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Hemodialysis
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Overview
In hemodialysis, a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately. Hemodialysis (he-moe-die-AL-uh-sis) is one way to treat advanced kidney failure and can help you carry on an active life despite failing kidneys.
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With hemodialysis, you'll need to:
Follow a strict treatment schedule
Take medications regularly
Make changes in your diet
Hemodialysis is a serious responsibility, but you don't have to shoulder it alone. You'll work closely with your health care team, including a kidney specialist and other professionals with experience managing hemodialysis. You may be able to do hemodialysis at home.
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Why it's done
Your doctor will help determine when you should start hemodialysis based on several factors, including your:
Overall health
Kidney function
Signs and symptoms
Quality of life
Personal preferences
You might notice signs and symptoms of kidney failure (uremia), such as nausea, vomiting, swelling or fatigue. Your doctor uses your estimated glomerular filtration rate (eGFR) to measure your level of kidney function. Your eGFR is calculated using your blood creatinine test results, sex, age and other factors. A normal value varies with age. This measure of your kidney function can help to plan your treatment, including when to start hemodialysis.
Hemodialysis can help your body control blood pressure and maintain the proper balance of fluid and various minerals — such as potassium and sodium — in your body. Normally, hemodialysis begins well before your kidneys have shut down to the point of causing life-threatening complications.
Common causes of kidney failure include:
Diabetes
High blood pressure (hypertension)
Kidney inflammation (glomerulonephritis)
Blood vessel inflammation (vasculitis)
Kidney cysts (polycystic kidney disease)
However, your kidneys may shut down suddenly (acute kidney injury) after a severe illness, complicated surgery, heart attack or other serious problem. Certain medications also can cause kidney injury.
Some people with severe long-standing (chronic) kidney failure may opt for a different path, choosing maximal medical therapy, also called maximum conservative management, instead of dialysis. This therapy involves active management of complications of advanced chronic kidney disease, such as fluid overload, high blood pressure and anemia, with a focus on supportive management of symptoms that affect quality of life.
Others may be candidates for a preemptive kidney transplant, instead of starting on dialysis. Ask your health care team for more information about your options. This is an individualized decision because benefits of dialysis may vary, depending on your particular health issues.
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Risks
Most people who require hemodialysis have a variety of health problems. Hemodialysis prolongs life for many people, but life expectancy for people who need it is still less than that of the general population.
While hemodialysis treatment can be efficient at replacing some of the kidney's lost functions, you may experience some of the related conditions listed below, although not everyone experiences all of these issues. Your dialysis team can help you deal with them.
Low blood pressure (hypotension). A drop in blood pressure is a common side effect of hemodialysis, particularly if you have diabetes. Low blood pressure may be accompanied by shortness of breath, abdominal cramps, muscle cramps, nausea or vomiting.
Muscle cramps. Although the cause is not clear, muscle cramps during hemodialysis are common. Sometimes the cramps can be eased by adjusting the hemodialysis prescription. Adjusting fluid and sodium intake between hemodialysis treatments also may help prevent symptoms during treatments.
Itching. Many people who undergo hemodialysis have itchy skin, which is often worse during or just after the procedure.
Sleep problems. People receiving hemodialysis often have trouble sleeping, sometimes because of breaks in breathing during sleep (sleep apnea) or because of aching, uncomfortable or restless legs.
Anemia. Not having enough red blood cells in your blood (anemia) is a common complication of kidney failure and hemodialysis. Failing kidneys reduce production of a hormone called erythropoietin (uh-rith-roe-POI-uh-tin), which stimulates formation of red blood cells. Diet restrictions, poor absorption of iron, frequent blood tests, or removal of iron and vitamins by hemodialysis also can contribute to anemia.
Bone diseases. If your damaged kidneys are no longer able to process vitamin D, which helps you absorb calcium, your bones may weaken. In addition, overproduction of parathyroid hormone — a common complication of kidney failure — can release calcium from your bones.
High blood pressure (hypertension). If you consume too much salt or drink too much fluid, your high blood pressure is likely to get worse and lead to heart problems or strokes.
Fluid overload. Since fluid is removed from your body during hemodialysis, drinking more fluids than recommended between hemodialysis treatments may cause life-threatening complications, such as heart failure or fluid accumulation in your lungs (pulmonary edema).
Inflammation of the membrane surrounding the heart (pericarditis). Insufficient hemodialysis can lead to inflammation of the membrane surrounding your heart, which can interfere with your heart's ability to pump blood to the rest of your body.
High potassium levels (hyperkalemia). Potassium is a mineral that is normally removed from your body by your kidneys. If you consume more potassium than recommended, your potassium level may become too high. In severe cases, too much potassium can cause your heart to stop.
Access site complications. Potentially dangerous complications ― such as infection, narrowing or ballooning of the blood vessel wall (aneurysm), or blockage ― can impact the quality of your hemodialysis. Follow your dialysis team's instructions on how to check for changes in your access site that may indicate a problem.
Amyloidosis. Dialysis-related amyloidosis (am-uh-loi-DO-sis) develops when proteins in blood are deposited on joints and tendons, causing pain, stiffness and fluid in the joints. The condition is more common in people who have undergone hemodialysis for more than five years.
Depression. Changes in mood are common in people with kidney failure. If you experience depression or anxiety after starting hemodialysis, talk with your health care team about effective treatment options.
How you prepare
Preparation for hemodialysis starts several weeks to months before your first procedure. To allow for easy access to your bloodstream, a surgeon will create a vascular access. The access provides a mechanism for a small amount of blood to be safely removed from your circulation and then returned to you in order for the hemodialysis process to work. The surgical access needs time to heal before you begin hemodialysis treatments.
There are three types of accesses:
Arteriovenous (AV) fistula. A surgically created AV fistula is a connection between an artery and a vein, usually in the arm you use less often. This is the preferred type of access because of effectiveness and safety.
AV graft. If your blood vessels are too small to form an AV fistula, the surgeon may instead create a path between an artery and a vein using a flexible, synthetic tube called a graft.
Central venous catheter. If you need emergency hemodialysis, a plastic tube (catheter) may be inserted into a large vein in your neck or near your groin. The catheter is temporary.
It's extremely important to take care of your access site to reduce the possibility of infection and other complications. Follow your health care team's instructions about caring for your access site.
What you can expect
You can receive hemodialysis in a dialysis center, at home or in a hospital. The frequency of treatment varies, depending on your situation:
In-center hemodialysis. Many people get hemodialysis three times a week in sessions of three to five hours each.
Daily hemodialysis. This involves more-frequent, but shorter sessions — usually performed at home six or seven days a week for about two to three hours each time.
Simpler hemodialysis machines have made home hemodialysis less cumbersome, so with special training and someone to help you, you may be able to do hemodialysis at home. You may even be able to do the procedure at night while you sleep.
There are dialysis centers located throughout the United States and in some other countries, so you can travel to many areas and still receive your hemodialysis on schedule. Your dialysis team can help you make appointments at other locations, or you can contact the dialysis center at your destination directly. Plan ahead to make sure space is available and proper arrangements can be made.
The procedure
During treatments, you sit or recline in a chair while your blood flows through the dialyzer ― a filter that acts as an artificial kidney to clean your blood. You can use the time to watch TV or a movie, read, nap, or perhaps talk to your "neighbors" at the center. If you receive hemodialysis at night, you can sleep during the procedure.
Preparation. Your weight, blood pressure, pulse and temperature are checked. The skin covering your access site — the point where blood leaves and then re-enters your body during treatment — is cleansed.
Starting. During hemodialysis, two needles are inserted into your arm through the access site and taped in place to remain secure. Each needle is attached to a flexible plastic tube that connects to a dialyzer. Through one tube, the dialyzer filters your blood a few ounces at a time, allowing wastes and extra fluids to pass from your blood into a cleansing fluid called dialysate. The filtered blood returns to your body through the second tube.
Symptoms. You may experience nausea and abdominal cramps as excess fluid is pulled from your body — especially if you have hemodialysis only three times a week rather than more often. If you're uncomfortable during the procedure, ask your care team about minimizing side effects by such measures as adjusting the speed of your hemodialysis, your medication or your hemodialysis fluids.
Monitoring. Because blood pressure and heart rate can fluctuate as excess fluid is drawn from your body, your blood pressure and heart rate will be checked several times during each treatment.
Finishing. When hemodialysis is completed, the needles are removed from your access site and a pressure dressing is applied to prevent bleeding. Your weight may be recorded again. Then you're free to go about your usual activities until your next session.
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Hemodialysis
Results
If you had sudden (acute) kidney injury, you may need hemodialysis only for a short time until your kidneys recover. If you had reduced kidney function before a sudden injury to your kidneys, the chances of full recovery back to independence from hemodialysis are lessened.
Although in-center, three-times-a-week hemodialysis is more common, some research suggests that home dialysis is linked to:
Better quality of life
Increased well-being
Reduced symptoms and less cramping, headaches and shortness of breath
Improved appetite, sleeping patterns, energy level and ability to concentrate
Your hemodialysis care team monitors your treatment to make sure you're getting the right amount of hemodialysis to remove enough wastes from your blood. Your weight and blood pressure are monitored very closely before, during and after your treatment. About once a month, you'll receive these tests:
Blood tests to measure urea reduction ratio (URR) and total urea clearance (Kt/V) to see how well your hemodialysis is removing waste from your body
Blood chemistry evaluation and assessment of blood counts
Measurements of the flow of blood through your access during hemodialysis
Your care team may adjust your hemodialysis intensity and frequency based, in part, on test results.
Between treatments
Between hemodialysis treatments you can help achieve the best possible results from your hemodialysis by:
Eating the right foods. Eating properly can improve your hemodialysis results and your overall health. While you're receiving hemodialysis, you'll need to carefully monitor your intake of fluids, protein, sodium, potassium and phosphorus. A dietitian can help you develop an individualized meal plan based on your weight, personal preferences, remaining kidney function and other medical conditions, such as diabetes or high blood pressure.
Taking your medications as prescribed. Carefully follow the instructions from your health care team.
Allowing your team to assist you by discussing your concerns. Your health care team can present options to you and help you deal with any concerns.
Overview
Illustration showing open-angle glaucoma
Open-angle glaucoma
Glaucoma is a group of eye conditions that damage the optic nerve, the health of which is vital for good vision. This damage is often caused by an abnormally high pressure in your eye.
Glaucoma is one of the leading causes of blindness for people over the age of 60. It can occur at any age but is more common in older adults.
Many forms of glaucoma have no warning signs. The effect is so gradual that you may not notice a change in vision until the condition is at an advanced stage.
Because vision loss due to glaucoma can't be recovered, it's important to have regular eye exams that include measurements of your eye pressure so a diagnosis can be made in its early stages and treated appropriately. If glaucoma is recognized early, vision loss can be slowed or prevented. If you have the condition, you'll generally need treatment for the rest of your life.
Symptoms
The signs and symptoms of glaucoma vary depending on the type and stage of your condition. For example:
Open-angle glaucoma
Patchy blind spots in your side (peripheral) or central vision, frequently in both eyes
Tunnel vision in the advanced stages
Acute angle-closure glaucoma
Severe headache
Eye pain
Nausea and vomiting
Blurred vision
Halos around lights
Eye redness
If left untreated, glaucoma will eventually cause blindness. Even with treatment, about 15 percent of people with glaucoma become blind in at least one eye within 20 years.
When to see a doctor
Promptly go to an emergency room or an eye doctor's (ophthalmologist's) office if you experience some of the symptoms of acute angle-closure glaucoma, such as severe headache, eye pain and blurred vision.
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Causes
Glaucoma is the result of damage to the optic nerve. As this nerve gradually deteriorates, blind spots develop in your visual field. For reasons that doctors don't fully understand, this nerve damage is usually related to increased pressure in the eye.
Elevated eye pressure is due to a buildup of a fluid (aqueous humor) that flows throughout the inside of your eye. This internal fluid normally drains out through a tissue called the trabecular meshwork at the angle where the iris and cornea meet. When fluid is overproduced or the drainage system doesn't work properly, the fluid can't flow out at its normal rate and eye pressure increases.
Glaucoma tends to run in families. In some people, scientists have identified genes related to high eye pressure and optic nerve damage.
Types of glaucoma include:
Open-angle glaucoma
Open-angle glaucoma is the most common form of the disease. The drainage angle formed by the cornea and iris remains open, but the trabecular meshwork is partially blocked. This causes pressure in the eye to gradually increase. This pressure damages the optic nerve. It happens so slowly that you may lose vision before you're even aware of a problem.
Angle-closure glaucoma
Angle-closure glaucoma, also called closed-angle glaucoma, occurs when the iris bulges forward to narrow or block the drainage angle formed by the cornea and iris. As a result, fluid can't circulate through the eye and pressure increases. Some people have narrow drainage angles, putting them at increased risk of angle-closure glaucoma.
Angle-closure glaucoma may occur suddenly (acute angle-closure glaucoma) or gradually (chronic angle-closure glaucoma). Acute angle-closure glaucoma is a medical emergency.
Normal-tension glaucoma
In normal-tension glaucoma, your optic nerve becomes damaged even though your eye pressure is within the normal range. No one knows the exact reason for this. You may have a sensitive optic nerve, or you may have less blood being supplied to your optic nerve. This limited blood flow could be caused by atherosclerosis — the buildup of fatty deposits (plaque) in the arteries — or other conditions that impair circulation.
Glaucoma in children
It's possible for infants and children to have glaucoma. It may be present from birth or develop in the first few years of life. The optic nerve damage may be caused by drainage blockages or an underlying medical condition.
Pigmentary glaucoma
In pigmentary glaucoma, pigment granules from your iris build up in the drainage channels, slowing or blocking fluid exiting your eye. Activities such as jogging sometimes stir up the pigment granules, depositing them on the trabecular meshwork and causing intermittent pressure elevations.
Risk factors
Because chronic forms of glaucoma can destroy vision before any signs or symptoms are apparent, be aware of these risk factors:
Having high internal eye pressure (intraocular pressure)
Being over age 60
Being black, Asian or Hispanic
Having a family history of glaucoma
Having certain medical conditions, such as diabetes, heart disease, high blood pressure and sickle cell anemia
Having corneas that are thin in the center
Being extremely nearsighted or farsighted
Having had an eye injury or certain types of eye surgery
Taking corticosteroid medications, especially eyedrops, for a long time
Prevention
These self-care steps can help you detect glaucoma in its early stages, which is important in preventing vision loss or slowing its progress.
Get regular dilated eye examinations. Regular comprehensive eye exams can help detect glaucoma in its early stages, before significant damage occurs. As a general rule, the American Academy of Ophthalmology recommends having a comprehensive eye exam every five to 10 years if you're under 40 years old; every two to four years if you're 40 to 54 years old; every one to three years if you're 55 to 64 years old; and every one to two years if you're older than 65. If you're at risk of glaucoma, you'll need more frequent screening. Ask your doctor to recommend the right screening schedule for you.
Know your family's eye health history. Glaucoma tends to run in families. If you're at increased risk, you may need more frequent screening.
Exercise safely. Regular, moderate exercise may help prevent glaucoma by reducing eye pressure. Talk with your doctor about an appropriate exercise program.
Take prescribed eyedrops regularly. Glaucoma eyedrops can significantly reduce the risk that high eye pressure will progress to glaucoma. To be effective, eyedrops prescribed by your doctor need to be used regularly even if you have no symptoms.
Wear eye protection. Serious eye injuries can lead to glaucoma. Wear eye protection when using power tools or playing high-speed racket sports in enclosed courts.
Diagnosis
Your doctor will review your medical history and conduct a comprehensive eye examination. He or she may perform several tests, including:
Measuring intraocular pressure (tonometry)
Testing for optic nerve damage with a dilated eye examination and imaging tests
Checking for areas of vision loss (visual field test)
Measuring corneal thickness (pachymetry)
Inspecting the drainage angle (gonioscopy)
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Treatment
The damage caused by glaucoma can't be reversed. But treatment and regular checkups can help slow or prevent vision loss, especially if you catch the disease in its early stages.
Glaucoma is treated by lowering your eye pressure (intraocular pressure). Depending on your situation, your options may include prescription eyedrops, oral medications, laser treatment, surgery or a combination of any of these.
Eyedrops
Glaucoma treatment often starts with prescription eyedrops. These can help decrease eye pressure by improving how fluid drains from your eye or by decreasing the amount of fluid your eye makes. Depending on how low your eye pressure needs to be, more than one of the eyedrops below may need to be prescribed.
Prescription eyedrop medications include:
Prostaglandins. These increase the outflow of the fluid in your eye (aqueous humor), thereby reducing your eye pressure. Medicines in this category include latanoprost (Xalatan), travoprost (Travatan Z), tafluprost (Zioptan), bimatoprost (Lumigan) and latanoprostene bunod (Vyzulta).
Possible side effects include mild reddening and stinging of the eyes, darkening of the iris, darkening of the pigment of the eyelashes or eyelid skin, and blurred vision. This class of drug is prescribed for once-a-day use.
Beta blockers. These reduce the production of fluid in your eye, thereby lowering the pressure in your eye (intraocular pressure). Examples include timolol (Betimol, Istalol, Timoptic) and betaxolol (Betoptic).
Possible side effects include difficulty breathing, slowed heart rate, lower blood pressure, impotence and fatigue. This class of drug can be prescribed for once- or twice-daily use depending on your condition.
Alpha-adrenergic agonists. These reduce the production of aqueous humor and increase outflow of the fluid in your eye. Examples include apraclonidine (Iopidine) and brimonidine (Alphagan P, Qoliana).
Possible side effects include an irregular heart rate, high blood pressure, fatigue, red, itchy or swollen eyes, and dry mouth. This class of drug is usually prescribed for twice-daily use but sometimes can be prescribed for use three times a day.
Carbonic anhydrase inhibitors. These medicines reduce the production of fluid in your eye. Examples include dorzolamide (Trusopt) and brinzolamide (Azopt). Possible side effects include a metallic taste, frequent urination, and tingling in the fingers and toes. This class of drug is usually prescribed for twice-daily use but sometimes can be prescribed for use three times a day.
Rho kinase inhibitor. This medicine lowers eye pressure by suppressing the rho kinase enzymes responsible for fluid increase. It is available as netarsudil (Rhopressa) and is prescribed for once-a-day use. Possible side effects include eye redness, eye discomfort and deposits forming on the cornea.
Miotic or cholinergic agents. These increase the outflow of fluid from your eye. An example is pilocarpine (Isopto Carpine). Side effects include headache, eye ache, smaller pupils, possible blurred or dim vision, and nearsightedness. This class of medicine is usually prescribed to be used up to four times a day. Because of potential side effects and the need for frequent daily use, these medications are not prescribed very often anymore.
Because some of the eyedrop medicine is absorbed into your bloodstream, you may experience some side effects unrelated to your eyes. To minimize this absorption, close your eyes for one to two minutes after putting the drops in. You may also press lightly at the corner of your eyes near your nose to close the tear duct for one or two minutes. Wipe off any unused drops from your eyelid.
If you have been prescribed multiple eyedrops or you need to use artificial tears, space them out so that you are waiting at least five minutes in between types of drops.
Oral medications
If eyedrops alone don't bring your eye pressure down to the desired level, your doctor may also prescribe an oral medication, usually a carbonic anhydrase inhibitor. Possible side effects include frequent urination, tingling in the fingers and toes, depression, stomach upset, and kidney stones.
Surgery and other therapies
Other treatment options include laser therapy and various surgical procedures. The following techniques are intended to improve the drainage of fluid within the eye, thereby lowering pressure:
Laser therapy. Laser trabeculoplasty (truh-BEK-u-low-plas-tee) is an option if you have open-angle glaucoma. It's done in your doctor's office. Your doctor uses a small laser beam to open clogged channels in the trabecular meshwork. It may take a few weeks before the full effect of this procedure becomes apparent.
Filtering surgery. With a surgical procedure called a trabeculectomy (truh-bek-u-LEK-tuh-me), your surgeon creates an opening in the white of the eye (sclera) and removes part of the trabecular meshwork.
Drainage tubes. In this procedure, your eye surgeon inserts a small tube shunt in your eye to drain away excess fluid to lower your eye pressure.
Minimally invasive glaucoma surgery (MIGS). Your doctor may suggest a MIGS procedure to lower your eye pressure. These procedures generally require less immediate postoperative care and have less risk than trabeculectomy or installing a drainage device. They are often combined with cataract surgery. There are a number of MIGS techniques available, and your doctor will discuss which procedure may be right for you.
After your procedure, you'll need to see your doctor for follow-up exams. And you may eventually need to undergo additional procedures if your eye pressure begins to rise or other changes occur in your eye.
Treating acute angle-closure glaucoma
Acute angle-closure glaucoma is a medical emergency. If you're diagnosed with this condition, you'll need urgent treatment to reduce the pressure in your eye. This generally will require both medication and laser or other surgical procedures.
You may have a procedure called a laser peripheral iridotomy in which the doctor creates a small opening in your iris using a laser. This allows fluid (aqueous humor) to flow through it, relieving eye pressure.
Lifestyle and home remedies
These tips may help you control high eye pressure or promote eye health.
Eat a healthy diet. Eating a healthy diet can help you maintain your health, but it won't prevent glaucoma from worsening. Several vitamins and nutrients are important to eye health, including zinc, copper, selenium, and antioxidant vitamins C, E, and A.
Exercise safely. Regular exercise may reduce eye pressure in open-angle glaucoma. Talk to your doctor about an appropriate exercise program.
Limit your caffeine. Drinking beverages with large amounts of caffeine may increase your eye pressure.
Sip fluids frequently. Drink only moderate amounts of fluids at any given time during the course of a day. Drinking a quart or more of any liquid within a short time may temporarily increase eye pressure.
Sleep with your head elevated. Using a wedge pillow that keeps your head slightly raised, about 20 degrees, has been shown to reduce intraocular pressure while you sleep.
Take prescribed medicine. Using your eyedrops or other medications as prescribed can help you get the best possible result from your treatment. Be sure to use the drops exactly as prescribed. Otherwise, your optic nerve damage could worsen.
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