In hemodialysis, a patient’s blood is pumped into a dialyzer containing 2 fluid compartments configured as bundles of hollow fiber capillary tubes or as parallel, sandwiched sheets of semipermeable membranes. In either configuration, blood in the first compartment is pumped along 1 side of a semipermeable membrane while a crystalloid solution (dialysate) is pumped along the other side, in a separate compartment, in the opposite direction. (See Overview of Renal Replacement Therapy for other renal replacement therapies [RRTs].)
Concentration gradients of solute between blood and dialysate lead to desired changes in the patient’s serum solutes, such as a reduction in urea nitrogen and creatinine; an increase in bicarbonate; and equilibration of sodium, chloride, potassium, and magnesium. The dialysate compartment is under negative pressure relative to the blood compartment and has a higher osmolality to prevent filtration of dialysate into the bloodstream and to remove the excess fluid from the patient. The dialyzed blood is then returned to the patient.
Immediate objectives of hemodialysis are to
Correct electrolyte and fluid imbalances
Remove toxins
Longer-term objectives in patients with renal failure are to
Optimize the patient’s functional status, comfort, and blood pressure
Prevent complications of uremia
Prolong survival
The optimal “dose” of hemodialysis is uncertain, but most patients do well with 3 to 5 hours of hemodialysis 3 times a week. One way to assess the adequacy of each session is by measuring blood urea nitrogen (BUN) before and after each session. A ≥ 65% decrease of BUN from predialysis level ([predialysis BUN − postdialysis BUN]/predialysis BUN × 100% is ≥ 65%) indicates an adequate session. Specialists may use other, more calculation-intensive formulas, such as Kt/V ≥urea [which is about equal to total body water] in mL) (1). Hemodialysis dose can be increased by increasing time on dialysis, blood flow, membrane surface area, and membrane porosity. Nightly hemodialysis sessions (6 to 8 hours, 3 to 6 days/week) and short (1.5 to 2.5 hours) daily sessions, when available, are used selectively for patients who have any of the following:
Excessive fluid gain between dialysis sessions
Frequent hypotension during dialysis
Poorly controlled blood pressure
Hyperphosphatemia that is otherwise difficult to control
These daily sessions are most economically feasible if patients can do hemodialysis at home.
Settings for hemodialysis
In-center hemodialysis is the most common type of hemodialysis in the United States (2). Most treatments are done 3 times a week for 3 to 5 hours per session. The main advantage of in-center hemodialysis is that the dialysis staff fully controls the dialysis treatment. The dialysis technician cannulates the fistula, decides how much fluid to remove, and does the entire dialysis treatment under the supervision of the dialysis nurse and the nephrologist.
In-center nocturnal hemodialysis is done 3 times a week for 6 to 8 hours per session. This modality is most suitable for patients who have high fluid gains, low blood pressure, or difficult-to-control phosphorus (3). It is also attractive for those who work during the day but who do not want to do home dialysis.
Home hemodialysis is as viable as in-center hemodialysis. Patients treated with home hemodialysis have longer survival and better control of hypertension (4), phosphorus and fluid levels, and better quality of life than those treated with in-center hemodialysis. Home hemodialysis is most commonly done 5 to 7 days a week for about 2 hours per session. However, home hemodialysis can also be done on a 3-times-per-week daytime schedule or on a nocturnal schedule. Most home hemodialysis programs require a care partner capable of helping in case help is needed. As with peritoneal dialysis, home hemodialysis requires more patient involvement than in-center hemodialysis.
Vascular access for dialysis
Surgically created arteriovenous fistula
Central vein catheter
Hemodialysis is usually done through a surgically created arteriovenous fistula.
Surgically created arteriovenous fistulas are better than central venous catheters because they are more durable and less likely to become infected (4, 5). But they are also prone to complications (thrombosis, infection, aneurysm, or pseudoaneurysm). A newly created fistula may take 2 to 3 months to mature and become usable. However, additional time may be needed for fistula revision, so in patients with chronic kidney disease, the fistula is best created at least 6 months before the anticipated need for dialysis. The surgical procedure anastomoses the radial, brachial, or femoral artery to an adjacent vein in an end-of-the-vein to the side-of-the-artery fashion. When the adjacent vein is not suitable for access creation, a piece of prosthetic graft is used. For patients who have poor veins, an autogenous saphenous vein graft is also an option.
A central vein catheter can be used for dialysis if an arteriovenous fistula has not yet been created or is not ready for use or if creation of an arteriovenous fistula is impossible. The primary disadvantages of central vein catheters are a relatively narrow caliber that does not allow for blood flow high enough to achieve optimal clearance and a high risk of catheter-site infection and thrombosis. Central venous catheterization for hemodialysis is best done by using the right internal jugular vein. Most internal jugular vein catheters remain useful for 2 to 6 weeks if strict aseptic skin care is practiced and if the catheter is used only for hemodialysis. Catheters with a subcutaneous tunnel and fabric cuff have a longer life span and may be useful for patients in whom creation of an arteriovenous fistula is impossible.
Vascular access complications
Complications of vascular access include
Infection
Stenosis
Thrombosis (often in a stenotic passage)
Aneurysm or pseudoaneurysm
These complications significantly limit the quality of hemodialysis that can be delivered, increase long-term morbidity and mortality, and are common enough that patients and practitioners should be vigilant for suggestive changes. These changes include pain, edema, erythema, breaks in the skin overlying the access, absence of bruit and pulse in the access, hematoma around the access, and prolonged bleeding from the dialysis cannula puncture site. Infection is treated with antibiotics, surgery, or both.
The fistula may be monitored for signs of impending failure by serial Doppler dilution blood flow measurements, thermal or urea dilution techniques, or by measurement of the static venous chamber pressures. One of these tests is usually recommended at least monthly. Treatment of stenosis, thrombosis, pseudoaneurysm, or aneurysm may involve angioplasty, stenting, or surgery.
General references
1. National Kidney Foundation: KDOQI clinical practice guideline for hemodialysis adequacy: 2015 Update. Am J Kidney Dis66(5):884-930, 2015. doi: 10.1053/j.ajkd.2015.07.015. Erratum in: Am J Kidney Dis 67(3):534, 2016. PMID: 26498416
2. U.S. Renal Data System (USRDS), National Institute of Diabetes and Digestive and Kidney Diseases: End Stage Renal Disease. Accessed May 14, 2024.
3. Copland M, Komenda P, Weinhandl ED, et al: Intensive hemodialysis, mineral and bone disorder, and phosphate binder use. Am J Kidney Dis 68(5S1):S24-S32, 2016. doi: 10.1053/j.ajkd.2016.05.024
4. Weinhandl ED, Liu J, Gilbertson DT, et al: Survival in daily home hemodialysis and matched thrice-weekly in-center hemodialysis patients. J Am Soc Nephrol 23(5):895-904, 2012. doi: 10.1681/ASN.2011080761
5. Fisher M, Golenstaneh L, Allon M: Prevention of bloodstream infections inpatients undergoing hemodialysis. Clin J Am Soc Nephrol 5(1):CJN.06820619, 2019.
Complications of Hemodialysis
Complications are listed in table Complications of Renal Replacement Therapy.
The most common complication of dialysis is
Hypotension
Hypotension has multiple causes, including too-rapid water removal, osmotic fluid shifts across cell membranes, acetate in the dialysate, heat-related vasodilation, allergic reactions, sepsis, and underlying conditions (eg, autonomic neuropathy, cardiomyopathy with poor ejection fraction, myocardial ischemia, arrhythmias).
Other frequent complications include
Cramps
Pruritus
Nausea and vomiting
Headache
Chest and back pain
In most cases, these complications occur for unknown reasons, but some may be part of a first-use syndrome (when the patient’s blood is exposed to cuprophane or cellulose membranes in the dialyzer) or dialysis dysequilibrium syndrome, a syndrome thought to be caused by too-rapid removal of urea and other osmolytes from the serum, causing osmotic movement of fluid into the brain. More severe cases of dialysis dysequilibrium manifest as disorientation, restlessness, blurred vision, confusion, seizures, and even death.
Dialysis-related amyloidosis affects patients who have been on hemodialysis for years and manifests as carpal tunnel syndrome, bone cysts, arthritis, and cervical spondyloarthropathy (1). Dialysis-related amyloidosis is believed to be less common with the high-flux dialyzers in wide use today because beta-2 microglobulin (the protein causing the amyloidosis) is removed more effectively with these dialyzers.
Complications of Renal Replacement Therapy
Type | Hemodialysis | Peritoneal Dialysis |
|---|---|---|
Cardiovascular | Air embolism Cardiac arrest (rare) | Arrhythmia Hypotension* Pulmonary edema |
Infectious | Colonization of temporary central venous catheters Exit-site infection of both tunneled and temporary central venous catheters Vascular access cellulitis or abscess | Catheter exit-site infection* |
Mechanical | Obstruction of the arteriovenous fistula due to thrombosis or infection Stenosis or thrombosis of the subclavian vein or superior vena cava due to recurrent use of subclavian and internal jugular vein catheters | Catheter obstruction by clots, fibrin, omentum, or fibrous encasement Dialysate leakage around the catheter Dissection of fluid into the abdominal wall Hematoma in the pericatheter tract Perforation of a viscus by the catheter |
Metabolic | Hypoglycemia in diabetics who use insulin Iron loss | Hypoalbuminemia Hyperglycemia Hyperlipidemia Obesity |
Pulmonary | Dyspnea due to anaphylactic reaction to hemodialysis membrane Hypoxia when acetate buffered dialysate is used | |
Miscellaneous | Amyloid deposits Catheter-related hemorrhage Fever due to bacteremia, pyrogens, or overheated dialysate Hemorrhage (gastrointestinal, intracranial, retroperitoneal, intraocular) Insomnia Muscle cramps* Pruritus Restlessness Seizures | Abdominal and inguinal hernias Catheter-related intra-abdominal bleeding Hypothermia Peritoneal sclerosis Seizures |
* Most common complications overall. | ||
Complications reference
1. Danesh F, Ho LT: Dialysis-related amyloidosis: History and clinical manifestations. Semin Dial 14(2):80-85, 2001. doi: 10.1046/j.1525-139x.2001.00035.x
Prognosis for Hemodialysis
Overall adjusted annual mortality in hemodialysis-dependent patients is about 15%. The 5-year survival rate is lower for patients with diabetes than for patients with glomerulonephritis (1). Death is generally mostly attributable to cardiovascular disease, followed by infection and withdrawal from hemodialysis. Nonhemodialysis contributors to mortality include comorbidities (eg, hyperparathyroidism, diabetes, undernutrition, other chronic disorders), older age, and late referral for dialysis.
Prognosis reference
1. U.S. Renal Data System (USRDS), National Institute of Diabetes and Digestive and Kidney Diseases: End Stage Renal Disease. Accessed May 14, 2024.
