkalemia) may cause:
Abnormal heart rhythms
Muscle paralysis[6]
Failure of kidneys to remove excess fluid may cause:
Swelling of the legs, ankles, feet, face and/or hands
Shortness of breath due to extra fluid on the lungs (may also be caused by anemia)
Polycystic kidney disease, which causes large, fluid-filled cysts on the kidneys and
sometimes the liver, can cause:
Pain in the back or side
Healthy kidneys produce the hormone erythropoietin which stimulates the bone
marrow to make oxygen-carrying red blood cells. As the kidneys fail, they produce less
erythropoietin, resulting in decreased production of red blood cells to replace the natural
breakdown of old red blood cells. As a result, the blood carries less hemoglobin, a
condition known as anemia. This can result in:
Feeling tired and/or weak
Memory problems
Difficulty concentrating
Dizziness
Low blood pressure
Other symptoms include:
Appetite loss, a bad taste in the mouth
Difficulty sleeping
Darkening of the skin

CAUSES

Causes of acute renal failure

Acute kidney failure usually occurs when the blood supply to the kidneys is suddenly
interrupted or when the kidneys become overloaded with toxins. Causes of acute failure
include accidents, injuries, or complications from surgeries in which the kidneys are
deprived of normal blood flow for extended periods of time. Heart-bypass surgery is an
example of one such procedure.

Drug overdoses, whether accidental or from chemical overloads of drugs such as

antibiotics or chemotherapeutics, may also cause the onset of acute kidney failure. Unlike in
chronic kidney disease, however, the kidneys can often recover from acute failure, allowing
the patient to resume a normal life. People suffering from acute failure require supportive
treatment until their kidneys recover function, and they often remain at increased risk of
developing future kidney failure.

Causes of chronic kidney disease

CKD has numerous causes. The most common is diabetes mellitus. The second most
common is long-standing, uncontrolled, hypertension, or high blood pressure. Polycystic
kidney disease is another well-known cause of CKD. The majority of people afflicted with
polycystic kidney disease have a family history of the disease. Other genetic illnesses affect
kidney function as well.
Overuse of common drugs such as aspirin, ibuprofen, codeine and acetaminophen can also
cause chronic kidney damage.

Genetic predisposition
APOL1 gene has been proposed as a major genetic risk locus for a spectrum of nondiabetic
renal failure in individuals of African orgin, these include HIV-associated
nephropathy(HIVAN), primary nonmonogenic forms of focal segmental glomerulosclerosis,
and hypertension affiliated chronic kidney disease not attributed to other etiologies[9]. Two
western Africans variants in APOL1 have been shown to associate with end stage kidney
disease in African Americans and Hispanic Americans.

DIAGNOSTIC APPROACH

Methods of Measurement for CKD

Stages of kidney failure

Chronic kidney failure is measured in five stages, which are calculated using a
patients GFR, or glomerular filtration rate. Stage 1 CKD is mildly diminished renal function,
with few overt symptoms. Stages 2 and 3 need increasing levels of supportive care from
their medical providers to slow and treat their renal dysfunction. Patients in stages 4 and 5
usually require preparation of the patient towards active treatment in order to survive.Stage
5 CKD is considered a severe illness and requires some form of renal replacement therapy
(dialysis) orkidney transplant whenever feasible.

Glomerular filtration rate

A normal GFR varies according to many factors, including sex, age, body size and
ethnicity. Renal professionals consider the glomerular filtration rate (GFR) to be the best
overall index of kidney function.[12]The National Kidney Foundation offers an easy to use
on-line GFR calculator.[13] for anyone who is interested in knowing their glomerular filtration
rate.(A serumcreatinine level, a simple blood test, is needed to use the calculator).
Use of the term uremia

Before the advancement of modern medicine, renal failure was often referred to as
uremic poisoning. Uremia was the term used to describe the contamination of the blood with
urine. Starting around 1847, this term was used to describe reduced urine output, that was
thought to be caused by the urine mixing with the blood instead of being voided through the
urethra.[citation needed] The term uremia is now used to loosely describe the illness
accompanying kidney failure.

ACUTE RENAL FAILURE

Acute kidney injury (AKI), previously called acute renal failure (ARF), is a rapid
loss of kidney function. Its causes are numerous and include low blood volume, exposure
to toxins, and prostate enlargement. AKI is diagnosed on the basis of clinical history, such
asdecreased urine production, and characteristic laboratory findings, such as elevated blood
urea nitrogen and creatinine. Depending on its severity, AKI may lead to a number of
complications, including metabolic acidosis, high potassium levels, changes in body fluid
balance, and effects to other organ systems. Management includes supportive care, such
as renal replacement therapy, as well as treatment of the underlying disorder.
EPIDEMIOLOGY

Acute kidney injury is common among hospitalized patients. It affects some 3-7% of
patients admitted to the hospital and approximately 25-30% of patients in the intensive care
unit.

CAUSES

The myriad causes of acute kidney injury are commonly categorised into prerenal, intrinsic,
and postrenal.

Prerenal

Prerenal causes of AKI are those that decrease effective blood flow to the kidney.
These include systemic causes, such as low blood volume, low blood pressure, and heart
failure, as well as local changes to the blood vessels supplying the kidney. The latter
include renal artery stenosis, which is a narrowing of the renal artery that supplies the
kidney, and renal vein thrombosis, which is the formation of a blood clot in the renal
veinthat drains blood from the kidney. Renal ischaemia ultimately results in functional
disorder, depression of GFR, or both. These causes the inadequate cardiac output and
hypovoumia or vascular diseases causing reduces perfusion of both kidneys.

Intrinsic

Sources of damage to the kidney itself are dubbed intrinsic. Intrinsic AKI can be due
to damage to the glomeruli, renal tubules, or interstitium. Common causes of each
areglomerulonephritis, acute tubular necrosis (ATN), and acute interstitial nephritis (AIN),
respectively.
Postrenal

Postrenal AKI is a consequence of urinary tract obstruction. This may be related

to benign prostatic hyperplasia, kidney stones, obstructed urinary catheter, bladder stone,
bladder, ureteral or renal malignancy. It is useful to perform a bladder scan or a post void
residual to rule out urinary retention. A renal ultrasound will demonstrate hydronephrosis if
present. A CT scan of the abdomen will also demonstrate bladder distension or
hydronephrosis, however, in case of acute renal failure, the use of IV contrast is
contraindicated. On the basic metabolic panel, the ratio of BUN to creatinine may indicate
post renal failure.

DIAGNOSIS

Acute kidney injury is diagnosed on the basis of clinical history and laboratory data. A
diagnosis is made when there is rapid reduction in kidney function, as measured by
serumcreatinine, or based on a rapid reduction in urine output, termed oliguria.

Definition

Introduced by the Acute Kidney Injury Network (AKIN), specific criteria exist for the diagnosis
of AKI:
1. Rapid time course (less than 48 hours)
2. Reduction of kidney function
Rise in serum creatinine
Absolute increase in serum creatinine of 0.3 mg/dl (26.4 mol/l)
Percentage increase in serum creatinine of 50%
 Reduction in urine output, defined as <0.5 ml/kg/hr for more than 6 hours

Staging

The RIFLE criteria, proposed by the Acute Dialysis Quality Initiative (ADQI) group, aid in the
staging of patients with AKI:
Risk: serum creatinine increased 1.5 times or urine production of <0.5 ml/kg for 6
hours
Injury: doubling of creatinine or urine production <0.5 ml/kg for 12 hours
Failure: tripling of creatinine or creatinine >355 mol/l (with a rise of >44) (>4 mg/dl)
OR urine output below 0.3 ml/kg for 24 hours
Loss: persistent AKI or complete loss of kidney function for more than 4 weeks
End-stage renal disease: complete loss of kidney function for more than 3 months

Further testing

Once the diagnosis of AKI is made, further testing is often required to determine the
underlying cause. These may include renal ultrasound and kidney biopsy. Indications for
renal biopsy in the setting of AKI include:[6]
1. Unexplained AKI
2. AKI in the presence of the nephritic syndrome
3. Systemic disease associated with AKI

COMPLICATIONS

Metabolic acidosis, hyperkalemia, and pulmonary edema[12] may require medical

treatment with sodium bicarbonate, antihyperkalemic measures, and diuretics.

Lack of improvement with fluid resuscitation, therapy-resistant hyperkalemia,

metabolic acidosis, or fluid overload may necessitate artificial support in the form
of dialysis or hemofiltration. Depending on the cause, a proportion of patients will never
regain full renal function, thus having end-stage renal failure requiring lifelong dialysis or
a kidney transplant.

Before the advancement of modern medicine, acute kidney injury might be referred
to as uremic poisoning. Uremia was the term used to describe the contamination of
the blood withurine. Starting around 1847 this term was used to describe reduced urine
output, now known as oliguria, which was thought to be caused by the urine's mixing with
the blood instead of being voided through the urethra.
Acute kidney injury due to acute tubular necrosis (ATN) was recognised in the 1940s in the
United Kingdom, where crush injury victims during the London Blitz developed patchy
necrosis of renal tubules, leading to a sudden decrease in renal function.[13] During
the Korean and Vietnam wars, the incidence of AKI decreased due to better acute
management and administration of intravenous fluids.

CHRONIC KIDNEY DISEASES

Chronic kidney disease (CKD), also known as chronic renal disease, is a

progressive loss in renal function over a period of months or years. The symptoms of
worsening kidney function are unspecific, and might include feeling generally unwell and
experiencing a reduced appetite. Often, chronic kidney disease is diagnosed as a result
of screening of people known to be at risk of kidney problems, such as those with high blood
pressure or diabetes and those with a blood relative with chronic kidney disease. Chronic
kidney disease may also be identified when it leads to one of its recognized complications,
such as cardiovascular disease, anemia or pericarditis.

Chronic kidney disease is identified by a blood test for creatinine. Higher levels of
creatinine indicate a falling glomerular filtration rate and as a result a decreased capability
of the kidneys to excrete waste products. Creatinine levels may be normal in the early
stages of CKD, and the condition is discovered if urinalysis (testing of a urine sample) shows
that the kidney is allowing the loss of protein or red blood cells into the urine. To fully
investigate the underlying cause of kidney damage, various forms of medical imaging, blood
tests and often renal biopsy(removing a small sample of kidney tissue) are employed to find
out if there is a reversible cause for the kidney malfunction.[1] Recent professional
guidelines classify the severity of chronic kidney disease in five stages, with stage 1 being
the mildest and usually causing few symptoms and stage 5 being a severe illness with poor
life expectancy if untreated. Stage 5 CKD is also called established chronic kidney
disease and is synonymous with the now outdated terms end-stage renal disease
(ESRD), chronic kidney failure (CKF) or chronic renal failure (CRF).

There is no specific treatment unequivocally shown to slow the worsening of chronic

kidney disease. If there is an underlying cause to CKD, such as vasculitis, this may be
treated directly with treatments aimed to slow the damage. In more advanced stages,
treatments may be required for anemia and bone disease. Severe CKD requires one of the
forms of renal replacement therapy; this may be a form of dialysis, but ideally constitutes
a kidney transplant.[1]

SIGNS AND SYMPTOMS

CKD is initially without specific symptoms and can only be detected as an increase in
serum creatinine or protein in the urine. As the kidney function decreases:
blood pressure is increased due to fluid overload and production of vasoactive
hormones, increasing one's risk of developing hypertension and/or suffering
from congestive heart failure
Urea accumulates, leading to azotemia and ultimately uremia (symptoms ranging
from lethargy to pericarditis and encephalopathy). Urea is excreted by sweating and
crystallizes on skin ("uremic frost").
Potassium accumulates in the blood (known as hyperkalemia with a range of
symptoms including malaise and potentially fatal cardiac arrhythmias)
Erythropoietin synthesis is decreased (potentially leading to anemia, which
causes fatigue)
Fluid volume overload - symptoms may range from mild edema to life-
threatening pulmonary edema
Hyperphosphatemia - due to reduced phosphate excretion, associated
with hypocalcemia (due to vitamin D3 deficiency). The major sign of hypocalcemia
is tetany.
Later this progresses to tertiary hyperparathyroidism, with hypercalcaemia, renal
osteodystrophy and vascular calcification that further impairs cardiac function.
Metabolic acidosis, due to accumulation of sulfates, phosphates, uric acid etc. This may
cause altered enzyme activity by excess acid acting on enzymes and also increased
excitability of cardiac and neuronal membranes by the promotion of hyperkalemia due to
excess acid (acidemia).
People with chronic kidney disease suffer from accelerated atherosclerosis and are
more likely to develop cardiovascular disease than the general population. Patients afflicted
with chronic kidney disease and cardiovascular disease tend to have significantly worse
prognoses than those suffering only from the latter.
CAUSES

The most common causes of CKD are diabetic nephropathy, hypertension,

and glomerulonephritis. Together, these cause approximately 75% of all adult cases. Certain
geographic areas have a high incidence of HIV nephropathy.

Historically, kidney disease has been classified according to the part of the renal anatomy
that is involved, as:

Vascular, includes large vessel disease such as bilateral renal artery stenosis and
small vessel disease such as ischemic nephropathy, hemolytic-uremic
syndrome and vasculitis
Glomerular, comprising a diverse group and subclassified into
Primary Glomerular disease such as focal segmental
glomerulosclerosis and IgA nephritis
Secondary Glomerular disease such as diabetic nephropathy and lupus
nephritis
Tubulointerstitial including polycystic kidney disease, drug and toxin-induced chronic
tubulointerstitial nephritis and reflux nephropathy
Obstructive such as with bilateral kidney stones and diseases of the prostate
On rare cases, pin worms infecting the kidney can also cause idiopathic nephropathy.

DIAGNOSIS

In many CKD patients, previous renal disease or other underlying diseases are
already known. A small number presents with CKD of unknown cause. In these patients, a
cause is occasionally identified retrospectively.

It is important to differentiate CKD from acute renal failure (ARF) because ARF can be
reversible. Abdominal ultrasound is commonly performed, in which the size of
the kidneys are measured. Kidneys with CKD are usually smaller (< 9 cm) than normal
kidneys with notable exceptions such as in diabetic nephropathy and polycystic kidney
disease. Another diagnostic clue that helps differentiate CKD and ARF is a gradual rise in
serum creatinine (over several months or years) as opposed to a sudden increase in the
serum creatinine (several days to weeks). If these levels are unavailable (because the
patient has been well and has had no blood tests) it is occasionally necessary to treat a
patient briefly as having ARF until it has been established that the renal impairment is
irreversible.

Additional tests may include nuclear medicine MAG3 scan to confirm blood flows and
establish the differential function between the two kidneys. DMSA scans are also used in
renal imaging; with both MAG3 and DMSA being used chelated with the radioactive
element Technetium-99.

In chronic renal failure treated with standard dialysis, numerous uremic toxins
accumulate. These toxins show various cytotoxic activities in the serum, have different
molecular weights and some of them are bound to other proteins, primarily to albumin. Such
toxic protein bound substances are receiving the attention of scientists who are interested in
improving the standard chronic dialysis procedures used today

Stages
 All individuals with a Glomerular filtration rate (GFR) <60 mL/min/1.73 m2 for 3
months are classified as having chronic kidney disease, irrespective of the presence or
absence of kidney damage. The rationale for including these individuals is that reduction in
kidney function to this level or lower represents loss of half or more of the adult level of
normal kidney function, which may be associated with a number of complications.

All individuals with kidney damage are classified as having chronic kidney disease,
irrespective of the level of GFR. The rationale for including individuals with GFR 60
mL/min/1.73 m2 is that GFR may be sustained at normal or increased levels despite
substantial kidney damage and that patients with kidney damage are at increased risk of
the two major outcomes of chronic kidney disease: loss of kidney function and development
of cardiovascular disease.
The loss of protein in the urine is regarded as an independent marker for worsening
of renal function and cardiovascular disease. Hence, British guidelines append the letter "P"
to the stage of chronic kidney disease if there is significant protein loss.

Stage 1
Slightly diminished function; Kidney damage with normal or relatively high GFR (90
mL/min/1.73 m2). Kidney damage is defined as pathologic abnormalities or markers of
damage, including abnormalities in blood or urine test or imaging studies.

Stage 2
Mild reduction in GFR (60-89 mL/min/1.73 m2) with kidney damage. Kidney damage is
defined as pathologic abnormalities or markers of damage, including abnormalities in blood
or urine test or imaging studies.

Stage 3
Moderate reduction in GFR (30-59 mL/min/1.73 m2).[1] British guidelines distinguish
between stage 3A (GFR 45-59) and stage 3B (GFR 30-44) for purposes of screening and
referral.

Stage 4
Severe reduction in GFR (15-29 mL/min/1.73 m2)[1] Preparation for renal replacement
therapy.

Stage 5
Established kidney failure (GFR <15 mL/min/1.73 m2, or permanent renal replacement
therapy (RRT).

TREATMENT

The goal of therapy is to slow down or halt the otherwise relentless progression of CKD to
stage 5. Control of blood pressure and treatment of the original disease, whenever feasible,
are the broad principles of management. Generally, angiotensin converting enzyme
inhibitors (ACEIs) or angiotensin II receptor antagonists (ARBs) are used, as they have been
found to slow the progression of CKD to stage 5. Although the use of ACE inhibitors and
ARBs represents the current standard of care for patients with CKD, patients progressively
lose kidney function while on these medications, as seen in the IDNT and RENAL studies,
which reported a decrease over time in estimated glomerular filtration rate (an accurate
measure of CKD progression, as detailed in the K/DOQI guidelines in patients treated by
these conventional methods.

Currently, several compounds are in development for CKD. These include, but are not
limited to, bardoxolone methyl, olmesartan medoxomil, sulodexide, and avosenta.
 Replacement of erythropoietin and calcitriol, two hormones processed by the kidney,
is often necessary in patients with advanced CKD. Phosphate binders are also used to
control the serum phosphate levels, which are usually elevated in advanced chronic kidney
disease.
When one reaches stage 5 CKD, renal replacement therapy is required, in the form of
either dialysis or a transplant.

In some cases, dietary modifications have been proven to slow and even reverse
further progression. Generally this includes limiting protein intake.

The normalization of hemoglobin has not been found to be of any benefit.

PROGNOSIS

The prognosis of patients with chronic kidney disease is guarded as epidemiological

data has shown that all cause mortality (the overall death rate) increases as kidney function
decreases. The leading cause of death in patients with chronic kidney disease is
cardiovascular disease, regardless of whether there is progression to stage 5.

While renal replacement therapies can maintain patients indefinitely and prolong life,
the quality of life is severely affected. Renal transplantation increases the survival of
patients with stage 5 CKD significantly when compared to other therapeutic options;
however, it is associated with an increased short-term mortality (due to complications of the
surgery). Transplantation aside, high intensity home hemodialysis appears to be associated
with improved survival and a greater quality of life, when compared to the conventional
three times a week hemodialysis and peritoneal dialysis.

HEPATORENAL SYNDROME

Hepatorenal syndrome (often abbreviated HRS) is a life-threatening medical

condition that consists of rapid deterioration in kidney functionin individuals
with cirrhosis or fulminant liver failure. HRS is usually fatal unless a liver transplant is
performed, although various treatments, such as dialysis, can prevent advancement of the
condition.

HRS can affect individuals with cirrhosis (regardless of cause), severe alcoholic
hepatitis, or fulminant hepatic failure, and usually occurs when liver function deteriorates
rapidly because of an acute injury such as an infection, bleeding in the gastrointestinal tract,
or overuse ofdiuretic medications. HRS is a relatively common complication of cirrhosis,
occurring in 18% of cirrhotics within one year of their diagnosis, and in 39% of cirrhotics
within five years of their diagnosis.

Deteriorating liver function is believed to cause changes in the circulation that

supplies the intestines, altering blood flow and blood vessel tone in the kidneys. The renal
failure of HRS is a consequence of these changes in blood flow, rather than direct damage to
the kidney; the kidneys themselves appear normal to the naked eye and tissue is normal
when viewed under the microscope, and the kidneys even function normally when placed in
an otherwise healthy environment (such as if transplanted into a person with a healthy
liver). The diagnosis of hepatorenal syndrome is based on laboratory tests of individuals
susceptible to the condition. Two forms of hepatorenal syndrome have been defined: Type 1
HRS entails a rapidly progressive decline in kidney function, while type 2 HRS is associated
with ascites (fluid accumulation in the abdomen) that does not improve with
standard diuretic medications.
 The risk of death in hepatorenal syndrome is very high; the mortality of individuals
with type 1 HRS is over 50% over the short term, as determined by historical case series.
The only long-term treatment option for the condition is liver transplantation. While awaiting
transplantation, people with HRS often receive other treatments that improve the
abnormalities in blood vessel tone, including supportive care with medications, or the
insertion of a transjugular intrahepatic portosystemic shunt (TIPS), which is a small shunt
placed to reduce blood pressure in the portal vein. Some patients may
require hemodialysis to support kidney function, or a newer technique called liver dialysis
which uses a dialysis circuit with albumin-bound membranes to bind and remove toxins
normally cleared by the livertomechanically support the liver until transplantation can be
performed.

CLASSIFICATION

Hepatorenal syndrome is a particular and common type of kidney failure that affects
individuals with liver cirrhosis or, less commonly, withfulminant liver failure. The syndrome
involves constriction of the blood vessels of the kidneys and dilation of blood vessels in the
splanchnic circulation, which supplies the intestines. The classification of hepatorenal
syndrome identifies two categories of renal failure, termed type 1and type 2 HRS, which
both occur in individuals with either cirrhosis or fulminant liver failure. In both categories,
the deterioration in kidney function is quantified either by an elevation in creatinine level in
the blood, or by decreased clearance of creatinine in the urine.

Type 1 hepatorenal syndrome

Type 1 HRS is characterized by rapidly progressive renal failure, with a doubling of

serum creatinine to a level greater than 221 mol/L (2.5mg/dL) or a halving of the creatinine
clearance to less than 20 mL/min over a period of less than two weeks. The prognosis of
individuals with type 1 HRS is particularly grim, with a mortality rate exceeding 50% after
one month. Patients with type 1 HRS are usually ill, may have low blood pressure, and may
require therapy with drugs to improve the strength of heart muscle contraction (inotropes)
or other drugs to maintain blood pressure (vasopressors).

Type 2 hepatorenal syndrome

In contrast, type 2 HRS is slower in onset and progression. It is defined by an increase

in serum creatinine level to >133 mol/L (1.5 mg/dL) or a creatinine clearance of less than
40 mL/min, and a urine sodium < 10 mol/L.[6] It also carries a poor outlook, with a median
survival of approximately six months unless the affected individual undergoes liver
transplantation. Type 2 HRS is thought to be part of a spectrum of illness associated
with increased pressures in the portal vein circulation, which begins with the development of
fluid in the abdomen (ascites). The spectrum continues with diuretic-resistant ascites, where
the kidneys are unable to excrete sufficient sodium to clear the fluid even with the use of
diuretic medications. Most individuals with type 2 HRS have diuretic-resistant ascites before
they develop deterioration in kidney function.

SIGNS AND SYMPTOMS

Both types of hepatorenal syndrome share three major components: altered liver
function, abnormalities in circulation, and renal failure. As these phenomena may not
necessarily produce symptoms until late in their course, individuals with hepatorenal
syndrome are typically diagnosed with the condition on the basis of altered laboratory tests.
Most people who develop HRS have cirrhosis, and may have signs and symptoms of the
same, which can include jaundice, altered mental status, evidence of decreased nutrition,
and the presence ofascites. Specifically, the production of ascites that is resistant to the use
of diuretic medications is characteristic of type 2 HRS. Oliguria, which is a decrease in urine
volume, may occur as a consequence of renal failure; however, some individuals with HRS
continue to produce a normal amount of urine. As these signs and symptoms may not
necessarily occur in HRS, they are not included in the major and minor criteria for making a
diagnosis of this condition; instead HRS is diagnosed in an individual at risk for the condition
on the basis of the results of laboratory tests, in the exclusion of other causes.

CAUSES

Hepatorenal syndrome usually affects individuals with cirrhosis and elevated

pressures in the portal vein system (termed portal hypertension). While HRS may develop in
any type of cirrhosis, it is most common in individuals with alcoholic cirrhosis, particularly if
there is concomitant alcoholic hepatitis identifiable on liver biopsies. HRS can also occur in
individuals without cirrhosis, but with acute onset of liver failure, termed fulminant hepatic
failure.

Certain precipitants of HRS have been identified in vulnerable individuals with

cirrhosis or fulminant hepatic failure. These include bacterial infection, acute alcoholic
hepatitis, or bleeding in the upper gastrointestinal tract. Spontaneous bacterial peritonitis,
which is the infection of ascites fluid, is the most common precipitant of HRS in cirrhotic
individuals. HRS can sometimes be triggered by treatments for complications of liver
disease: iatrogenic precipitants of HRS include the aggressive use of diuretic medications or
the removal of large volumes of ascitic fluid by paracentesis from the abdominal cavity
without compensating for fluid losses by intravenous replacement.

The major criteria include liver disease in the setting of portal hypertension; renal
failure; the absence of shock, infection, recent treatment with medications that affect the
function of the kidney (nephrotoxins), and fluid losses; the absence of sustained
improvement in renal function despite treatment with 1.5 litres of intravenous normal saline;
the absence ofproteinuria, or protein in the urine; and, the absence of renal disease or
obstruction of renal outflow as seen on ultrasound.

The minor criteria are the following: a low urine volume (less than 500 mL (18 imp
fl oz; 17 US fl oz) per day), low sodium concentration in the urine, a urine osmolality that is
greater than that in the blood, the absence of red blood cells in the urine, and a serum
sodium concentration of less than 130 mmol/L.

Many other diseases of the kidney are associated with liver disease and must be
excluded before making a diagnosis of hepatorenal syndrome. Individuals with pre-renal
failure do not have damage to the kidneys, but as in individuals with HRS, have renal
dysfunction due to decreased blood flow to the kidneys. Also, similarly to HRS, pre-renal
failure causes the formation of urine that has a very low sodium concentration. In contrast to
HRS, however, pre-renal failure usually responds to treatment with intravenous fluids,
resulting in reduction in serum creatinine and increased excretion of sodium. Acute tubular
necrosis (ATN) involves damage to the tubules of the kidney, and can be a complication in
individuals with cirrhosis, because of exposure to toxic medications or the development of
decreased blood pressure. Because of the damage to the tubules, ATN affected kidneys
usually are unable to maximally resorb sodium from the urine. As a result, ATN can be
distinguished from HRS on the basis of laboratory testing, as individuals with ATN will have
urine sodium measurements that are much higher than in HRS; however, this may not
always be the case in cirrhotics. Individuals with ATN also may have evidence of hyaline
casts or muddy-brown casts in the urine on microscopy, whereas the urine of individuals
with HRS is typically devoid of cellular material, as the kidneys have not been directly
injured. Some viral infections of the liver, including hepatitis B and hepatitis C can also lead
to inflammation of the glomerulus of the kidney. Other causes of renal failure in individuals
with liver disease include drug toxicity (notably the antibiotic gentamicin) or contrast
nephropathy, caused by intravenous administration of contrast agents used for medical
imaging tests.

PREVENTION

The risk of death in hepatorenal syndrome is very high; consequently, there is a

significant emphasis on the identification of patients who are at risk for HRS, and prevention
of triggers for onset of HRS. As infection (specifically spontaneous bacterial peritonitis)
and gastrointestinal hemorrhage are both complications in individuals with cirrhosis, and are
common triggers for HRS, specific care is made in early identification and treatment of
cirrhotics with these complications to prevent HRS. Some of the triggers for HRS are induced
by treatment of ascites and can be preventable. The aggressive use of diuretic medications
should be avoided. In addition, many medications that are either used to treat cirrhotic
complications (such as some antibiotics) or other conditions may cause sufficient
impairment in renal function in the cirrhotic to lead to HRS. Also, large volume paracentesis
which is the removal of ascites fluid from the abdomen using a needle or catheter in order
to relieve discomfortmay cause enough alteration in hemodynamics to precipitate HRS,
and should be avoided in individuals at risk. The concomitant infusion of albumin can avert
the circulatory dysfunction that occurs after large volume paracentesis, and may prevent
HRS. Conversely, in individuals with very tense ascites, it has been hypothesized that
removal of ascitic fluid may improve renal function if it decreases the pressure on the renal
veins.

Individuals with ascites that has become infected spontaneously

(termed spontaneous bacterial peritonitis or SBP) are at an especially high risk for the
development of HRS.[2] In individuals with SBP, one randomized controlled trial found that
the administration of intravenous albumin on the day of admission and on the third day in
hospital reduced both the rate of renal insufficiency and the mortality rate.[21]

TREATMENT

Liver transplantation

The definitive treatment for hepatorenal syndrome is orthotopic liver transplantation,

and all other therapies can best be described as bridges to transplantation. While liver
transplantation is by far the best available management option for HRS, the mortality of
individuals with HRS has been shown to be as high as 25% within the first month after
transplantation. Individuals with HRS and evidence of greater hepatic dysfunction
(quantified as model for end-stage liver disease scores above 36) have been found to be at
greatest risk of early mortality after liver transplantation. A further deterioration of renal
function even after liver transplantation in individuals with HRS has been demonstrated in
several studies; however, this is transient and thought to be due to the use of medications
with toxicity to the kidneys, and specifically the introduction of immunosuppressants such
astacrolimus and cyclosporine that are known to worsen renal function. Over the long-term,
however, individuals with HRS who are the recipients of liver transplants almost universally
recover kidney function, and studies show that their survival rates at three years are similar
to those who have received liver transplants for reasons other than HRS.

In anticipation of liver transplantation (which may be associated with considerable in-

hospital delay), several other strategies have been found to be beneficial in preserving renal
function. These include the use of intravenous albumin infusion, medications (for which the
best evidence is for analogues of vasopressin, which causes splanchnic vasoconstriction),
radiological shunts to decrease pressure in the portal vein, dialysis, and a specialized
albumin-bound membrane dialysis system termed molecular adsorbents recirculation
system (MARS) or liver dialysis

Medical therapy

Many major studies showing improvement in renal function in patients with hepatorenal
syndrome have involved expansion of the volume of the plasma with albumin given
intravenously.[2][24][25] The quantity of albumin administered intravenously varies: one
cited regimen is 1 gram of albumin per kilogram of body weight intravenously on the first
day, followed by 20 to 40 grams daily.[26] Notably, studies have shown that treatment with
albumin alone is inferior to treatment with other medications in conjunction with albumin;
most studies evaluating pre-transplant therapies for HRS involve the use of albumin in
conjunction with other medical or procedural treatment.

Liver Dialysis Involves extracorporeal dialysis to remove toxins from the circulation,
usually through the addition of a second dialysis circuit that contains an albumin-bound
membrane.

Renal replacement therapy may be required to bridge individuals with hepatorenal

syndrome to liver transplantation, although the condition of the patient may dictate the
modality used. The use of dialysis, however, does not lead to recuperation or preservation of
renal function in patients with HRS, and is essentially only used to avoid complications of
renal failure until transplantation can take place. In patients who undergo hemodialysis,
there may even be an increased risk of mortality due to hypotension in patients with HRS,
although appropriate studies have yet to be performed. As a result, the role of renal
replacement therapy in patients with HRS remains unclear.
THE KIDNEYS AND HOW THEY WORK

The kidneys are a pair of vital organs that perform many functions to keep the blood
clean and chemically balanced. Understanding how the kidneys work can help a person keep
them healthy.

What do the kidneys do?

The kidneys are bean-shaped organs, each about the size of a fist. They are located
near the middle of the back, just below the rib cage, one on each side of the spine. The
kidneys are sophisticated reprocessing machines. Every day, a persons kidneys process
about 200 quarts of blood to sift out about 2 quarts of waste products and extra water. The
wastes and extra water become urine, which flows to the bladder through tubes called
ureters. The bladder stores urine until releasing it through urination.

Wastes in the blood come from the normal breakdown of active tissues, such as
muscles, and from food. The body uses food for energy and self-repairs. After the body has
taken what it needs from food, wastes are sent to the blood. If the kidneys did not remove
them, these wastes would build up in the blood and damage the body.
The actual removal of wastes occurs in tiny units inside the kidneys called nephrons. Each
kidney has about a million nephrons. In the nephron, a glomeruluswhich is a tiny blood
vessel, or capillaryintertwines with a tiny urine-collecting tube called a tubule. The
glomerulus acts as a filtering unit, or sieve, and keeps normal proteins and cells in the
bloodstream, allowing extra fluid and wastes to pass through. A complicated chemical
exchange takes place, as waste materials and water leave the blood and enter the urinary
system.

At first, the tubules receive a combination of waste materials and chemicals the body
can still use. The kidneys measure out chemicals like sodium, phosphorus, and potassium
and release them back to the blood to return to the body. In this way, the kidneys regulate
the bodys level of these substances. The right balance is necessary for life.

In addition to removing wastes, the kidneys release three important hormones:

erythropoietin, or EPO, which stimulates the bone marrow to make red blood cells
renin, which regulates blood pressure
calcitriol, the active form of vitamin D, which helps maintain calcium for bones and
for normal chemical balance in the body

What is renal function?

The word renal refers to the kidneys. The terms renal function and kidney
function mean the same thing. Health professionals use the term renal function to talk
about how efficiently the kidneys filter blood. People with two healthy kidneys have 100
percent of their kidney function. Small or mild declines in kidney functionas much as 30 to
40 percentwould rarely be noticeable. Kidney function is now calculated using a blood
sample and a formula to find the estimated glomerular filtration rate (eGFR). The eGFR
corresponds to the percent of kidney function available. The section What medical tests
detect kidney disease? contains more details about the eGFR.
Some people are born with only one kidney but can still lead normal, healthy lives. Every
year, thousands of people donate one of their kidneys for transplantation to a family
member or friend.
For many people with reduced kidney function, a kidney disease is also present and will get
worse. Serious health problems occur when people have less than 25 percent of their kidney
function. When kidney function drops below 10 to 15 percent, a person needs some form of
renal replacement therapyeither blood-cleansing treatments called dialysis or a kidney
transplantto sustain life.

Why do kidneys fail?

Most kidney diseases attack the nephrons, causing them to lose their filtering
capacity. Damage to the nephrons can happen quickly, often as the result of injury or
poisoning. But most kidney diseases destroy the nephrons slowly and silently. Only after
years or even decades will the damage become apparent. Most kidney diseases attack both
kidneys simultaneously.
The two most common causes of kidney disease are diabetes and high blood pressure.
People with a family history of any kind of kidney problem are also at risk for kidney disease.

Diabetic Kidney Disease

Diabetes is a disease that keeps the body from using glucose, a form of sugar, as it
should. If glucose stays in the blood instead of breaking down, it can act like a poison.
Damage to the nephrons from unused glucose in the blood is called diabetic kidney disease.
Keeping blood glucose levels down can delay or prevent diabetic kidney disease. Use of
medications called angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor
blockers (ARBs) to treat high blood pressure can also slow or delay the progression of
diabetic kidney disease.

High Blood Pressure

High blood pressure can damage the small blood vessels in the kidneys. The
damaged vessels cannot filter wastes from the blood as they are supposed to.
A doctor may prescribe blood pressure medication. ACE inhibitors and ARBs have been
found to protect the kidneys even more than other medicines that lower blood pressure to
similar levels. The National Heart, Lung, and Blood Institute (NHLBI), one of the National
Institutes of Health, recommends that people with diabetes or reduced kidney function keep
their blood pressure below 130/80.

Glomerular Diseases
Several types of kidney disease are grouped together under this category, including
autoimmune diseases, infection-related diseases, and sclerotic diseases. As the name
indicates, glomerular diseases attack the tiny blood vessels, or glomeruli, within the kidney.
The most common primary glomerular diseases include membranous nephropathy, IgA
nephropathy, and focal segmental glomerulosclerosis. The first sign of a glomerular disease
is often proteinuria, which is too much protein in the urine. Another common sign is
hematuria, which is blood in the urine. Some people may have both proteinuria and
hematuria. Glomerular diseases can slowly destroy kidney function. Blood pressure control is
important with any kidney disease. Glomerular diseases are usually diagnosed with a biopsy
a procedure that involves taking a piece of kidney tissue for examination with a
microscope. Treatments for glomerular diseases may include immunosuppressive drugs or
steroids to reduce inflammation and proteinuria, depending on the specific disease.

Inherited and Congenital Kidney Diseases

Some kidney diseases result from hereditary factors. Polycystic kidney disease (PKD),
for example, is a genetic disorder in which many cysts grow in the kidneys. PKD cysts can
slowly replace much of the mass of the kidneys, reducing kidney function and leading to
kidney failure.

Some kidney problems may show up when a child is still developing in the womb.
Examples include autosomal recessive PKD, a rare form of PKD, and other developmental
problems that interfere with the normal formation of the nephrons. The signs of kidney
disease in children vary. A child may grow unusually slowly, vomit often, or have back or
side pain. Some kidney diseases may be silentcausing no signs or symptomsfor months
or even years.

If a child has a kidney disease, the childs doctor should find it during a regular
checkup. The first sign of a kidney problem may be high blood pressure; a low number of red
blood cells, called anemia; proteinuria; or hematuria. If the doctor finds any of these
problems, further tests may be necessary, including additional blood and urine tests or
radiology studies. In some cases, the doctor may need to perform a biopsy.
Some hereditary kidney diseases may not be detected until adulthood. The most common
form of PKD was once called adult PKD because the symptoms of high blood pressure and
renal failure usually do not occur until patients are in their twenties or thirties. But with
advances in diagnostic imaging technology, doctors have found cysts in children and
adolescents before any symptoms appear.

Other Causes of Kidney Disease

Poisons and trauma, such as a direct and forceful blow to the kidneys, can lead to
kidney disease.
Some over-the-counter medicines can be poisonous to the kidneys if taken regularly over a
long period of time. Anyone who takes painkillers regularly should check with a doctor to
make sure the kidneys are not at risk.

How do kidneys fail?

Many factors that influence the speed of kidney failure are not completely
understood. Researchers are still studying how protein in the diet and cholesterol levels in
the blood affect kidney function.
Acute Kidney Injury
Some kidney problems happen quickly, such as when an accident injures the kidneys.
Losing a lot of blood can cause sudden kidney failure. Some drugs or poisons can make the
kidneys stop working. These sudden drops in kidney function are called acute kidney injury
(AKI). Some doctors may also refer to this condition as acute renal failure (ARF).

AKI may lead to permanent loss of kidney function. But if the kidneys are not
seriously damaged, acute kidney disease may be reversed.

Chronic Kidney Disease

Most kidney problems, however, happen slowly. A person may have silent kidney
disease for years. Gradual loss of kidney function is called chronic kidney disease (CKD) or
chronic renal insufficiency. People with CKD may go on to develop permanent kidney failure.
They also have a high risk of death from a stroke or heart attack.

End-stage Renal Disease

Total or nearly total and permanent kidney failure is called end-stage renal disease
(ESRD). People with ESRD must undergo dialysis or transplantation to stay alive.

What are the signs of chronic kidney disease (CKD)?

People in the early stages of CKD usually do not feel sick at all.
People whose kidney disease has gotten worse may
need to urinate more often or less often
feel tired
lose their appetite or experience nausea and vomiting
have swelling in their hands or feet
feel itchy or numb
get drowsy or have trouble concentrating
have darkened skin
have muscle cramps

What medical tests detect kidney disease?

Because a person can have kidney disease without any symptoms, a doctor may first
detect the condition through routine blood and urine tests. The National Kidney Foundation
recommends three simple tests to screen for kidney disease: a blood pressure
measurement, a spot check for protein or albumin in the urine, and a calculation of
glomerular filtration rate (GFR) based on a serum creatinine measurement. Measuring urea
nitrogen in the blood provides additional information.

Blood Pressure Measurement

High blood pressure can lead to kidney disease. It can also be a sign that the kidneys
are already impaired. The only way to know whether a persons blood pressure is high is to
have a health professional measure it with a blood pressure cuff. The result is expressed as
two numbers. The top number, which is called the systolic pressure, represents the pressure
in the blood vessels when the heart is beating. The bottom number, which is called the
diastolic pressure, shows the pressure when the heart is resting between beats. A persons
blood pressure is considered normal if it stays below 120/80, stated as 120 over 80. The
NHLBI recommends that people with kidney disease use whatever therapy is necessary,
including lifestyle changes and medicines, to keep their blood pressure below 130/80.
Microalbuminuria and Proteinuria
Healthy kidneys take wastes out of the blood but leave protein. Impaired kidneys
may fail to separate a blood protein called albumin from the wastes. At first, only small
amounts of albumin may leak into the urine, a condition known as microalbuminuria, a sign
of deteriorating kidney function. As kidney function worsens, the amount of albumin and
other proteins in the urine increases, and the condition is called proteinuria. A doctor may
test for protein using a dipstick in a small sample of a persons urine taken in the doctors
office. The color of the dipstick indicates the presence or absence of proteinuria.

A more sensitive test for protein or albumin in the urine involves laboratory
measurement and calculation of the protein-to-creatinine or albumin-to-creatinine ratio.
Creatinine is a waste product in the blood created by the normal breakdown of muscle cells
during activity. Healthy kidneys take creatinine out of the blood and put it into the urine to
leave the body. When the kidneys are not working well, creatinine builds up in the blood.
The albumin-to-creatinine measurement should be used to detect kidney disease in people
at high risk, especially those with diabetes or high blood pressure. If a persons first
laboratory test shows high levels of protein, another test should be done 1 to 2 weeks later.
If the second test also shows high levels of protein, the person has persistent proteinuria
and should have additional tests to evaluate kidney function.

Glomerular Filtration Rate (GFR) Based on Creatinine Measurement

GFR is a calculation of how efficiently the kidneys are filtering wastes from the blood.
A traditional GFR calculation requires an injection into the bloodstream of a substance that is
later measured in a 24-hour urine collection. Recently, scientists found they could calculate
GFR without an injection or urine collection. The new calculationthe eGFRrequires only a
measurement of the creatinine in a blood sample.

In a laboratory, a persons blood is tested to see how many milligrams of creatinine

are in one deciliter of blood (mg/dL). Creatinine levels in the blood can vary, and each
laboratory has its own normal range, usually 0.6 to 1.2 mg/dL. A person whose creatinine
level is only slightly above this range will probably not feel sick, but the elevation is a sign
that the kidneys are not working at full strength. One formula for estimating kidney function
equates a creatinine level of 1.7 mg/dL for most men and 1.4 mg/dL for most women to 50
percent of normal kidney function. But because creatinine values are so variable and can be
affected by diet, a GFR calculation is more accurate for determining whether a person has
reduced kidney function.

The eGFR calculation uses the patients creatinine measurement along with age and
values assigned for sex and race. Some medical laboratories may make the eGFR calculation
when a creatinine value is measured and include it on the lab report. The National Kidney
Foundation has determined different stages of CKD based on the value of the eGFR. Dialysis
or transplantation is needed when the eGFR is less than 15 milliliters per minute (mL/min).

Blood Urea Nitrogen (BUN)

Blood carries protein to cells throughout the body. After the cells use the protein, the
remaining waste product is returned to the blood as urea, a compound that contains
nitrogen. Healthy kidneys take urea out of the blood and put it in the urine. If a persons
kidneys are not working well, the urea will stay in the blood.
A deciliter of normal blood contains 7 to 20 milligrams of urea. If a persons BUN is more
than 20 mg/dL, the kidneys may not be working at full strength. Other possible causes of an
elevated BUN include dehydration and heart failure.

Additional Tests for Kidney Disease

If blood and urine tests indicate reduced kidney function, a doctor may recommend
additional tests to help identify the cause of the problem.
Kidney imaging. Methods of kidney imagingtaking pictures of the kidneysinclude
ultrasound, computerized tomography (CT) scan, and magnetic resonance imaging (MRI).
These tools are most helpful in finding unusual growths or blockages to the flow of urine.

Kidney biopsy. A doctor may want to examine a tiny piece of kidney tissue with a
microscope. To obtain this tissue sample, the doctor will perform a kidney biopsya hospital
procedure in which the doctor inserts a needle through the patients skin into the back of the
kidney. The needle retrieves a strand of tissue less than an inch long. For the procedure, the
patient lies facedown on a table and receives a local anesthetic to numb the skin. The
sample tissue will help the doctor identify problems at the cellular level.
For more information, see the fact sheet Kidney Biopsy from the National Kidney and
Urologic Diseases Information Clearinghouse.

What are the stages of CKD?

A persons eGFR is the best indicator of how well the kidneys are working. An eGFR of
90 or above is considered normal. A person whose eGFR stays below 60 for 3 months or
longer has CKD. As kidney function declines, the risk of complications rises.

Moderate decrease in eGFR (30 to 59). At this stage of CKD, hormones and minerals
can be thrown out of balance, leading to anemia and weak bones. A health care provider can
help prevent or treat these complications with medicines and advice about food choices.

Severe reduction in eGFR (15 to 29). The patient should continue following the
treatment for complications of CKD and learn as much as possible about the treatments for
kidney failure. Each treatment requires preparation. Those who choose hemodialysis will
need to have a procedure to make veins in their arms larger and stronger for repeated
needle insertions. For peritoneal dialysis, one will need to have a catheter placed in the
abdomen. A catheter is a thin, flexible tube used to fill the abdominal cavity with fluid. A
person may want to ask family or friends to consider donating a kidney for transplantation.

Kidney failure (eGFR less than 15). When the kidneys do not work well enough to
maintain life, dialysis or a kidney transplant will be needed.
In addition to tracking eGFR, blood tests can show when substances in the blood are out of
balance. If phosphorus or potassium levels start to climb, a blood test will prompt the health
care provider to address these issues before they permanently affect the persons health.

What can be done about CKD?

Unfortunately, CKD often cannot be cured. But people in the early stages of CKD may be
able to make their kidneys last longer by taking certain steps. They will also want to
minimize the risks for heart attack and stroke because CKD patients are susceptible to these
problems.
People with reduced kidney function should see their doctor regularly. The primary
doctor may refer the patient to a nephrologist, a doctor who specializes in kidney
disease.
People who have diabetes should watch their blood glucose levels closely to keep
them under control. They should ask their health care provider about the latest in
treatment.
People with reduced renal function should avoid pain pills that may make their kidney
disease worse. They should check with their health care provider before taking any
medicine.
Controlling Blood Pressure
People with reduced kidney function and high blood pressure should control their blood
pressure with an ACE inhibitor or an ARB. Many people will require two or more types of
medication to keep their blood pressure below 130/80. A diuretic is an important addition
when the ACE inhibitor or ARB does not meet the blood pressure goal.

Changing the Diet

People with reduced kidney function need to be aware that some parts of a normal diet may
speed their kidney failure.

Protein. Protein is important to the body. It helps the body repair muscles and fight
disease. Protein comes mostly from meat but can also be found in eggs, milk, nuts, beans,
and other foods. Healthy kidneys take wastes out of the blood but leave in the protein.
Impaired kidneys may fail to separate the protein from the wastes.
Some doctors tell their kidney patients to limit the amount of protein they eat so the kidneys
have less work to do. But a person cannot avoid protein entirely. People with CKD can work
with a dietitian to create the right food plan.

Cholesterol. Another problem that may be associated with kidney failure is high
cholesterol. High levels of cholesterol in the blood may result from a high-fat diet.
Cholesterol can build up on the inside walls of blood vessels. The buildup makes pumping
blood through the vessels harder for the heart and can cause heart attacks and strokes.

Sodium. Sodium is a chemical found in salt and other foods. Sodium in the diet may raise a
persons blood pressure, so people with CKD should limit foods that contain high levels of
sodium. High-sodium foods include canned or processed foods like frozen dinners and hot
dogs.

Potassium. Potassium is a mineral found naturally in many fruits and vegetables, such as
oranges, potatoes, bananas, dried fruits, dried beans and peas, and nuts. Healthy kidneys
measure potassium in the blood and remove excess amounts. Diseased kidneys may fail to
remove excess potassium. With very poor kidney function, high potassium levels can affect
the heart rhythm.

Not Smoking
Smoking not only increases the risk of kidney disease, but it also contributes to deaths from
strokes and heart attacks in people with CKD.

Treating Anemia
Anemia is a condition in which the blood does not contain enough red blood cells. These
cells are important because they carry oxygen throughout the body. A person who is anemic
will feel tired and look pale. Healthy kidneys make the hormone EPO, which stimulates the
bones to make red blood cells. Diseased kidneys may not make enough EPO. A person with
CKD may need to take injections of a form of EPO.

Preparing for End-stage Renal Disease (ESRD)

As kidney disease progresses, a person needs to make several decisions. People in the later
stages of CKD need to learn about their options for treating the last stages of kidney failure
so they can make an informed choice between hemodialysis, peritoneal dialysis, and
transplantation.

What happens if the kidneys fail completely?

 Total or nearly total and permanent kidney failure is called ESRD. If a persons
kidneys stop working completely, the body fills with extra water and waste products. This
condition is called uremia. Hands or feet may swell. A person will feel tired and weak
because the body needs clean blood to function properly.
Untreated uremia may lead to seizures or coma and will ultimately result in death. A person
whose kidneys stop working completely will need to undergo dialysis or kidney
transplantation.

Dialysis
The two major forms of dialysis are hemodialysis and peritoneal dialysis.
Hemodialysis uses a special filter called a dialyzer that functions as an artificial kidney to
clean a persons blood. The dialyzer is a canister connected to the hemodialysis machine.
During treatment, the blood travels through tubes into the dialyzer, which filters out wastes,
extra salt, and extra water. Then the cleaned blood flows through another set of tubes back
into the body. The hemodialysis machine monitors blood flow and removes wastes from the
dialyzer. Hemodialysis is usually performed at a dialysis center three times per week for 3 to
4 hours. A small but growing number of clinics offer home hemodialysis in addition to
standard in-clinic treatments. The patient first learns to do treatments at the clinic, working
with a dialysis nurse. Daily home hemodialysis is done 5 to 7 days per week for 2 to 3 hours
at a time. Nocturnal dialysis can be performed for 8 hours at night while a person sleeps.
Research as to which is the best method for dialysis is under way, but preliminary data
indicate that daily dialysis schedules such as short daily dialysis or nocturnal dialysis may be
the best form of dialysis therapy.

Transplantation
A donated kidney may come from an anonymous donor who has recently died or
from a living person, usually a relative. The kidney must be a good match for the patients
body. The more the new kidney is like the person receiving the kidney, the less likely the
immune system is to reject it. The immune system protects a person from disease by
attacking anything that is not recognized as a normal part of the body. So the immune
system will attack a kidney that appears too foreign. The patient will take special drugs to
help trick the immune system so it does not reject the transplanted kidney. Unless they are
causing infection or high blood pressure, the diseased kidneys are left in place. Kidneys from
living, related donors appear to be the best match for success, but kidneys from unrelated
people also have a long survival rate. Patients approaching kidney failure should ask their
doctor early about starting the process to receive a kidney transplant.

Points to Remember
The kidneys are two vital organs that keep the blood clean and chemically balanced.
Kidney disease can be detected through a spot check for protein or albumin in the
urine and a calculation of glomerular filtration rate (GFR) based on a blood test.
The progression of kidney disease can be slowed, but it cannot always be reversed.
End-stage renal disease (ESRD) is the total or nearly total and permanent loss of
kidney function.
Dialysis and transplantation can extend the lives of people with kidney failure.
Diabetes and high blood pressure are the two leading causes of kidney failure.
People with reduced kidney function should see their doctor regularly. Doctors who
specialize in kidney disease are called nephrologists.
Chronic kidney disease (CKD) increases the risk of heart attacks and strokes.
People in the early stages of CKD may be able to save their remaining kidney
function for many years by
o controlling their blood glucose
o controlling their blood pressure
o following a low-protein diet
 o maintaining healthy levels of cholesterol in the blood
o taking an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin
receptor blocker (ARB)
o not smoking

KIDNEY FAILURE: CHOOSING A TREATMENT THAT IS RIGHT FOR YOU

Introduction

Your kidneys filter wastes from your blood and regulate other functions of your body.
When your kidneys fail, you need treatment to replace the work your kidneys normally
perform.
Developing kidney failure means you have some decisions to make about your
treatment. You may choose to forgo treatment. If you choose to receive treatment, your
choices include hemodialysis, which requires a machine used to filter your blood outside
your body; peritoneal dialysis, which uses the lining of your belly to filter your blood inside
the body; and kidney transplantation, in which a new kidney is placed in your body. Each
treatment has advantages and disadvantages. Your choice of treatment will have a big
impact on your day-to-day lifestyle, such as being able to keep a job if you are working. You
are the only one who can decide what means most to you. Reading this information is a
good way to learn about your options so you can make an informed choice. And, if you find
that your choice is not a good fit for your life, you can change treatments. With the help of
your health care team, family, and friends, you can lead a full, active life.

When Your Kidneys Fail

Healthy kidneys clean your blood by removing excess fluid, minerals, and wastes.
They also make hormones that keep your bones strong and your blood healthy. When your
kidneys fail, harmful wastes build up in your body, your blood pressure may rise, and your
body may retain excess fluid and not make enough red blood cells. When this happens, you
need treatment to replace the work of your failed kidneys.

Treatment Choice: Hemodialysis

Purpose
Hemodialysis cleans and filters your blood using a machine to temporarily rid your
body of harmful wastes, extra salt, and extra water. Hemodialysis helps control blood
pressure and helps your body keep the proper balance of important chemicals such as
potassium, sodium, calcium, and bicarbonate.

Dialysis can replace part of the function of your kidneys. Diet, medications, and fluid
limits are often needed as well. Your diet, fluids, and the number of medications you need
will depend on which treatment you choose.

How Hemodialysis Works

Hemodialysis uses a special filter called a dialyzer that functions as an artificial
kidney to clean your blood. The dialyzer is a canister connected to the hemodialysis
machine.

During treatment, your blood travels through tubes into the dialyzer, which filters out
wastes, extra salt, and extra water. Then the cleaned blood flows through another set of
tubes back into your body. The hemodialysis machine monitors blood flow and removes
wastes from the dialyzer.
Hemodialysis is usually done three times a week. Each treatment lasts from 3 to 5 or more
hours. During treatment, you can read, write, sleep, talk, or watch TV.

Getting Ready

Arteriovenous fistula.Several months before your first hemodialysis treatment, an access

to your bloodstream will need to be created. You may need to stay overnight in the hospital,
but many patients have their access created on an outpatient basis. This access provides an
efficient way for blood to be carried from your body to the dialyzer and back without causing
discomfort. The two main types of access are a fistula and a graft.
A surgeon makes a fistula by using your own blood vessels; an artery is connected
directly to a vein, usually in your forearm. The increased blood flow makes the vein
grow larger and stronger so it can be used for repeated needle insertions. This kind
of access is the preferred type. It may take several weeks to be ready for use.
A graft connects an artery to a vein by using a synthetic tube. It doesnt need to
develop as a fistula does, so it can be used sooner after placement. But a graft is
more likely to have problems with infection and clotting.

Before dialysis, needles are placed into the access to draw out the blood.
If your kidney disease has progressed quickly, you may not have time to get a permanent
vascular access before you start hemodialysis treatments. You may need to use a catheter
a small, soft tube inserted into a vein in your neck, chest, or leg near the groinas a
temporary access. Some people use a catheter for long-term access as well. Catheters that
will be needed for more than about 3 weeks are designed to be placed under the skin to
increase comfort and reduce complications.

Who Performs Hemodialysis

Hemodialysis is most often done in a dialysis center by patient care technicians who
are supervised by nurses. Medicare pays for three hemodialysis treatments each week. If
you choose in-center treatment, you will have a fixed time slot three times per week on
Monday-Wednesday-Friday or Tuesday-Thursday-Saturday. If you do not get the time slot
you want at first, you can ask to be put on a waiting list for the time slot you prefer. For a
special event, you may be able to trade times with someone else. You will want to think
about the dialysis schedule if you work or have children to care for. Some centers offer in-
center nocturnal dialysis. This treatment is done for a longer period at night, while you sleep
at the center. Getting more dialysis means fewer diet and fluid limits, and this treatment
leaves your days free for work, child care, hobbies, or other tasks.

You can choose to learn how to do your own hemodialysis treatments at home. When
you are the only patient, it is possible to do longer or more frequent dialysis, which comes
closer to replacing the steady work healthy kidneys do. Daily home hemodialysis (DHHD) is
done 5 to 7 days per week for 2 to 3 hours at a time, and you set the schedule. If your
health plan will pay for more than three treatments, you might do the short treatments in
the mornings or in the evenings. Nocturnal home hemodialysis (NHHD) is done 3 to 6 nights
per week while you sleep. Either DHHD or NHHD will allow a more normal diet and fluids,
with fewer blood pressure and other medications. Most programs want people doing
hemodialysis at home to have a trained partner in the home while they do treatments.
Learning to do home hemodialysis is like learning to drive a carit takes a few weeks and is
scary at first, but then it becomes routine. The dialysis center provides the machine and
training, plus 24-hour support if you have a question or problem. New machines for home
dialysis are smaller and easier to use than in-center ones.

You have a choice of dialysis centers, and most towns have more than one center to
choose from. You can visit a center to see if it has the treatments you want or the time slot
you need. Some centers will let you use a laptop or cell phone or have visitors, and others
will not. Medicare has a list of all U.S. centers on its Dialysis Facility Compare website
(www.medicare.gov/dialysis) with quality ratings for each. Your health plan may have a list
of centers you can use. If you choose in-center treatment, you may want the center to be
close to your home to reduce your travel time. If you do a home treatment, once you are
trained you only need to visit the center once a month. So, the center can be as far away as
you are willing to travel once a month.

Possible Complications
Vascular access problems are the most common reason for hospitalization among
people on hemodialysis. Common problems include infection, blockage from clotting, and
poor blood flow. These problems can keep your treatments from working. You may need to
undergo repeated surgeries in order to get a properly functioning access.

Other problems can be caused by rapid changes in your bodys water and chemical
balance during treatment. Muscle cramps and hypotensiona sudden drop in blood
pressureare two common side effects. Hypotension can make you feel weak, dizzy, or sick
to your stomach.
Youll probably need a few months to adjust to hemodialysis. Side effects can often be
treated quickly and easily, so you should always report them to your doctor and dialysis
staff. You can avoid many side effects if you follow a proper diet, limit your liquid intake, and
take your medicines as directed.

Diet for Hemodialysis

Hemodialysis and a proper diet help reduce the wastes that build up in your blood. A
dietitian is available at all dialysis centers to help you plan meals according to your doctors
orders. When choosing foods, remember to
eat balanced amounts of high-protein foods such as meat, chicken, and fish.
control the amount of potassium you eat. Potassium is a mineral found in salt
substitutes; some fruits, such as bananas and oranges; vegetables; chocolate; and
nuts. Too much potassium can be dangerous to your heart.
limit how much you drink. When your kidneys arent working, water builds up quickly
in your body. Too much liquid makes your tissues swell and can lead to high blood
pressure, heart trouble, and cramps and low blood pressure during dialysis.
avoid salt. Salty foods make you thirsty and make your body hold water.
limit foods such as milk, cheese, nuts, dried beans, and dark colas. These foods
contain large amounts of the mineral phosphorus. Too much phosphorus in your
blood causes calcium to be pulled from your bones, which makes them weak and
brittle and can cause arthritis. To prevent bone problems, your doctor may give you
special medicines, which you must take with meals every day as directed.

Pros and Cons

Each person responds differently to similar situations. What may be a negative factor for one
person may be a positive one for another. See a list of the general advantages and
disadvantages of in-center and home hemodialysis below.

In-Center Hemodialysis
Pros
+ Facilities are widely available.
+ Trained professionals are with you at all times.
+ You can get to know other patients.
+ You dont have to have a partner or keep equipment in your home.
Cons
- Treatments are scheduled by the center and are relatively fixed.
- You must travel to the center for treatment.
 - This treatment has the strictest diet and fluid limits of all.
- You will need to takeand pay formore medications.
- You may have more frequent ups and downs in how you feel from day to day.
- It may take a few hours to feel better after a treatment.

Home Hemodialysis
Pros
+ You can do it at the times you choosebut you still must do it as often as your
doctor orders.
+ You dont have to travel to a center.
+ You gain a sense of independence and control over your treatment.
+ Newer machines require less space.
+ You will have fewer ups and downs in how you feel from day to day.
+ Home hemodialysis is more work-friendly than in-center treatment.
+ Your diet and fluids will be much closer to normal
+ You can take along new, portable machines on car trips, in campers, or on
airplanes.
+ You can spend more time with your loved ones.

Cons
- You must have a partner.
- Helping with treatments may be stressful to your family.
- You and your partner need training.
- You need space for storing the machine and supplies at home.
- You may need to take a leave of absence from work to complete training.
- You will need to learn to put in the dialysis needles.
- Daily and nocturnal home hemodialysis are not yet offered in all locations.

Treatment Choice: Peritoneal Dialysis

Purpose
Peritoneal dialysis is another procedure that removes wastes, chemicals, and extra
water from your body. This type of dialysis uses the lining of your abdomen, or belly, to filter
your blood. This lining is called the peritoneal membrane and acts as the artificial kidney.

How Peritoneal Dialysis Works

A mixture of minerals and sugar dissolved in water, called dialysis solution, travels
through a catheter into your belly. The sugarcalled dextrosedraws wastes, chemicals,
and extra water from the tiny blood vessels in your peritoneal membrane into the dialysis
solution. After several hours, the used solution is drained from your abdomen through the
tube, taking the wastes from your blood with it. Then your abdomen is refilled with fresh
dialysis solution, and the cycle is repeated. The process of draining and refilling is called an
exchange.

Getting Ready
Before your first treatment, a surgeon places a catheter into your abdomen or chest.
The catheter tends to work better if there is adequate timeusually from 10 days to 2 or 3
weeksfor the insertion site to heal. Planning your dialysis access can improve treatment
success. This catheter stays there permanently to help transport the dialysis solution to and
from your abdomen.
Types of Peritoneal Dialysis
Three types of peritoneal dialysis are available.

1. Continuous Ambulatory Peritoneal Dialysis (CAPD)

CAPD requires no machine and can be done in any clean, well-lit place. With CAPD,
your blood is always being cleaned. The dialysis solution passes from a plastic bag
through the catheter and into your abdomen, where it stays for several hours with
the catheter sealed. The time period that dialysis solution is in your abdomen is
called the dwell time. Next, you drain the dialysis solution into an empty bag for
disposal. You then refill your abdomen with fresh dialysis solution so the cleaning
process can begin again. With CAPD, the dialysis solution stays in your abdomen for a
dwell time of 4 to 6 hours, or more. The process of draining the used dialysis solution
and replacing it with fresh solution takes about 30 to 40 minutes. Most people
change the dialysis solution at least four times a day and sleep with solution in their
abdomens at night. With CAPD, its not necessary to wake up and perform dialysis
tasks during the night.

2. Continuous Cycler-assisted Peritoneal Dialysis (CCPD)

CCPD uses a machine called a cycler to fill and empty your abdomen three to five
times during the night while you sleep. In the morning, you begin one exchange with
a dwell time that lasts the entire day. You may do an additional exchange in the
middle of the afternoon without the cycler to increase the amount of waste removed
and to reduce the amount of fluid left behind in your body.

3. Combination of CAPD and CCPD

If you weigh more than 175 pounds or if your peritoneum filters wastes slowly, you
may need a combination of CAPD and CCPD to get the right dialysis dose. For
example, some people use a cycler at night but also perform one exchange during
the day. Others do four exchanges during the day and use a minicycler to perform
one or more exchanges during the night. Youll work with your health care team to
determine the best schedule for you.

Who Performs Peritoneal Dialysis

Both types of peritoneal dialysis are usually performed by the patient without help
from a partner. CAPD is a form of self-treatment that needs no machine. However, with
CCPD, you need a machine to drain and refill your abdomen.

Possible Complications
The most common problem with peritoneal dialysis is peritonitis, a serious abdominal
infection. This infection can occur if the opening where the catheter enters your body
becomes infected or if contamination occurs as the catheter is connected or disconnected
from the bags. Infection is less common in presternal catheters, which are placed in the
chest. Peritonitis requires antibiotic treatment by your doctor.

To avoid peritonitis, you must be careful to follow procedures exactly and learn to
recognize the early signs of peritonitis, which include fever, unusual color or cloudiness of
the used fluid, and redness or pain around the catheter. Report these signs to your doctor or
nurse immediately so that peritonitis can be treated quickly to avoid additional problems.

Diet for Peritoneal Dialysis

A peritoneal dialysis diet is slightly different from an in-center hemodialysis diet.
 Youll still need to limit salt and liquids, but you may be able to have more of each,
compared with in-center hemodialysis.
You must eat more protein.
You may have different restrictions on potassium. You may even need to eat high-
potassium foods.
You may need to cut back on the number of calories you eat because there are
calories in the dialysis fluid that may cause you to gain weight.
Your doctor and a dietitian who specializes in helping people with kidney failure will be able
to help you plan your meals.

Pros and Cons

Each type of peritoneal dialysis has advantages and disadvantages.
Peritoneal Dialysis
CAPD
Pros
+ You can do it alone.
+ You can do it at times you choose as long as you perform the required number of
exchanges each day.
+ You can do it in many locations.
+ You dont need a machine.
+ You wont have the ups and downs that many patients on hemodialysis feel.
+ You dont need to travel to a center three times a week.
Cons
- It can disrupt your daily schedule.
- It is a continuous treatment, and all exchanges must be performed 7 days a week.
CCPD
Pros
+ You can do it at night, mainly while you sleep.
+ You are free from performing exchanges during the day.
Cons
- You need a machine.
- Your movement at night is limited by your connection to the cycler.

Dialysis Is Not a Cure

Hemodialysis and peritoneal dialysis are treatments that help replace the work your
kidneys did. These treatments help you feel better and live longer, but they dont cure
kidney failure. Although patients with kidney failure are now living longer than ever, over the
years kidney disease can cause problems such as heart disease, bone disease, arthritis,
nerve damage, infertility, and malnutrition. These problems wont go away with dialysis, but
doctors now have new and better ways to prevent or treat them. You should discuss these
complications and their treatments with your doctor.

Treatment Choice: Kidney Transplantation

Purpose
Kidney transplantation surgically places a healthy kidney from another person into
your body. The donated kidney does enough of the work that your two failed kidneys used to
do to keep you healthy and symptom free.

How Kidney Transplantation Works

A surgeon places the new kidney inside your lower abdomen and connects the artery
and vein of the new kidney to your artery and vein. Your blood flows through the donated
kidney, which makes urine, just like your own kidneys did when they were healthy. The new
kidney may start working right away or may take up to a few weeks to make urine. Unless
your own kidneys are causing infection or high blood pressure, they are left in place.

Getting Ready
The transplantation process has many steps. First, talk with your doctor because
transplantation isnt for everyone. You could have a condition that would make
transplantation dangerous or unlikely to succeed.
You may receive a kidney from a deceased donora person who has recently diedor from
a living donor. A living donor may be related or unrelatedusually a spouse or a friend. If
you dont have a living donor, youre placed on a waiting list for a deceased donor kidney.
The wait for a deceased donor kidney can be several years.
The transplant team considers three factors in matching kidneys with potential recipients.
These factors help predict whether your bodys immune system will accept the new kidney
or reject it.
Blood type. Your blood type (A, B, AB, or O) must be compatible with the donors.
Blood type is the most important matching factor.
Human leukocyte antigens (HLAs). Your cells carry six important HLAs, three
inherited from each parent. Family members are most likely to have a complete
match. You may still receive a kidney if the HLAs arent a complete match as long as
your blood type is compatible with the organ donors and other tests show no
problems with matching.
Cross-matching antigens. The last test before implanting an organ is the cross-
match. A small sample of your blood will be mixed with a sample of the organ donors
blood in a tube to see if theres a reaction. If no reaction occurs, the result is called a
negative cross-match, and the transplant operation can proceed.

The Time Kidney Transplantation Takes

How long youll have to wait for a kidney varies. Because there arent enough
deceased donors for every person who needs a transplant, you must be placed on a waiting
list. However, if a voluntary donor gives you a kidney, the transplant can be scheduled as
soon as youre both ready. Avoiding the long wait is a major advantage of living donation.

The surgery takes 3 to 4 hours. The usual hospital stay is about a week. After you
leave the hospital, youll have regular follow-up visits.
In a living donation, the donor will probably stay in the hospital about the same amount of
time. However, a new technique for removing a kidney for donation uses a smaller incision
and may make it possible for the donor to leave the hospital in 2 to 3 days.

Between 85 and 90 percent of transplants from deceased donors are working 1 year
after surgery. Transplants from living relatives often work better than transplants from
unrelated or deceased donors because theyre usually a closer match.

Possible Complications
Transplantation is the closest thing to a cure. But no matter how good the match,
your body may reject your new kidney. A common cause of rejection is not taking
medication as prescribed.

Your doctor will give you medicines called immunosuppressants to help prevent your
bodys immune system from attacking the kidney, a process called rejection. Youll need to
take immunosuppressants every day for as long as the transplanted kidney is functioning.
Sometimes, however, even these medicines cant stop your body from rejecting the new
kidney. If this happens, youll go back to some form of dialysis and possibly wait for another
transplant.
 Immunosuppressants weaken your immune system, which can lead to infections.
Some medicines may also change your appearance. Your face may get fuller; you may gain
weight or develop acne or facial hair. Not all patients have these problems, though, and diet
and makeup can help.
Immunosuppressants work by diminishing the ability of immune cells to function. In some
patients, over long periods of time, this diminished immunity can increase the risk of
developing cancer. Some immunosuppressants can cause cataracts, diabetes, extra
stomach acid, high blood pressure, and bone disease. When used over time, these drugs
may also cause liver or kidney damage in a few patients.

Diet for Kidney Transplantation

Diet for transplant patients is less limited than it is for dialysis patients, although you
may still have to cut back on some foods. Your diet will probably change as your medicines,
blood values, weight, and blood pressure change.
You may need to count calories. Your medicine may give you a bigger appetite
and cause you to gain weight.
You may have to eat less salt. Your medications may cause your body to retain
sodium, leading to high blood pressure.

Pros and Cons

Kidney transplantation has advantages and disadvantages. See the list below.
Kidney Transplantation
Pros
+ A transplanted kidney works like a normal kidney.
+ You may feel healthier and more normal.
+ You have fewer diet restrictions.
+ You wont need dialysis.
+ Patients who successfully go through the selection process have a higher chance of
living a longer life.
Cons
- It requires major surgery.
- You may need to wait for a donor.
- Your body may reject the new kidney, so one transplant may not last a lifetime.
- Youll need to take immunosuppressants, which may cause complications.

Treatment Choice: Refusing or Withdrawing from Treatment

For many people, dialysis and transplantation not only extend life but also improve
quality of life. For others who have serious ailments in addition to kidney failure, dialysis
may seem a burden that only prolongs suffering. You have the right to refuse or withdraw
from dialysis. You may want to speak with your spouse, family, religious counselor, or social
worker as you make this decision.

If you withdraw from dialysis treatments or refuse to begin them, you may live for a
few days or for several weeks, depending on your health and your remaining kidney
function. Your doctor can give you medicines to make you more comfortable during this
time. You may start or resume your treatments if you change your mind about refusing
dialysis.

Even if youre satisfied with your quality of life on dialysis, you should think about
circumstances that might make you want to stop dialysis treatments. At some point in a
medical crisis, you might lose the ability to express your wishes to your doctor. An advance
directive is a statement or document in which you give instructions either to withhold
treatment or to provide it, depending on your wishes and the specific circumstances.

An advance directive may be a living will, a document that details the conditions
under which you would want to refuse treatment. You may state that you want your health
care team to use all available means to sustain your life. Or you may direct that you be
withdrawn from dialysis if you become permanently unresponsive or fall into a coma from
which you wont awake. In addition to dialysis, other life-sustaining treatments you may
choose or refuse include
cardiopulmonary resuscitation (CPR)
tube feedings
mechanical or artificial respiration
antibiotics
surgery
blood transfusions

Another form of advance directive is called a durable power of attorney for health
care decisions or a health care proxy. In this type of advance directive, you assign a person
to make health care decisions for you if you become unable to make them for yourself. Make
sure the person you name understands your values and is willing to follow through on your
instructions.

Points to Remember
Your kidneys filter wastes from your blood and regulate other functions of your body.
When your kidneys fail, you need treatment to replace the work your kidneys
normally perform.
Your three choices for treatment are hemodialysis, peritoneal dialysis, and kidney
transplantation.
The choice you make will affect your diet, your ability to work, and other life style
issues.
You have the right to refuse or withdraw from treatment if you choose.
Medicare and Medicaid pay much of the cost of treatment for kidney failure.

Treatment Methods for Kidney Failure: Hemodialysis

Hemodialysis is the most common method used to treat advanced and permanent
kidney failure. Since the 1960s, when hemodialysis first became a practical treatment for
kidney failure, weve learned much about how to make hemodialysis treatments more
effective and minimize side effects. In recent years, more compact and simpler dialysis
machines have made home dialysis increasingly attractive. But even with better procedures
and equipment, hemodialysis is still a complicated and inconvenient therapy that requires a
coordinated effort from your whole health care team, including your nephrologist, dialysis
nurse, dialysis technician, dietitian, and social worker. The most important members of your
health care team are you and your family. By learning about your treatment, you can work
with your health care team to give yourself the best possible results, and you can lead a full,
active life.
When Your Kidneys Fail

Healthy kidneys clean your blood by removing excess fluid, minerals, and wastes.
They also make hormones that keep your bones strong and your blood healthy. When your
kidneys fail, harmful wastes build up in your body, your blood pressure may rise, and your
body may retain excess fluid and not make enough red blood cells. When this happens, you
need treatment to replace the work of your failed kidneys.

How Hemodialysis Works

In hemodialysis, your blood is allowed to flow, a few ounces at a time, through a

special filter that removes wastes and extra fluids. The clean blood is then returned to your
body. Removing the harmful wastes and extra salt and fluids helps control your blood
pressure and keep the proper balance of chemicals like potassium and sodium in your body.

One of the biggest adjustments you must make when you start hemodialysis
treatments is following a strict schedule. Most patients go to a clinica dialysis center
three times a week for 3 to 5 or more hours each visit. For example, you may be on a
Monday-Wednesday-Friday schedule or a Tuesday-Thursday-Saturday schedule. You may be
asked to choose a morning, afternoon, or evening shift, depending on availability and
capacity at the dialysis unit. Your dialysis center will explain your options for scheduling
regular treatments.

Researchers are exploring whether shorter daily sessions, or longer sessions

performed overnight while the patient sleeps, are more effective in removing wastes. Newer
dialysis machines make these alternatives more practical with home dialysis. But the
Federal Government has not yet established a policy to pay for more than three
hemodialysis sessions a week.

Several centers around the country teach people how to perform their own
hemodialysis treatments at home. A family member or friend who will be your helper must
also take the training, which usually takes at least 4 to 6 weeks. Home dialysis gives you
more flexibility in your dialysis schedule. With home hemodialysis, the time for each session
and the number of sessions per week may vary, but you must maintain a regular schedule
by giving yourself dialysis treatments as often as you would receive them in a dialysis unit.

Adjusting to Changes

Even in the best situations, adjusting to the effects of kidney failure and the time you
spend on dialysis can be difficult. Aside from the lost time, you may have less energy. You
may need to make changes in your work or home life, giving up some activities and
responsibilities. Keeping the same schedule you kept when your kidneys were working can
be very difficult now that your kidneys have failed. Accepting this new reality can be very
hard on you and your family. A counselor or social worker can answer your questions and
help you cope.
Many patients feel depressed when starting dialysis, or after several months of
treatment. If you feel depressed, you should talk with your social worker, nurse, or doctor
because this is a common problem that can often be treated effectively.

Getting Your Vascular Access Ready

Arteriovenous fistula.One important step before starting hemodialysis is preparing a

vascular access, a site on your body from which your blood is removed and returned. A
vascular access should be prepared weeks or months before you start dialysis. It will allow
easier and more efficient removal and replacement of your blood with fewer complications.

Equipment and Procedures

When you first visit a hemodialysis center, it may seem like a complicated mix of machines
and people. But once you learn how the procedure works and become familiar with the
equipment, youll be more comfortable.

Dialysis Machine
The dialysis machine is about the size of a dishwasher. This machine has three main jobs:
pump blood and watch flow for safety
clean wastes from blood
watch your blood pressure and the rate of fluid removal from your body

Dialyzer
Structure of a typical hollow fiber dialyzer.The dialyzer is a large canister containing
thousands of small fibers through which your blood is passed. Dialysis solution, the
cleansing fluid, is pumped around these fibers. The fibers allow wastes and extra fluids to
pass from your blood into the solution, which carries them away. The dialyzer is sometimes
called an artificial kidney.
Reuse. Your dialysis center may use the same dialyzer more than once for your
treatments. Reuse is considered safe as long as the dialyzer is cleaned before each
use. The dialyzer is tested each time to make sure its still working, and it should
never be used for anyone but you. Before each session, you should be sure that the
dialyzer is labeled with your name and check to see that it has been cleaned,
disinfected, and tested.

Dialysis Solution
Dialysis solution, also known as dialysate, is the fluid in the dialyzer that helps
remove wastes and extra fluid from your blood. It contains chemicals that make it act like a
sponge. Your doctor will give you a specific dialysis solution for your treatments. This
formula can be adjusted based on how well you handle the treatments and on your blood
tests.

Needles
Many people find the needle sticks to be one of the hardest parts of hemodialysis
treatments. Most people, however, report getting used to them after a few sessions. If you
find the needle insertion painful, an anesthetic cream or spray can be applied to the skin.
The cream or spray will numb your skin briefly so you wont feel the needle.

Most dialysis centers use two needlesone to carry blood to the dialyzer and one to
return the cleaned blood to your body. Some specialized needles are designed with two
openings for two-way flow of blood, but these needles are less efficient and require longer
sessions. Needles for high-flux or high-efficiency dialysis need to be a little larger than those
used with regular dialyzers.

Some people prefer to insert their own needles. Youll need training on inserting
needles properly to prevent infection and protect your vascular access. You may also learn a
ladder strategy for needle placement in which you climb up the entire length of the
access session by session so that you dont weaken an area with a grouping of needle sticks.
A different approach is the buttonhole strategy in which you use a limited number of sites
but insert the needle back into the same hole made by the previous needle stick. Whether
you insert your own needles or not, you should know these techniques to better care for
your access.
Tests to See How Well Your Dialysis Is Working

About once a month, your dialysis care team will test your blood by using one of two
formulasURR or Kt/Vto see whether your treatments are removing enough wastes. Both
tests look at one specific waste product, called blood urea nitrogen (BUN), as an indicator for
the overall level of waste products in your system. For more information about these
measurements, see the NIDDK fact sheet Hemodialysis Dose and Adequacy.

Conditions Related to Kidney Failure and Their Treatments

Your kidneys do much more than remove wastes and extra fluid. They also make
hormones and balance chemicals in your system. When your kidneys stop working, you may
have problems with anemia and conditions that affect your bones, nerves, and skin. Some of
the more common conditions caused by kidney failure are extreme tiredness, bone
problems, joint problems, itching, and restless legs. Restless legs will keep you awake as
you feel them twitching and jumping.

Anemia and Erythropoietin (EPO)

Anemia is a condition in which the volume of red blood cells is low. Red blood cells
carry oxygen to cells throughout the body. Without oxygen, cells cant use the energy from
food, so someone with anemia may tire easily and look pale. Anemia can also contribute to
heart problems.
Anemia is common in people with kidney disease because the kidneys produce the hormone
erythropoietin, or EPO, which stimulates the bone marrow to produce red blood cells.
Diseased kidneys often dont make enough EPO, and so the bone marrow makes fewer red
blood cells. EPO is available commercially and is commonly given to patients on dialysis.

Renal Osteodystrophy
The term renal describes things related to the kidneys. Renal osteodystrophy, or
bone disease of kidney failure, affects 90 percent of dialysis patients. It causes bones to
become thin and weak or formed incorrectly and affects both children and adults. Symptoms
can be seen in growing children with kidney disease even before they start dialysis. Older
patients and women who have gone through menopause are at greater risk for this disease.
For more information about the causes of this bone disease and its treatment in dialysis
patients, see the NIDDK fact sheet Renal Osteodystrophy.

Itching (Pruritus)
Many people treated with hemodialysis complain of itchy skin, which is often worse
during or just after treatment. Itching is common even in people who dont have kidney
disease; in kidney failure, however, itching can be made worse by wastes in the bloodstream
that current dialyzer membranes cant remove from the blood.
The problem can also be related to high levels of parathyroid hormone (PTH). Some people
have found dramatic relief after having their parathyroid glands removed. The four
parathyroid glands sit on the outer surface of the thyroid gland, which is located on the
windpipe in the base of your neck, just above the collarbone. The parathyroid glands help
control the levels of calcium and phosphorus in the blood.

But a cure for itching that works for everyone has not been found. Phosphate binders
seem to help some people; these medications act like sponges to soak up, or bind,
phosphorus while it is in the stomach. Others find relief after exposure to ultraviolet light.
Still others improve with EPO shots. A few antihistamines (Benadryl, Atarax, Vistaril) have
been found to help; also, capsaicin cream applied to the skin may relieve itching by
deadening nerve impulses. In any case, taking care of dry skin is important. Applying
creams with lanolin or camphor may help.
Sleep Disorders
Patients on dialysis often have insomnia, and some people have a specific problem
called the sleep apnea syndrome, which is often signaled by snoring and breaks in snoring.
Episodes of apnea are actually breaks in breathing during sleep. Over time, these sleep
disturbances can lead to day-night reversal (insomnia at night, sleepiness during the day),
headache, depression, and decreased alertness. The apnea may be related to the effects of
advanced kidney failure on the control of breathing. Treatments that work with people who
have sleep apnea, whether they have kidney failure or not, include losing weight, changing
sleeping position, and wearing a mask that gently pumps air continuously into the nose
(nasal continuous positive airway pressure, or CPAP).
Many people on dialysis have trouble sleeping at night because of aching, uncomfortable,
jittery, or restless legs. You may feel a strong impulse to kick or thrash your legs. Kicking
may occur during sleep and disturb a bed partner throughout the night. The causes of
restless legs may include nerve damage or chemical imbalances.
Moderate exercise during the day may help, but exercising a few hours before bedtime can
make it worse. People with restless leg syndrome should reduce or avoid caffeine, alcohol,
and tobacco; some people also find relief with massages or warm baths. A class of drugs
called benzodiazepines, often used to treat insomnia or anxiety, may help as well. These
prescription drugs include Klonopin, Librium, Valium, and Halcion. A newer and sometimes
more effective therapy is levodopa (Sinemet), a drug used to treat Parkinsons disease.
Sleep disorders may seem unimportant, but they can impair your quality of life. Dont
hesitate to raise these problems with your nurse, doctor, or social worker.

Amyloidosis
Dialysis-related amyloidosis (DRA) is common in people who have been on dialysis
for more than 5 years. DRA develops when proteins in the blood deposit on joints and
tendons, causing pain, stiffness, and fluid in the joints, as is the case with arthritis. Working
kidneys filter out these proteins, but dialysis filters are not as effective.

How Diet Can Help

Eating the right foods can help improve your dialysis and your health. Your clinic has a
dietitian to help you plan meals. Follow the dietitians advice closely to get the most from
your hemodialysis treatments. Here are a few general guidelines.
Fluids. Your dietitian will help you determine how much fluid to drink each day. Extra
fluid can raise your blood pressure, make your heart work harder, and increase the
stress of dialysis treatments. Remember that many foodssuch as soup, ice cream,
and fruitscontain plenty of water. Ask your dietitian for tips on controlling your
thirst.
Potassium. The mineral potassium is found in many foods, especially fruits and
vegetables. Potassium affects how steadily your heart beats, so eating foods with too
much of it can be very dangerous to your heart. To control potassium levels in your
blood, avoid foods like oranges, bananas, tomatoes, potatoes, and dried fruits. You
can remove some of the potassium from potatoes and other vegetables by peeling
and soaking them in a large container of water for several hours, then cooking them
in fresh water.
Phosphorus. The mineral phosphorus can weaken your bones and make your skin
itch if you consume too much. Control of phosphorus may be even more important
than calcium itself in preventing bone disease and related complications. Foods like
milk and cheese, dried beans, peas, colas, nuts, and peanut butter are high in
phosphorus and should be avoided. Youll probably need to take a phosphate binder
with your food to control the phosphorus in your blood between dialysis sessions.
Salt (sodium chloride). Most canned foods and frozen dinners contain high
amounts of sodium. Too much of it makes you thirsty, and when you drink more fluid,
your heart has to work harder to pump the fluid through your body. Over time, this
 can cause high blood pressure and congestive heart failure. Try to eat fresh foods
that are naturally low in sodium, and look for products labeled low sodium.
Protein. Before you were on dialysis, your doctor may have told you to follow a low-
protein diet to preserve kidney function. But now you have different nutritional
priorities. Most people on dialysis are encouraged to eat as much high-quality protein
as they can. Protein helps you keep muscle and repair tissue, but protein breaks
down into urea (blood urea nitrogen, or BUN) in your body. Some sources of protein,
called high-quality proteins, produce less waste than others. High-quality proteins
come from meat, fish, poultry, and eggs. Getting most of your protein from these
sources can reduce the amount of urea in your blood.
Calories. Calories provide your body with energy. Some people on dialysis need to
gain weight. You may need to find ways to add calories to your diet. Vegetable oils
like olive, canola, and safflower oilsare good sources of calories and do not
contribute to problems controlling your cholesterol. Hard candy, sugar, honey, jam,
and jelly also provide calories and energy. If you have diabetes, however, be very
careful about eating sweets. A dietitians guidance is especially important for people
with diabetes.
Supplements. Vitamins and minerals may be missing from your diet because you
have to avoid so many foods. Dialysis also removes some vitamins from your body.
Your doctor may prescribe a vitamin and mineral supplement designed specifically
for people with kidney failure. Take your prescribed supplement after treatment on
the days you have hemodialysis. Never take vitamins that you can buy off the
store shelf, since they may contain vitamins or minerals that are harmful to
you.

Treatment Methods for Kidney Failure: Transplantation

If you have advanced and permanent kidney failure, kidney transplantation may be
the treatment option that allows you to live much like you lived before your kidneys failed.
Since the 1950s, when the first kidney transplants were performed, much has been learned
about how to prevent rejection and minimize the side effects of medicines.

But transplantation is not a cure; its an ongoing treatment that requires you to take
medicines for the rest of your life. And the wait for a donated kidney can be years long.

A successful transplant takes a coordinated effort from your whole health care team,
including your nephrologist, transplant surgeon, transplant coordinator, pharmacist,
dietitian, and social worker. But the most important members of your health care team are
you and your family. By learning about your treatment, you can work with your health care
team to give yourself the best possible results, and you can lead a full, active life.

When Your Kidneys Fail

Healthy kidneys clean your blood by removing excess fluid, minerals, and wastes.
They also make hormones that keep your bones strong and your blood healthy. When your
kidneys fail, harmful wastes build up in your body, your blood pressure may rise, and your
body may retain excess fluid and not make enough red blood cells. When this happens, you
need treatment to replace the work of your failed kidneys.

How Transplantation Works

Kidney transplantation is a procedure that places a healthy kidney from another

person into your body. This one new kidney takes over the work of your two failed kidneys.
 A surgeon places the new kidney inside your lower abdomen and connects the artery
and vein of the new kidney to your artery and vein. Your blood flows through the new
kidney, which makes urine, just like your own kidneys did when they were healthy. Unless
they are causing infection or high blood pressure, your own kidneys are left in place.

The Transplant Process

Your Doctors Recommendation

T he transplantation process begins when you learn that your kidneys are failing and
you must start to consider your treatment options. Whether transplantation is to be among
your options will depend on your specific situation. Transplantation isnt for everyone. Your
doctor may tell you that you have a condition that would make transplantation dangerous or
unlikely to succeed.

Medical Evaluation at a Transplant Center

If your doctor sees transplantation as an option, the next step is a thorough medical
evaluation at a transplant hospital. The pretransplant evaluation may require several visits
over the course of several weeks or even months. Youll need to have blood drawn and x
rays taken. Youll be tested for blood type and other matching factors that determine
whether your body will accept an available kidney.
The medical team will want to see whether youre healthy enough for surgery. Cancer, a
serious infection, or significant cardiovascular disease would make transplantation unlikely
to succeed. In addition, the medical team will want to make sure that you can understand
and follow the schedule for taking medicines.
If a family member or friend wants to donate a kidney, he or she will need to be evaluated
for general health and to see whether the kidney is a good match.

Placement on the Waiting List

If the medical evaluation shows that youre a good candidate for a transplant but you
dont have a family member or friend who can donate a kidney, youll be put on the
transplant programs waiting list to receive a kidney from a deceased donorsomeone who
has just died.

Every person waiting for a deceased donor organ is registered with the Organ
Procurement and Transplantation Network (OPTN), which maintains a centralized computer
network linking all regional organ gathering organizations (known as organ procurement
organizations, or OPOs) and transplant centers. The United Network for Organ Sharing
(UNOS), a private nonprofit organization, administers OPTN under a contract with the
Federal Government.

UNOS rules allow patients to register with multiple transplant centers. Each
transplant center will probably require a separate medical evaluation, even if a patient is
already registered at another center.
Observers of OPTN operations have raised the concern that people in certain regions of the
country have to wait longer than others because allocation policies for some organs give
preference to patients within the donors region. Kidneys, however, are assigned to the best
match regardless of geographic region. The Federal Government continues to monitor
policies and regulations to ensure that every person waiting for an organ has a fair chance.
The key to making waiting times shorter is to increase the number of donated organs.

Waiting Period
How long youll have to wait depends on many things but is primarily determined by
the degree of matching between you and the donor. Some people wait several years for a
good match, while others get matched within a few months.
While youre on the waiting list, notify the transplant center of changes in your health. Also,
let the transplant center know if you move or change telephone numbers. The center will
need to find you immediately when a kidney becomes available.

OPOs are responsible for identifying potential organs for transplant and coordinating
with the national network. The 69 regional OPOs are all UNOS members. When a deceased
donor kidney becomes available, the OPO notifies UNOS, and a computer-generated list of
suitable recipients is created. Suitability is initially based on two factors:
Blood type. Your blood type (A, B, AB, or O) must be compatible with the donors
blood type.
HLA factors. HLA stands for human leukocyte antigen, a genetic marker located on
the surface of your white blood cells. You inherit a set of three antigens from your
mother and three from your father. A higher number of matching antigens increases
the chance that your kidney will last for a long time.
If youre selected on the basis of the first two factors, a third is evaluated:
Antibodies. Your immune system may produce antibodies that act specifically
against something in the donors tissues. To see whether this is the case, a small
sample of your blood will be mixed with a small sample of the donors blood in a
tube. If no reaction occurs, you should be able to accept the kidney. Your transplant
team might use the term negative cross-match to describe this lack of reaction.

Transplant Operation
If you have a living donor, youll schedule the operation in advance. You and your
donor will be operated on at the same time, usually in side-by-side rooms. One team of
surgeons will perform the nephrectomythat is, the removal of the kidney from the donor
while another prepares the recipient for placement of the donated kidney.

If youre on a waiting list for a deceased donor kidney, you must be ready to hurry to
the hospital as soon as a kidney becomes available. Once there, youll give a blood sample
for the antibody cross-match test. If you have a negative cross-match, it means that your
antibodies dont react and the transplantation can proceed.
Youll be given a general anesthetic to make you sleep during the operation, which usually
takes 3 or 4 hours. The surgeon will make a small cut in your lower abdomen. The artery and
vein from the new kidney will be attached to your artery and vein. The ureter from the new
kidney will be connected to your bladder.
Often, the new kidney will start making urine as soon as your blood starts flowing through it,
but sometimes a few weeks pass before it starts working.

Recovery From Surgery

As after any major surgery, youll probably feel sore and groggy when you wake up.
However, many transplant recipients report feeling much better immediately after surgery.
Even if you wake up feeling great, youll need to stay in the hospital for about a week to
recover from surgery, and longer if you have any complications.

Posttransplant Care
Your bodys immune system is designed to keep you healthy by sensing foreign
invaders, such as bacteria, and rejecting them. But your immune system will also sense
that your new kidney is foreign. To keep your body from rejecting it, youll have to take
drugs that turn off, or suppress, your immune response. You may have to take two or more
of these immunosuppressant medicines, as well as medications to treat other health
problems. Your health care team will help you learn what each pill is for and when to take it.
Be sure that you understand the instructions for taking your medicines before you leave the
hospital.
 If youve been on hemodialysis, youll find that your posttransplant diet is much less
restrictive. You can drink more fluids and eat many of the fruits and vegetables you were
previously told to avoid. You may even need to gain a little weight, but be careful not to gain
weight too quickly and avoid salty foods that can lead to high blood pressure.

Rejection
You can help prevent rejection by taking your medicines and following your diet, but
watching for signs of rejectionlike fever or soreness in the area of the new kidney or a
change in the amount of urine you makeis important. Report any such changes to your
health care team.

Even if you do everything youre supposed to do, your body may still reject the new
kidney and you may need to go back on dialysis. Unless your health care team determines
that youre no longer a good candidate for transplantation, you can go back on the waiting
list for another kidney.

Side Effects of Immunosuppressants

Immunosuppressants can weaken your immune system, which can lead to infections.
Some drugs may also change your appearance. Your face may get fuller; you may gain
weight or develop acne or facial hair. Not all patients have these problems, though, and diet
and makeup can help.

Immunosuppressants work by diminishing the ability of immune cells to function. In

some patients, over long periods of time, this diminished immunity can increase the risk of
developing cancer. Some immunosuppressants cause cataracts, diabetes, extra stomach
acid, high blood pressure, and bone disease. When used over time, these drugs may also
cause liver or kidney damage in a few patients.

Organ Donation

Deceased Donor
Most transplanted kidneys come from people who have died. However, the number of
people waiting for kidneys has increased in recent years, while the number of kidneys
available from deceased donors has remained constant. The result is a shortage of kidneys
and a longer waiting time for people with kidney failure.

Many suitable kidneys go unused because family members of potential donors dont
know their loved ones wishes. People who wish to donate their organs should talk about this
issue with their families. Several organizations, including UNOS and the National Kidney
Foundation (see the "Resources" section), provide organ donor cards for people who wish to
make this life-preserving gift when they die. A properly completed organ donor card notifies
medical officials that youve decided to donate your organs. In most states, you can indicate
your desire to be an organ donor on your drivers license.

Living Donor
A growing number of transplanted kidneys are donated by living family members or
friends. Potential donors need to be tested to make sure that donating a kidney wont
endanger their health, as well as for matching factors. Most people, however, can donate a
kidney with little risk.
A kidney from a living donor often has advantages over a deceased donor kidney:
People who receive a kidney from a family member or friend dont have to wait until
a kidney becomes available. Living donation allows for greater preparation and for
the operation to be scheduled at a convenient time.
Kidneys from family members are more likely to be good matches, although theres
no guarantee.
 Kidneys from living donors dont need to be transported from one site to another, so
the kidney is in better condition when its transplanted.
Living donation helps people waiting for kidneys from deceased donors by lowering
the number of people on the waiting list.

Minority Donation
Diseases of the kidney are found more frequently in racial and ethnic minority
populations in the United States than in the general population. African Americans, Asian
Americans, Hispanics/Latinos, and Pacific Islander Americans are three times more likely to
suffer from kidney failure than Americans of European descent. Successful transplantation is
often enhanced if organs are matched between members of the same ethnic and racial
group. A shortage of organs donated by minorities can contribute to longer waiting periods
for transplants for minorities.

The National Minority Organ/Tissue Transplant Education Program (MOTTEP), with the
support of the National Institutes of Healths (NIHs) Office of Research on Minority Health
and the NIDDK, is the first national program to empower minority communities to promote
minority donation and transplantation, as well as good health habits. In turn, this effort
should improve the chances for a well-matched organ among all those waiting for a
transplant.

Eat Right to Feel Right on Hemodialysis

When you start hemodialysis, you must make many changes in your life. Watching
the foods you eat will make you healthier. This publication will help you choose the right
foods.

How does food affect my hemodialysis?

Food gives you energy and helps your body repair itself. Food is broken down in your
stomach and intestines. Your blood picks up nutrients from the digested food and carries
them to all your body cells. These cells take nutrients from your blood and put waste
products back into the bloodstream. When your kidneys were healthy, they worked around
the clock to remove wastes from your blood. The wastes left your body when you urinated.
Other wastes are removed in bowel movements.

Now that your kidneys have stopped working, hemodialysis removes wastes from
your blood. But between dialysis sessions, wastes can build up in your blood and make you
sick. You can reduce the amount of wastes by watching what you eat and drink. A good meal
plan can improve your dialysis and your health.
Your clinic has a dietitian to help you plan meals. A dietitian specializes in food and nutrition.
A dietitian with special training in care for kidney health is called a renal dietitian.

What do I need to know about fluids?

You already know you need to watch how much you drink. Any food that is liquid at room
temperature also contains water. These foods include soup, Jell-O, and ice cream. Many
fruits and vegetables contain lots of water, too. They include melons, grapes, apples,
oranges, tomatoes, lettuce, and celery. All these foods add to your fluid intake.
Fluid can build up between dialysis sessions, causing swelling and weight gain. The extra
fluid affects your blood pressure and can make your heart work harder. You could have
serious heart trouble from overloading your system with fluid.

Control Your thirst

The best way to reduce fluid intake is to reduce thirst caused by the salt you eat.
Avoid salty foods like chips and pretzels. Choose low-sodium products.

You can keep your fluids down by drinking from smaller cups or glasses. Freeze juice
in an ice cube tray and eat it like a popsicle. (Remember to count the popsicle in your fluid
allowance!) The dietitian will be able to give you other tips for managing your thirst.

Your dry weight is your weight after a dialysis session when all of the extra fluid in
your body has been removed. If you let too much fluid buildup between sessions, it is harder
to get down to your proper dry weight. Your dry weight may change over a period of 3 to 6
weeks. Talk with your doctor regularly about what your dry weight should be.

My dry weight should be _____________.

What do I need to know about potassium?

Potassium is a mineral found in many foods, especially milk, fruits, and vegetables. It
affects how steadily your heart beats. Healthy kidneys keep the right amount of potassium
in the blood to keep the heart beating at a steady pace. Potassium levels can rise between
dialysis sessions and affect your heartbeat. Eating too much potassium can be very
dangerous to your heart. It may even cause death.
To control potassium levels in your blood, avoid foods like avocados, bananas, kiwis,
and dried fruit, which are very high in potassium. Also, eat smaller portions of other high-
potassium foods. For example, eat half a pear instead of a whole pear. Eat only very small
portions of oranges and melons.

Dicing and Boiling Potatoes to Reduce Potassium

You can remove some of the potassium from potatoes by dicing or shredding them and then
boiling them in water. Your dietitian will give you more specific information about the
potassium content of foods.

High-Potassium Foods:
apricots
kiwi fruit potatoes
avocados
lima prune juice
bananas
melons prunes
beets
milk raisins
Brussels
nectarines sardines
cantaloupe
orange juice spinach
clams
oranges tomatoes
dates
peanuts winter squash
figs
pears (fresh) yogurt
Sprout beans

What do I need to know about phosphorus?

Phosphorus is a mineral found in many foods. If you have too much phosphorus in
your blood, it pulls calcium from your bones. Losing calcium will make your bones weak and
likely to break. Also, too much phosphorus may make your skin itch. Foods like milk and
cheese, dried beans, peas, colas, nuts, and peanut butter are high in phosphorus. Usually,
people on dialysis are limited to 1/2 cup of milk per day. The renal dietitian will give you
more specific information regarding phosphorus.

You probably will need to take a phosphate binder like Renagel, PhosLo, Tums, or
calcium carbonate to control the phosphorus in your blood between dialysis sessions. These
medications act like sponges to soak up, or bind, phosphorus while it is in the stomach.
Because it is bound, the phosphorus does not get into the blood. Instead, it is passed out of
the body in the stool.

What do I need to know about protein?

Before you were on dialysis, your doctor may have told you to follow a low-protein
diet. Being on dialysis changes this. Most people on dialysis are encouraged to eat as much
high-quality protein as they can. Protein helps you keep muscle and repair tissue. The better
nourished you are, the healthier you will be. You will also have greater resistance to
infection and recover from surgery more quickly.

Your body breaks protein down into a waste product called urea. If urea builds up in
your blood, its a sign you have become very sick. Eating mostly high-quality proteins is
important because they produce less waste than others. High-quality proteins come from
meat, fish, poultry, and eggs (especially egg whites).

What do I need to know about sodium?

Sodium is found in salt and other foods. Most canned foods and frozen dinners
contain large amounts of sodium. Too much sodium makes you thirsty. But if you drink more
fluid, your heart has to work harder to pump the fluid through your body. Over time, this can
cause high blood pressure and congestive heart failure.

Try to eat fresh foods that are naturally low in sodium Look for products labeled low
sodium.
Do not use salt substitutes because they contain potassium. Talk with a dietitian
about spices you can use to flavor your food. The dietitian can help you find spice blends
without sodium or potassium.

What do I need to know about calories?

Calories provide energy for your body. If your doctor recommends it, you may need
to cut down on the calories you eat. A dietitian can help you plan ways to cut calories in the
best possible way.
Some people on dialysis need to gain weight. You may need to find ways to add calories to
your diet. Vegetable oilslike olive oil, canola oil, and safflower oilare good sources of
calories. Use them generously on breads, rice, and noodles.

Butter and margarines are rich in calories. But these fatty foods can also clog your
arteries. Use them less often. Soft margarine that comes in a tub is better than stick
margarine. Vegetable oils are the healthiest way to add fat to your diet if you need to gain
weight.

Hard candy, sugar, honey, jam, and jelly provide calories and energy without
clogging arteries or adding other things that your body does not need. If you have
diabetes, be very careful about eating sweets. A dietitians guidance is very
important for people with diabetes.

Should I take vitamins and minerals?

 Vitamins and minerals may be missing from your diet because you have to avoid so
many foods. Your doctor may prescribe a vitamin and mineral supplement like Nephrocaps.

Warning: Do not take vitamin supplements that you can buy off the store shelf. They may
contain vitamins or minerals that are harmful to you.

Vascular Access for Hemodialysis

If you are starting hemodialysis treatments in the next several months, you need to
work with your health care team to learn how the treatments work and how to get the most
from them. One important step before starting regular hemodialysis sessions is preparing a
vascular access, which is the site on your body where blood is removed and returned during
dialysis. To maximize the amount of blood cleansed during hemodialysis treatments, the
vascular access should allow continuous high volumes of blood flow.

A vascular access should be prepared weeks or months before you start dialysis. The
early preparation of the vascular access will allow easier and more efficient removal and
replacement of your blood with fewer complications.

The three basic kinds of vascular access for hemodialysis are an arteriovenous (AV)
fistula, an AV graft, and a venous catheter. A fistula is an opening or connection between
any two parts of the body that are usually separatefor example, a hole in the tissue that
normally separates the bladder from the bowel. While most kinds of fistula are a problem, an
AV fistula is useful because it causes the vein to grow larger and stronger for easy access to
the blood system. The AV fistula is considered the best long-term vascular access for
hemodialysis because it provides adequate blood flow, lasts a long time, and has a lower
complication rate than other types of access. If an AV fistula cannot be created, an AV graft
or venous catheter may be needed.

What is an arteriovenous fistula?

An AV fistula requires advance planning because a fistula takes a while after surgery to
developin rare cases, as long as 24 months. But a properly formed fistula is less likely than
other kinds of vascular access to form clots or become infected. Also, properly formed
fistulas tend to last many yearslonger than any other kind of vascular access.

A surgeon creates an AV fistula by connecting an artery directly to a vein, frequently

in the forearm. Connecting the artery to the vein causes more blood to flow into the vein. As
a result, the vein grows larger and stronger, making repeated needle insertions for
hemodialysis treatments easier. For the surgery, youll be given a local anesthetic. In most
cases, the procedure can be performed on an outpatient basis.

What is an arteriovenous graft?

If you have small veins that wont develop properly into a fistula, you can get a
vascular access that connects an artery to a vein using a synthetic tube, or graft, implanted
under the skin in your arm. The graft becomes an artificial vein that can be used repeatedly
for needle placement and blood access during hemodialysis. A graft doesnt need to develop
as a fistula does, so it can be used sooner after placement, often within 2 or 3 weeks.

Compared with properly formed fistulas, grafts tend to have more problems with
clotting and infection and need replacement sooner. However, a well-cared-for graft can last
several years.
What is a venous catheter for temporary access?

If your kidney disease has progressed quickly, you may not have time to get a
permanent vascular access before you start hemodialysis treatments. You may need to use
a venous catheter as a temporary access.
A catheter is a tube inserted into a vein in your neck, chest, or leg near the groin. It has two
chambers to allow a two-way flow of blood. Once a catheter is placed, needle insertion is not
necessary.
Catheters are not ideal for permanent access. They can clog, become infected, and cause
narrowing of the veins in which they are placed. But if you need to start hemodialysis
immediately, a catheter will work for several weeks or months while your permanent access
develops.

For some people, fistula or graft surgery is unsuccessful, and they need to use a long-
term catheter access. Catheters that will be needed for more than about 3 weeks are
designed to be tunneled under the skin to increase comfort and reduce complications. Even
tunneled catheters, however, are prone to infection.

What can I expect during hemodialysis?

Every hemodialysis session using an AV fistula or AV graft requires needle insertion.

Most dialysis centers use two needlesone to carry blood to the dialyzer and one to return
the cleansed blood to your body. Some specialized needles are designed with two openings
for two-way flow of blood, but these needles are less efficient. For some people, using this
needle may mean longer treatments.

Some people prefer to insert their own needle, which requires training to learn how to
prevent infection and protect the vascular access. You can also learn a ladder strategy for
needle placement in which you climb up the entire length of the fistula, session by
session, so you wont weaken an area with a grouping of needle sticks.

An alternative approach is the buttonhole strategy in which you use a limited

number of sites but insert the needle precisely into the same hole made by the previous
needle stick. Whether you insert your own needles or not, you should know about these
techniques so you can understand and ask questions about your treatments.

What are some possible complications of my vascular access?

All three types of vascular accessAV fistula, AV graft, and venous cathetercan
have complications that require further treatment or surgery. The most common
complications are access infection and low blood flow due to blood clotting in the access.

Venous catheters are most likely to develop infection and clotting problems that may
require medication and catheter removal or replacement.

AV grafts can also develop low blood flow, an indication of clotting or narrowing of
the access. In this situation, the AV graft may require angioplasty, a procedure to widen the
small segment that is narrowed. Another option is to perform surgery on the AV graft and
replace the narrow segment.
I nfection and low blood flow are much less common in properly formed AV fistulas
than in AV grafts and venous catheters. Still, having an AV fistula is not a guarantee against
complications.

How should I take care of my vascular access?

You can take several steps to protect your access:

Make sure your nurse or technician checks your access before each treatment.
Keep your access clean at all times.
Use your access site only for dialysis.
Be careful not to bump or cut your access.
Dont let anyone put a blood pressure cuff on your access arm.
Dont wear jewelry or tight clothes over your access site.
Dont sleep with your access arm under your head or body.
Dont lift heavy objects or put pressure on your access arm.
Check the pulse in your access every day.

Hemodialysis Dose and Adequacy

When kidneys fail, dialysis is necessary to remove waste products such as urea from
the blood. By itself, urea is only mildly toxic, but a high urea level means that the levels of
many other waste products that are more harmful and not as easily measured are also
building up.
To see whether dialysis is removing enough urea, the dialysis clinic should periodically
normally once a monthtest a patients blood to measure dialysis adequacy. Blood is
sampled at the start of dialysis and at the end. The levels of urea in the two blood samples
are then compared. Two methods are generally used to assess dialysis adequacy, URR and
Kt/V.

What can patients do to improve their Kt/V?

If a patients average Kt/Vusually the average of three measurementsis consistently
below 1.2, the patient and the nephrologist need to discuss ways to improve it. Since the V
value is fixed, Kt/V can be improved either by increasing K or t.

Increase Blood Flow through the Dialyzer

Increasing K depends primarily on the rate of blood flow through the dialyzer. No
matter how good a dialyzer is, how well it works depends primarily on moving blood through
it. In many patients, a good rate is difficult to achieve because of vascular access problems.

If a patients blood flow rate is good, further improvements in clearance can be

obtained by using a big dialyzer or, in some cases, by increasing the flow rate for dialysis
solution from the usual 500 mL/min to 600 or 800 mL/min. A good flow rate for adult
patients is 350 mL/min and higher. A few centers are even using two dialyzers at the same
time to increase K in larger than average patients.
However, the rate of blood flow through the dialyzer is key, and a good vascular access is
crucial to make sure a patient is getting good clearance.

Increase Time on Dialysis

The other way to improve the Kt in Kt/V is to increase t by dialyzing for a longer period. For
example, if the Kt/V is 0.9 and the goal is 1.2, then 1.2/0.9 = 1.33, so 1.33 times more Kt is
needed. If K is not changed, this means the length of the session needs to increase by 33
percent. If the inadequate sessions lasted 3 hours, they should be increased to 4 hours.
Identify and Eliminate Circulation Problems
If during any given month a patients Kt/V is extremely low, the measurement should be
repeated, unless a reason for the low Kt/V is obvious. Obvious reasons include treatment
interruption, problems with blood or solution flow, and a problem in sampling either the pre-
or postdialysis blood. If no reason for the sudden drop is apparent, then a problem with
needle placement, like accidental needle reversal, or with the vascular access, such as
recirculation, should be suspected.

Points to Remember
The two methods generally used to assess dialysis adequacy are URR and Kt/V.
A patients average URR should exceed 65 percent.
A patients average Kt/V should be at least 1.2.
A patients URR or Kt/V can be increased either by increasing time on dialysis or
increasing blood flow through the dialyzer.

Amyloidosis and Kidney Disease

Proteins are important building blocks for all body parts, including muscles, bones,
hair, and nails. Proteins circulate throughout the body in the blood and are normally
harmless. Occasionally, cells produce abnormal proteins that can settle in body tissue,
forming deposits and causing disease. When these deposits of abnormal proteins were first
discovered, they were called amyloid, and the disease process amyloidosis.
In recent years, researchers have discovered that different kinds of proteins can form
amyloid deposits and have identified several types of amyloidosis. Two of these types are
closely related to kidney disease. In primary amyloidosis, abnormal protein production
occurs as a first step and can lead to kidney disease. Dialysis-related amyloidosis (DRA), on
the other hand, is a result of kidney disease.

Primary Amyloidosis

Primary amyloidosis occurs when the body's antibody-producing cells do not function
properly and produce abnormal protein fibers made of antibody fragments. Some people
with primary amyloidosis have a condition called multiple myeloma. The antibody fragments
come together to form amyloid deposits in different organs, including the kidneys, where
they cause serious damage. Injured kidneys can't function effectively and may be unable to
remove urea and other wastes from the blood. Elevated levels of these protein fibers can
also damage the heart, lungs, brain, and digestive system.

One common sign of kidney amyloidosis is the presence of abnormally high levels of
protein in the urine, a condition known as proteinuria. Healthy kidneys prevent protein from
entering the urine, so the presence of protein may be a sign that the kidneys aren't working
properly. A physician who finds large amounts of protein in the urine may also perform a
biopsytake a small sample of tissue for examination with a microscopeto confirm
amyloidosis.

Current treatments are aimed at slowing the progression of amyloid build-up.

Combination drug therapy with melphalan, a cancer drug, and prednisone, an anti-
inflammatory steroid drug, may improve organ function and survival rates by interrupting
the growth of the abnormal cells that produce amyloid protein. These are the same drugs
used in chemotherapy to treat certain cancers, such as multiple myeloma, and they may
have serious side effects, such as nausea and vomiting, hair loss, and fatigue.
 Some clinics have reported promising results treating amyloidosis by transplanting
the patients own blood stem cells to replace diseased or damaged bone marrow. The
therapy also requires high doses of melphalan, so side effects can be serious. Patients with
heart problems may not be considered for this treatment.

Dialysis-Related Amyloidosis

Normal kidneys filter and remove excess small proteins from the blood, thus keeping
blood levels normal. When the kidneys don't work properly, as in patients receiving dialysis,
one type of small protein calle beta-2-microglobulin builds up in the blood. When this occurs,
beta-2-microglobulin molecules may join together, like the links of a chain, forming a few
very large molecules from many smaller ones. These large molecules can form deposits and
eventually damage the surrounding tissues and cause great discomfort. This condition is
called dialysis-related amyloidosis (DRA).

DRA is relatively common in patients, especially older adults, who have been on
hemodialysis for more than 5 years. Hemodialysis membranes that have been used for
many years don't effectively remove the large, complex beta-2-microglobulin proteins from
the bloodstream. Newer hemodialysis membranes, as well as peritoneal dialysis, remove
beta-2-microglobulin more effectively, but not enough to keep blood levels normal. As a
result, blood levels remain elevated, and deposits form in bone, joints, and tendons (the
tissue that connects the muscle to the bone). DRA may result in pain, stiffness, and fluid in
the joints. Patients with DRA may also develop hollow cavities, or cysts, in some of their
bones; these may lead to unexpected bone fractures. Amyloid deposits may cause tears in
ligaments and tendons. Most patients with these problems can be helped by surgical
intervention.

Half of the people with DRA also develop a condition called carpal tunnel syndrome,
which results from the unusual buildup of protein in the wrists. Patients with this condition
may experience numbness or tingling, sometimes associated with muscle weakness, in their
fingers and hands. This is a treatable condition.

Anemia in Kidney Disease and Dialysis

What is anemia?

A person whose blood is low in red blood cells has anemia. Red blood cells carry
oxygen (O2) to tissues and organs throughout the body and enable them to use the energy
from food. Without oxygen, these tissues and organsparticularly the heart and brainmay
not do their jobs as well as they should. For this reason, a person who has anemia may tire
easily and look pale. Anemia may also contribute to heart problems.

Anemia is common in people with kidney disease. Healthy kidneys produce a

hormone called erythropoietin, or EPO, which stimulates the bone marrow to produce the
proper number of red blood cells needed to carry oxygen to vital organs. Diseased kidneys,
however, often dont make enough EPO. As a result, the bone marrow makes fewer red
blood cells. Other common causes of anemia include blood loss from hemodialysis and low
levels of iron and folic acid. These nutrients from food help young red blood cells make
hemoglobin, their main oxygen-carrying protein.

What are the laboratory tests for anemia?

A complete blood count (CBC), a laboratory test performed on a sample of blood,

includes a determination of a persons hematocrit, the percentage of the blood that consists
of red blood cells. The CBC also measures the amount of hemoglobin in the blood. The range
of normal hematocrit and hemoglobin in women who have a period is slightly lower than for
healthy men and healthy women who have stopped having periods (postmenopausal). The
hemoglobin is usually about one-third the value of the hematocrit.

When does anemia begin?

Anemia may begin to develop in the early stages of kidney disease, when you still
have 20 percent to 50 percent of your normal kidney function. This partial loss of kidney
function is often called chronic renal insufficiency. Anemia tends to worsen as kidney
disease progresses. End-stage kidney failure, the point at which dialysis or kidney
transplantation becomes necessary, doesn't occur until you have only about 10 percent of
your kidney function remaining. Nearly everyone with end-stage kidney failure has anemia.

How is anemia diagnosed?

If a person has lost at least half of normal kidney function and has a low hematocrit,
the most likely cause of anemia is decreased EPO production. The estimate of kidney
function, also called the glomerular filtration rate, is based on a blood test that measures
creatinine. Experts recommend that doctors begin a detailed evaluation of anemia in men
and postmenopausal women on dialysis when the hematocrit falls below 37 percent. For
women of childbearing age, evaluation should begin when the hematocrit falls below 33
percent. The evaluation will include tests for iron deficiency and blood loss in the stool to be
certain there are no other reasons for the anemia.

How is anemia treated?

EPO
If no other cause for anemia is found, it can be treated with a genetically engineered
form of EPO. The EPO is usually injected under the skin two or three times a week. Patients
on hemodialysis who cant tolerate EPO shots may receive the hormone intravenously
during treatment. The intravenous method, however, requires a larger, more expensive dose
and may not be as effective.

The U.S. Food and Drug Administration (FDA) recommends that patients treated with
EPO therapy should achieve a target hemoglobin between 10 and 12 grams per deciliter
(g/dL). Recent studies have shown that raising the hemoglobin above 12 g/dL in people who
have kidney disease increases the risk of heart attack, heart failure, and stroke. People who
take EPO shots should have regular tests to monitor their hemoglobin. If it climbs above 12
g/dL, their doctor should prescribe a lower dose of EPO. The FDA recommends that patients
whose hemoglobin does not rise to the target level with normal doses of EPO ask their
doctor to check for other causes of anemia.

Iron
Many people with kidney disease need both EPO and iron supplements to raise their
hematocrit to a satisfactory level. If a persons iron levels are too low, EPO wont help and
that person will continue to experience the effects of anemia. Some people are able to take
an iron pill, but many studies show that iron pills dont work as well in people with kidney
failure as iron given intravenously. Iron can be injected into an arm vein or into the tube that
returns blood to the body during hemodialysis.

A nurse or doctor will give each patient a test dose because a small number of people
less than 1 percenthave a bad reaction to iron injections. If a patient begins to wheeze
or have trouble breathing, the health care provider can give epinephrine or corticosteroids
to counter the reaction. Even though the risk is small, patients are asked to sign a form
stating they understand the possible reaction and they agree to have the treatment.
Patients should talk with their health care providers if they have any questions.
In addition to measuring hematocrit and hemoglobin, the CBC test will include two other
measurements to show whether a person has enough iron.
The ferritin level indicates the amount of iron stored in the body. The ferritin score
should be no less than 100 micrograms per liter (mcg/L) and no more than 800
mcg/L.
TSAT stands for transferrin saturation, a score that indicates how much iron is
available to make red blood cells. The TSAT score should be between 20 and 50
percent.

What are some other causes of anemia?

In addition to EPO and iron, a few people may need vitamin B12 and folic acid
supplements.
If EPO, iron, vitamin B12, and folic acid supplements do not help, the doctor should look for
other causes of anemia such as sickle cell disease or an inflammatory problem. At one time,
aluminum poisoning contributed to anemia in people with kidney failure. Many phosphate
binders used to treat bone disease caused by kidney failure were antacids that contained
aluminum. But aluminum-free alternatives are now widely available. People with CKD and
kidney failure should be sure their phosphate binder and other drugs are free of aluminum.
Anemia keeps many people with kidney disease from feeling their best. But EPO treatments
help most patients raise their hemoglobin and have more energy.

Points to Remember
A person whose blood is low in red blood cells has anemia.
Anemia is common in people with kidney disease.
Healthy kidneys produce a hormone called erythropoietin, or EPO, which stimulates
the bone marrow to produce the proper number of red blood cells needed to carry
oxygen to vital organs. Diseased kidneys, however, often dont make enough EPO.
A complete blood count (CBC), a laboratory test performed on a sample of blood,
includes a determination of a persons hematocrit, the percentage of the blood that
consists of red blood cells.
If no cause for anemia other than reduced EPO production is found, it can be treated
with a genetically engineered form of EPO, which is usually injected under the skin
two or three times a week.
The U.S. Food and Drug Administration (FDA) recommends that patients treated with
EPO therapy should achieve a target hemoglobin between 10 and 12 grams per
deciliter (g/dL).
People who take EPO shots should have regular tests to monitor their hemoglobin. If
it climbs above 12 g/dL, their doctor should prescribe a lower dose of EPO.
Many people with kidney disease need both EPO and iron supplements to raise their
hematocrit to a satisfactory level.

Chronic Kidney Disease-Mineral and Bone Disorder

What is chronic kidney disease-mineral and bone disorder (CKD-MBD)?

CKD-MBD occurs when the kidneys fail to maintain the proper levels of calcium and
phosphorus in the blood, leading to abnormal bone hormone levels. CKD-MBD is a common
problem in people with kidney disease and affects almost all patients receiving dialysis.
 CKD-MBD is most serious in children because their bones are still growing. The
condition slows bone growth and causes deformities. One such deformity occurs when the
legs bend inward toward each other or outward away from each other; this deformity is
referred to as renal rickets. Another serious complication is short stature. Symptoms can
be seen in growing children with renal disease even before they start dialysis.

The bone changes from CKD-MBD can begin many years before symptoms appear in
adults with kidney disease. For this reason, the disease is known as a silent crippler. If
CKD-MBD in adults is left untreated, the bones gradually become thin and weak, and a
person with CKD-MBD may begin to feel bone and joint pain. CKD-MBD also increases the
risk of bone fractures.

Doctors used to use the term renal osteodystrophy to describe the mineral and hormone
disturbances caused by kidney disease. Now renal osteodystrophy is used only to describe
the bone problems that result from CKD-MBD.

Why are hormones and minerals important?

In healthy adults, bone tissue is continually being remodeled and rebuilt. The kidneys
play an important role in maintaining healthy bone mass and structure because one of their
jobs is to balance calcium and phosphorus levels in the blood and ensure the vitamin D a
person receives from sunlight and food becomes activated.

Calcium is a mineral that builds and strengthens bones. Calcium is found in many
foods, particularly milk and other dairy products. If calcium levels in the blood become too
low, four small glands in the neck called the parathyroid glands release a hormone called
parathyroid hormone (PTH). This hormone draws calcium from the bones to raise blood
calcium levels. Too much PTH in the blood will remove too much calcium from the bones;
over time, the constant removal of calcium weakens the bones.

Phosphorus, an element found in most foods, also helps regulate calcium levels in the
bones. Healthy kidneys remove excess phosphorus from the blood. When the kidneys stop
working normally, phosphorus levels in the blood can become too high, leading to lower
levels of calcium in the blood and resulting in higher PTH levels and the loss of calcium from
the bones. Even before blood levels of phosphorus become elevated, the kidneys are forced
to work harder to clear phosphorus from the body.

Healthy kidneys produce calcitriol from vitamin D that is received from sunlight and
food. Calcitriol helps the body absorb dietary calcium and phosphorus into the blood and
bones. Calcitriol and PTH work together to keep calcium balance normal and bones healthy.
If calcitriol levels drop too low, PTH levels increase and calcium is removed from the bones.
In a person with kidney failure, the kidneys stop making calcitriol. The body then cannot
absorb calcium from food, leading to increased PTH levels. The combination of decreased
calcium absorption from food and PTH drawing calcium from bones makes the bones weak
and brittle.

How is CKD-MBD diagnosed?

To diagnose CKD-MBD, a doctor may take a blood sample to measure levels of

calcium, phosphorus, PTH, and sometimes vitamin D. The doctor may perform a bone biopsy
to see if the bone cells are building normal bone. A bone biopsy is done under local
anesthesia and involves removing a small sample of bone from the hip and analyzing it with
a microscope. Determining the cause of CKD-MBD helps the doctor decide on a course of
treatment.
How is CKD-MBD treated?

Controlling PTH levels prevents damage to bones. Usually, overactive parathyroid

glands are controllable with a change in diet, dialysis treatment, or medication.

CKD-MBD can be treated with changes in diet. Reducing dietary intake of phosphorus
is one of the most important steps in preventing bone disease. Almost all foods contain
phosphorus, but it is especially high in milk, cheese, dried beans, peas, nuts, and peanut
butter. Drinks such as cocoa, dark sodas, and beer are also high in phosphorus. Often,
medications called phosphate binderssuch as calcium carbonate (Tums), calcium acetate
(PhosLo), sevelamer hydrochloride (Renagel), or lanthanum carbonate (Fosrenol)are
prescribed with meals and snacks to bind phosphorus in the bowel. These medications
decrease the absorption of phosphorus into the blood. A renal dietitian can help develop a
dietary plan to control phosphorus levels in the blood.

Increasing dialysis dose by increasing a patients flow rate or time in treatment can
also help control phosphorus.
If the kidneys are not making adequate amounts of calcitriol, a person can take synthetic
calcitriol as a pill (Rocaltrol) or in an injectable form (Calijex). Other types of vitamin D that
may be prescribed are ergocalciferol (Calciferol, Drisdol), cholecalciferol (Delta D3),
doxercalciferol (Hectoral), and paricalcitol (Zemplar). A doctor may prescribe a calcium
supplement in addition to calcitriol. The drug cinacalcet hydrochloride (Sensipar), approved
by the U.S. Food and Drug Administration in 2004, lowers PTH levels by imitating calciums
effects on the parathyroid gland. If PTH levels cannot be controlled, the parathyroid glands
may need to be removed surgically.
A good treatment program, including proper attention to diet, dialysis, and medications, can
improve the bodys ability to repair bones damaged by CKD-MBD. Overall bone health can
also be improved by exercising and not smoking. People on dialysis should consult a health
care professional before beginning any exercise program.

Points to Remember
Chronic kidney disease-mineral and bone disorder (CKD-MBD) occurs when the
kidneys fail to maintain the proper levels of calcium and phosphorus in the blood.
CKD-MBD is a common problem in people with kidney disease and affects almost all
patients receiving dialysis.
If calcium levels in the blood become too low, or phosphorus levels too high, four
small glands in the neck called the parathyroid glands release a hormone called
parathyroid hormone (PTH). This hormone draws calcium and phosphorus from the
bones to raise blood calcium levels.
Healthy kidneys convert vitamin D into calcitriol to help the body absorb dietary
calcium and phosphorus into the blood and bones. If calcitriol levels drop too low,
PTH levels increase and the bones can become weak and brittle.
Reducing dietary intake of phosphorus is one of the most important steps in
preventing bone disease.
Medications called phosphate binders are prescribed with meals and snacks to bind
phosphorus in the bowel.
Increasing dialysis dose by increasing a patients flow rate or time in treatment can
also help control phosphorus.
If the kidneys are not making adequate amounts of calcitriol, a person can take
synthetic calcitriol or other forms of vitamin D as a pill or in an injectable form.
If PTH levels cannot be controlled, the parathyroid glands may need to be removed
surgically.
 Kidney Failure: What to Expect

Kidney failure can hit you in surprising ways. You may get headaches and other
pains. You may be tired all the time and lose your appetite. But what do the kidneys have to
do with these conditions?
Healthy kidneys remove waste products from your blood. When your kidneys stop working
waste products build up in your blood. These waste products are called uremic toxins. This
condition is known as uremia. Your kidneys also make hormones and balance chemicals in
your system. When your kidneys stop working many problems can happen. You may develop
anemia (low blood count) or conditions that affect your bones, nerves, and skin. Some of the
more common conditions caused by kidney failure are fatigue, bone problems, joint
problems, itching, and "restless legs."

Anemia and Fatigue

Anemia is a condition in which the red blood cells in the body are low. Red blood cells
carry oxygen to the cells in the body. Without oxygen, cells cant use the energy from food.
Someone with anemia may tire easily and look pale. Anemia can also add to heart problems.

Anemia is common in people with kidney disease because the kidneys produce the
hormone erythropoietin (EPO). EPO helps the bone marrow to make red blood cells. People
with kidney disease often dont make enough EPO. Their bone marrow makes fewer red
blood cells so they get anemia. EPO is available by prescription. EPO is commonly given to
patients who are on dialysis.

Loss of Appetite and Nausea

Having uremia can change the way food tastes to you. You may no longer like foods
you used to crave. In fact, sometimes you may feel sick to your stomach at the thought of
eating. But getting enough protein and calories is important for staying healthy. Work with
your clinics dietitian to find meals that appeal to you and provide the nutrients you need.

Itching (Pruritus)

Many people treated with hemodialysis complain of itchy skin. This is often worse
during or just after the dialysis treatment. Itching is common even in people who do not
have kidney disease. If you have kidney failure the itching can be made worse by uremic
toxins that aren't removed from the blood during dialysis. The problem can also be related
to high levels of parathyroid hormone (PTH). This is also common in kidney failure. Some
people feel much better after having their parathyroid glands removed. But a cure for
itching that works for everyone has not been found. Phosphate binders seem to help some
people. Others find relief after exposure to ultraviolet light. Still others improve with EPO
shots. A few antihistamines (Benadryl, Atarax, Vistaril) have been found to help. Capsaicin
cream applied to the skin may relieve itching by deadening nerve impulses. Whatever
treatment you choose, taking care of dry skin is important. Applying creams with lanolin or
camphor may help keep your skin moist.

Sleep Disorders

Patients on dialysis often have insomnia (trouble getting to sleep). Some people have
a special problem called the sleep apnea syndrome. Episodes of apnea are breaks in
breathing during sleep. Over time, these sleep disturbances can lead to "day-night reversal"
(insomnia at night, sleepiness during the day). This can cause headaches, depression, and
decreased alertness. The apnea may be related to the effects advanced kidney failure has
on the control of breathing. Some treatments may work with people who have sleep apnea,
whether they have kidney failure or not. These include losing weight, changing sleeping
position, and wearing a mask that gently pumps air continuously into the nose (nasal
continuous positive airway pressure, or CPAP).

Many people on dialysis have trouble sleeping at night because of aching,

uncomfortable, jittery, or "restless" legs. You may feel a strong impulse to kick or thrash
your legs. Kicking may occur during sleep and disturb a bed partner throughout the night.
Theories about the causes of this syndrome include nerve damage and chemical
imbalances.

Moderate exercise during the day may help, but exercising a few hours before
bedtime can make restless legs worse. People with restless leg syndrome should reduce or
avoid caffeine, alcohol, and tobacco. Some people also find relief through massages or warm
baths. A class of drugs called benzodiazepines may also help. They are often used to treat
insomnia or anxiety. These prescription drugs include Klonopin, Librium, Valium, and
Halcion. A newer and sometimes more effective therapy is levodopa (Sinemet). This drug is
also used to treat Parkinsons disease.

Sleep disorders may not seem important, but they can make your quality of life
worse. Make sure to bring these problems up with your nurse, doctor, or social worker.

Renal Osteodystrophy

The term "renal" describes things related to the kidneys. Renal osteodystrophy
means bone disease of kidney failure. It affects 90 percent of dialysis patients, both children
and adults, causing bones to become thin, weak, or malformed. Symptoms can be seen in
growing children with kidney disease even before they start dialysis. Older patients and
women who have gone through menopause are at greater risk for this disease.

Amyloidosis

Dialysis-related amyloidosis (DRA) is common in people who have been on dialysis

for more than 5 years. DRA develops when proteins in the blood deposit on joints and
tendons. This causes pain, stiffness, and fluid in the joints, as is the case with arthritis.
Working kidneys filter out these proteins. With kidney disease these proteins can build up.
Dialysis filters are not as good as the kidney. That is why DRA can happen in dialysis
patients.

Depression

Adjusting to the effects of kidney failure and the time you spend on dialysis can be
difficult. Aside from the "lost time," you may have less energy. You may need to make
changes in your work or home life, giving up some activities and responsibilities. Keeping
the same schedule you kept when your kidneys were working can be very difficult now that
your kidneys have failed. Accepting this new reality can be very hard on you and your
family. A counselor or social worker can help you cope.

Many patients feel depressed when starting dialysis, or after several months of
treatment. If you feel depressed, you should talk with your social worker, nurse, or doctor.
This is a common problem that can often be treated effectively.

Your treatment should do more than just keep you alive. It should also give you the
best quality of life possible. Don't assume that you have to live with fatigue and pain. Talk
with your health care team so they can help you get the most from your treatments.
NORMAL VALUES

Albumin 3.2 - 5 g/dl

Alkaline phosphatase
33 - 131 IU/L
(Adults: 25-60)

Adults > 61 yo: 51 - 153 IU/L

Ammonia 20 - 70 mcg/dl

Bilirubin, direct 0 - 0.3 mg/dl

Bilirubin, total 0.1 - 1.2 mg/dl

Blood Gases

Arterial Venous

pH 7.35 - 7.45 7.32 - 7.42

pCO2 35 - 45 38 - 52

pO2 70 - 100 28 - 48

HCO3 19 - 25 19 - 25

O2 Sat % 90 - 95 40 - 70

BUN 7 - 20 mg/dl

Complete blood count (CBC) Adults

Male Female

Hemoglobin (g/dl) 13.5 - 16.5 12.0 - 15.0

Hematocrit (%) 41 - 50 36 - 44

RBC's ( x 106 /ml) 4.5 - 5.5 4.0 - 4.9

RDW (RBC distribution width) < 14.5

MCV 80 - 100

MCH 26 - 34

MCHC % 31 - 37

Platelet count 100,000 to 450,000

Creatinine kinase (CK) isoenzymes

Creatinine (mg/dl) 0.5 - 1.4

Electrolytes

Calcium 8.8 - 10.3 mg/dL

Calcium, ionized 2.24 - 2.46 meq/L

Chloride 95 - 107 mEq/L

Magnesium 1.6 - 2.4 mEq/L

Phosphate 2.5 - 4.5 mg/dL

Potassium 3.5 - 5.2 mEq/L

Sodium 135 - 147 mEq/L

Ferritin (ng/ml) 13 - 300

Folate (ng/dl) 3.6 - 20

Glucose, fasting (mg/dl) 60 - 110

Glucose (2 hours postprandial)

Up to 140
(mg/dl)

Iron (mcg/dl) 65 - 150

Lipoproteins and triglycerides

Cholesterol, total < 200 mg/dl

HDL cholesterol 30 - 70 mg/dl

LDL cholesterol 65 - 180 mg/dl

Triglycerides 45 - 155 mg/dl (< 160)

Osmolality 289 - 308 mOsm/kg

SGOT (AST) < 35 IU/L (20-48)

SGPT (ALT) <35 IU/L

WBC + differential

WBC (cells/ml) 4,500 - 10,000

Segmented neutrophils 54 - 62%

Band forms 3 - 5% (above 8% indicates left shift)

Basophils 0 - 1 (0 - 0.75%)

Eosinophils 0 - 3 (1 - 3%)

lymphocytes 24 - 44 (25 - 33%)

Monocytes 3 - 6 (3 - 7%)