Understanding the Burdens of Dialysis

August 30, 2022 - Chronic kidney disease (CKD) occurs when the kidneys fail to filter waste as they typically do in a healthy body. Patients in the late stage of chronic kidney disease progress to end-stage renal failure (ESRF) when they need a transplant or dialysis. For these patients, dialysis applies an additional burden impacting lifestyle and finances.

What Is Dialysis?

The American Kidney Fund (AKF) defines dialysis as “a treatment to clean your blood when your kidneys are not able to. It helps your body remove waste and extra fluids in your blood. It does some of the work that your kidneys did when they were healthy. A healthy, working kidney can remove fluid and waste 24 hours a day. Dialysis can only do 10–15% of what a normal kidney does.”

According to the National Kidney Foundation (NKF), dialysis has three main functions:

• removing and filtering waste from the body to prevent buildup
• maintaining appropriate chemical levels in the blood
• managing blood pressure

Dialysis can be done in hospitals, dialysis centers, or at home, depending on the patient and type of dialysis, under the guidance of a healthcare professional.

There are two kinds of dialysis: hemodialysis and peritoneal dialysis. Approximately 90% of all dialysis patients undergo hemodialysis, the more common of the two.

Hemodialysis

Hemodialysis uses an artificial kidney — sometimes called a hemodialyzer — to remove waste from the blood.

According to AKF, “during hemodialysis, your blood travels through tubes from your body into a dialysis machine. While your blood is in the machine, it goes through a filter called a dialyzer, which cleans your blood by removing some of the waste and extra fluid. Then, the cleaned blood travels through tubes from the dialysis machine back into your body.”

During hemodialysis, a technician inserts two needles in the arm using vascular access, one for the blood to flow out of and another to return the blood into the body.

Vascular Access for Hemodialysis

Before hemodialysis, a minor surgery must be done to obtain vascular access. The safest form of vascular access is an arteriovenous (AV) fistula. According to AKF, in this procedure, “a surgeon connects an artery (a large blood vessel that carries blood from your heart) and a vein (a blood vessel that carries blood to your heart) under the skin in your arm.” Due to the healing time, an AV fistula should be inserted 2–3 months before the start of dialysis.

Another option for vascular access is an AV graft. This is also done via a surgical procedure where a surgeon connects an artery and a vein via a plastic tube. This procedure is done only 2–3 weeks before dialysis but is more susceptible to infection and blood clots.

Finally, a catheter can act as vascular access. It is a Y-shaped plastic tube that connects a vein inside the body to the two plastic ends outside the body. There are two kinds of catheters: venous and tunneled.

In-Center Hemodialysis

In-center hemodialysis can be done at a dialysis center or hospital by a nephrology nurse or dialysis technician. This type of dialysis is typically done three times a week for a duration of 2–4 hours per week, amounting to an average of 6–12 hours per week.

In-center hemodialysis typically requires a specialized diet that limits potassium, sodium, phosphorous, protein, and fluid intake. This treatment is administered via AV fistula or graft in the arm, thighs, or groin area. Unfortunately, this type of dialysis has some limitations as the appointments are in person. Patients undergoing this kind of treatment must ensure that there is a dialysis center wherever they travel and schedule appointments regularly.

Home Hemodialysis

Home hemodialysis functions very similarly to in-center hemodialysis but is administered at home by the patient or a caregiver. The frequency of home hemodialysis varies based on the patient’s condition and the doctor’s recommendations. One benefit of home hemodialysis is that more frequent or prolonged sessions can be done. These more frequent sessions may give patients additional freedoms with their diet. Unfortunately, people without at-home support may not be able to keep up with this form of treatment.

Peritoneal Dialysis

Based on information from AKF, there are two stages in PD: dwell time and exchange. A catheter is inserted into the patient’s stomach when a patient begins PD. A dialysate fluid is inserted into the stomach to filter the waste using this catheter.

The dwell time is the 4–6 hours the fluid remains in the body, cleaning the blood. After that period, the exchange process begins where the dialysate is drained, and fresh dialysate replaces it.

AKF states that “dialysate is a liquid with sugar in it that pulls fluid and waste from your blood. The dialysate holds on to the waste and fluid and removes them from your body when you do an exchange.”

The patient or a caregiver can do PD anywhere that is clean and dry. The frequency of PD is dependent on the patient’s condition and lifestyle.

Patients undergoing PD need limited potassium, sodium, phosphorous, protein, and fluid intake; however, their diet may not be as strict as those undergoing in-center hemodialysis as patients can have PD treatments more often.

There are two kinds of PD: continuous cycler (CCPD) and continuous ambulatory (CAPD).

Continuous Cycler PD (CCPD)

CCPD uses a machine to do dialysate exchanges. Typically, the exchanges happen at night. According to AKF, the cycler exchanges the dialysate between three and five times each night over nine hours and refills the stomach with dialysate in the morning.

The doctor instructs the dwell time and the number of exchanges.

Continuous Ambulatory PD (CAPD)

Rather than using a machine to do the exchanges, in CAPD, the dialysate exchange is done manually using gravity to assist. Unlike CPPD, CAPD is done during the day. On average, patients undergoing CAPD do approximately four exchanges, but the exact number is determined by a licensed healthcare professional.

“It takes about 30–40 minutes to drain and refill your belly with dialysate for each of the four exchanges,” says AKF.

Cost of Dialysis

While patients with kidney failure comprise only 1% of the US Medicare population, they account for 7% of the Medicare budget. According to the UCSF Kidney Project, “hemodialysis care costs the Medicare system an average of $90,000 per patient annually in the United States, for a total of $28 billion.”

The American Society of Nephrology (ASN) states that the annual economic burden of ESRD is $32 billion. On average, patients with end-stage kidney disease (ESKD) spend $14,399 each month on all healthcare services. A significant portion of that spending goes toward dialysis treatment. The cost of outpatient dialysis is approximately $10,149 each month. With Medicare coverage, patients typically pay $3,364.

An article published in the USC Center for Health Policy and Economics states, “patients with ESKD have average monthly spending 33× higher than patients without.”

The cost of dialysis imposes a financial burden on patients with ESRD and their families. Furthermore, dialysis costs may be a barrier to accessing care.

Patients with ESRD who choose to forgo dialysis will die unless they receive a transplant. Those with ESRD will need dialysis forever or until a transplant is successful.

Affording Dialysis

According to the AKF, “people of color bear a higher burden of kidney failure, and the treatment regimen for this life-threatening disease very often makes it impossible for patients to continue working.”

Even with insurance, the cost of dialysis is an enormous burden. Organizations such as the American Kidney Fund work to provide financial assistance to those unable to pay for dialysis themselves.

Although the use of Medicare, Medicaid, and the assistance of organizations like AKF, dialysis burdens persist for patients with end-stage renal disease. While many public health officials advocate for more affordable dialysis care and more equitable access to transplants, ESRD patients continue navigating the complexities of their illness, treatment, and financial responsibilities.