The Role of Dialysis in Kidney Treatment

Dialysis is a type of renal replacement therapy (RRT) that filters waste products and removes excess fluid from the blood when someone's kidneys stop working sufficiently. It can be performed in a hospital, dialysis center, or at home.

To survive beyond a few weeks or months, people with stage 5 chronic kidney disease (CKD), also known as end-stage renal disease (ESRD), end-stage kidney disease (ESKD), or kidney failure, typically must use dialysis or get a kidney transplant. 

This article explains everything you need to know about what kidney dialysis is used for, why and when to go through the dialysis process, offers some tips for adapting to life on dialysis, managing side effects, and more. 

When to Go on Dialysis

In most cases, chronic kidney failure can't be reversed. If left untreated, it's a life-threatening condition. If you have CKD and your kidneys start to fail, you can choose between two types of dialysis—hemodialysis or peritoneal dialysis—based on the following:

• Which modality best suits your lifestyle
• Your personal preferences
• Your overall health
• The recommendations of your kidney specialist (nephrologist)

People with end-stage kidney disease have to make difficult dialysis decisions when their kidneys start functioning below 15% of normal levels. If you have lost 85% to 90% of kidney function as indexed by an estimated glomerular filtration rate (eGFR) number below 15, you are classified as having stage 5 chronic kidney disease. People with stage 5 CKD typically needs dialysis or a kidney transplant to survive, especially when kidney function dips below 10% of healthy function.

Deciding if and when to go on dialysis is a huge, life-changing decision. It requires educating yourself about all the various options and giving yourself ample time (three to six months) to mull over dialysis's pros and cons based on your specific circumstances and personal preferences.

The typical guideline is that people with stage 5 chronic kidney disease who are relatively asymptomatic can safely delay starting dialysis until their eGFR (filtration rate) is around 5–7 mL/min/1.73 m². When eGFR is still above 10 (but below 15), continue with your regular checkups to monitor symptom progression or eGFR changes.

Stages of Kidney Failure

Below is a table that illustrates stages of chronic kidney disease based on eGFR numbers.

Home vs. Hospital Dialysis

People who can do dialysis at home are generally healthier than those who have to get dialysis in the hospital. Oftentimes, critically ill patients with acute kidney injury (AKI) are given dialysis when they’re in a hospital's intensive care unit (ICU). Very sick CKD patients with stage 5 kidney failure may also receive dialysis in the intensive care unit.

After Starting Dialysis: What Happens?

Although there are commonalities, responses to dialysis are varied and heterogeneous. Every person's experience will be unique. That said, below are some common features of starting in-center hemodialysis (ICHD)

From Start to Finish

During dialysis, a dialysis nurse will place a needle into a special conduit in your arm called arteriovenous fistula to access your blood supply. Then, your blood will be removed through the needle and filtered into a machine that acts as an artificial kidney by filtering out waste and other harmful material from your bloodstream. Typically, dialysis will take place three times per week.

It's common to feel wiped out after the dialysis session. Consider this when planning your transportation to and from the dialysis center. You might be too tired or light-headed to drive immediately after the session. While recovery time varies for each individual, some regain their energy within about 30 minutes and can safely operate a motor vehicle once light-headedness or blurry vision has subsided.

Feeling lousy after treatment is sometimes referred to as a "dialysis hangover." Much like feeling hungover gradually dissipates throughout the day after drinking too much, people who wake up with a dialysis hangover the morning after treatment often feel much better by early afternoon the next day. 

Symptoms and Side Effects to Know

Below is a list of common symptoms and side effects associated with dialysis:

• Constipation
• Depression or anxiety
• Fatigue, tiredness, or weakness
• Headache
• Itching (pruritus)
• Loss of appetite
• Muscle cramps
• Nausea, vomiting, or diarrhea
• Pain
• Sexual dysfunction
• Sleep issues (e.g., restless legs syndrome or sleep apnea)
• Thirst
• Urination or urine output problems

Dialysis Timing and Frequency

Most people still get in-center HD treatment during the day. However, some people choose to use a home machine that does nocturnal dialysis while they sleep in their own bed or at a long-term nocturnal dialysis center, which allows for longer nighttime sessions.

Increasingly, people who have the physical and cognitive capacity to self-administer peritoneal dialysis at home choose this option. Home PD can be done in short 30–40 minute bursts throughout the night, which gives people more flexibility and control of their daily schedule.

Logistically, not having to drive to a dialysis center makes home PD much more convenient and saves time. For many people who live in rural areas, driving to and from a dialysis center can add an hour or two to their four-hour treatment. Plus, there's often a half hour or so of time spent getting ready and wrapping up each in-center treatment session.

All told, including transportation, each day's in-center HD treatment can take more than six hours, well beyond the typical four hours on the dialyzer.

People can be on dialysis for many years. It's not uncommon for someone who's waiting for a kidney transplant to be on dialysis for four years or longer. Depending on what age someone is when they start dialysis, they might be on this renal replacement therapy for many years.

How to Manage Dialysis-Related Effects

Every person will experience slightly different dialysis-related side effects. For example, some people get really cold during in-center hemodialysis, so they might bring an extra blanket and wear a hat to stay warm. Others don't feel cold during ICHD.

Itchy skin is another side effect experienced by many. The causes of itching in dialysis patients are complex, and it can be tricky to treat.

Having your nephrologist adjust the amount you're being dialyzed and identify an optimal dose of dialysis that reduces itchiness can help manage this side effect. Maintaining a healthy skin barrier with a suitable moisturizer may help alleviate pruritus. In some instances, the use of antihistamines provide relief.

Some people may experience muscle cramping during hemodialysis if too much water is removed in their last hour of HD. In this case, they might talk to their nephrologist about adjusting their target dry weight (how much a patient weighs when finishing a dialysis session) and removing less water.

Dialysis Before Transplant

For those eligible for a kidney transplant who are on a wait list, the median time on dialysis is four years. The average wait time for a viable kidney in the United States is three to five years, depending on where you live.

In some parts of the country, wait times are longer, which means someone with end-stage kidney disease will be on dialysis that much longer before treatment.

Adapting to Life on Dialysis

Social workers can help with the process of adapting to life on dialysis. Federal law mandates that every dialysis center in the United States has social workers on staff. These professionals, also known as renal social workers, provide guidance when navigating uncharted physical and psychological territory associated with dialysis treatment.

Your social worker is a vital part of your dialysis care team and is equipped with the knowledge to help you manage both the mental and physical side effects of treatment. Renal social workers also act as administrative assistants who can help with financial and insurance-related issues.

Summary

The kidneys filter and clean blood. If the kidneys stop working, dialysis performs these functions. Although dialysis can extend someone's life for many years, it isn't easy. Some people choose not to have dialysis if they're older or don't qualify for a kidney transplant. Ideally, dialysis is a way to prolong someone's life while they are wait-listed for a kidney transplant, which usually takes a few years.

There are different types of dialysis and ways to receive treatment. If someone has advanced chronic kidney disease, it's wise to start making dialysis decisions before kidney failure. It can take three to six months to organize everything, and you want to give yourself time to think over all the options.