What is End Stage Renal Disease?

End-stage renal disease (ESRD) is a failure of the kidneys’ function to excrete wastes, concentrate urine, and regulate electrolytes. Most people have two kidneys, which sit in the upper abdomen, on either side of the spine. They are connected to the bladder by tubes called ureters. The kidneys’ job is to make urine by filtering the blood of the waste products of metabolism. This process is essential for life. When the kidney function drops to less than 10% of normal, dialysis or kidney transplantation is life saving.

In the United States, nearly 300,000 people are on long-term dialysis and more than 20,000 have a functioning transplanted kidney. The most common cause of ESRD in the US is diabetes. Other causes are longstanding hypertension, renal artery stenosis, chronic scarring from reflux disease or infection, drug toxicity or other medical conditions such as amyloidosis, sarcoidosis, polycystic kidney disease or glomerulonephritis. Renal failure can result in sudden congestive heart failure (fluid overload in the lungs) or altered mental status, but most often, the symptoms of chronic kidney failure are more subtle. They include:

• Nausea or vomiting
• General ill feeling
• Fatigue
• Edema (swelling)
• Generalized itching
• Decreased urine output
• Easy bruising or bleeding
• Drowsiness or mild confusion
• Muscle twitching or cramps

How is ESRD Treated?

Peritoneal dialysis, hemodialysis and kidney transplantation are the only treatments for ESRD. The decision about the type of treatment is individualized and is based on medical urgency, general medical condition and personal preference.

Associated diseases that cause or result from chronic renal failure must also be controlled. Hypertension, congestive heart failure, urinary tract infection, kidney stones, diabetes and other disorders should be treated as appropriate. Blood transfusions and medications such as iron and erythroprotein may be needed to treat anemia. Fluids may be restricted to an amount nearly equal to the volume of urine produced (usually 1.5 to 2 liters per day).

Dietary restrictions may slow the build-up of wastes in the bloodstream and control associated symptoms such as nausea and vomiting. A low protein, high carbohydrate diet is generally advised. Salt, potassium, phosphorus, and other electrolytes may be restricted. Renagel is a medication that is often given to bind phosphorus and reduce its absorption.

What are my options for vascular Access for Hemodialysis?

Hemodialysis (HD) involves removing blood from the body, filtering it through a machine and returning it to the body. Most treatment sessions are done 3 days a week for 3 hours a session. To maximize the amount of blood cleansed during each HD session, an HD access should provide high continuous flow rates (250 milliliters per minute). There are three basic kinds of vascular accesses for hemodialysis: a venous catheter, an arteriovenous (AV) fistula and an AV graft. The AV fistula is considered the best long-term vascular access for hemodialysis because it provides adequate blood flow for dialysis, lasts a long time, and has a complication rate lower than the other access types. If an AV fistula cannot be created, an AV graft may be needed. A venous catheter is considered temporary, as it has a high risk of infection, thrombosis (clotting) and venous stenosis (scarring or narrowing of the veins in the chest). However, the catheter is the only way to provide dialysis access urgently.

Venous Catheter for Temporary Access

A catheter is a tube inserted into a vein in either the neck, chest, or leg near the groin. It has two chambers to allow two-way flow of blood. It is usually tunneled underneath the skin on the chest to reduce the chances of infection or accidental dislodgement. The two catheter ports stick out of the skin and are attached to the dialysis machine during a dialysis session. They must be kept dry to prevent infection, so showers and swimming are not permitted with catheters.

Venous catheter for temporary hemodialysis access.

Arteriovenous Fistula (AV Fistula)

An AV fistula means a vein is connected directly to an artery. Veins are thin walled and distensible. They carry deoxygenated blood back toward the heart. Arteries are muscular, thick walled vessels which carry oxygenated blood from the heart out to the arms and legs; they have a pulse. When the vein is sewn to the artery, it enlarges and develops a thick wall because there is more high-pressure flow in it. The dialysis needles are then placed through the skin directly into the vein for dialysis.

AV fistulas are less likely to clot or get infected, so they last longer than AV grafts. However, maturation of the fistula (the process of the vein enlarging and developing a thick wall) takes 2-3 months on average, so placement of the fistula must occur months before dialysis is needed in order to avoid the need for a catheter.

Forearm AV Fistula

Arteriovenous Graft (AV Graft)

AV grafts are placed when the veins are too small to create a fistula. A graft is a tube of synthetic material (Gortex) or bioprosthesis (bovine artery or frozen human vein) which is used to connect the artery and the vein. It is fully implanted (tunneled under the skin), either in the forearm or upper arm. It feels like a ridge under the skin. The dialysis needles are placed through the skin into the graft for dialysis. AV grafts can be used within a week or two after they are placed, but they usually do not last as long as AV fistulas.

One kind of AV graft