The fact that kidneys come in pairs is a testament to the importance of their function in the human body. They are each a little over four inches long, and at approximately 6 ounces a piece, they pack a powerful punch in terms of what they can do. Besides filtering toxins and extra water from the blood, they maintain the appropriate acid-base balance in the blood, regulate blood pressure, and manufacture hormones that control everything from the production of red blood cells to vitamin D, which is vital to calcium absorption. When the kidneys develop problems, the entire body is in danger.
Since the first patient received dialysis successfully in 1945, the process has been refined over and over again. In the 1960s the problem of vascular access for chronic dialysis was solved by use of the arteriovenous (AV) fistula, and in 1960, the first long-term patient began ongoing dialysis treatment for chronic renal disease. Dialysis is not one size fits all, because as the field has advanced, the therapy has become more tailored to the individual patient.
Advances improve outcomes
The dialyzer, which once featured a huge rotating drum, has now been reduced to the size of a dishwasher filled with hollow fibers through which the blood flows. The solution surrounding the fibers, called the dialysate, can now be adjusted, depending on the patients condition and needs. The arteriovenous shunt has been one of the most important advances in the hemodialysis process.
The availability of a genetically engineered version of erythropoietin (EPO), a hormone that stimulates the formation of red blood cells, has helped prevent anemia, which has plagued patients; it may be given during dialysis or subcutaneously. Other improved aspects include the addition of night treatments in some facilities, shorter dialyzing times, and a wider variety and availability of low sodium and high protein foods.
Patients are usually tested every 12 to 14 treatments to determine the effectiveness of the treatments. The two most common tests that focus on the blood urea nitrogen (BUN), a common waste product indicating effective clearing of the blood, are: the urea reduction ratio (URR) test and the Kt/V. The tests are more specific to the efficacy of dialysis than is the familiar BUN test. The National Institutes of Health (NIH) offers patient information that is helpful. Go to: http://kidney.niddk.nih.gov/kudiseases/pubs/hemodialysisdose.
Patient compliance is essential
In 1972, in Haskell, New Jersey, Edward Strudwick was diagnosed with pyelonephritis and developed kidney failure. At the time, access to dialysis was limited, and he was hospitalized while he started dialysis. Today, 36 years later, he receives his regular treatment at Holy Name Hospitals Acute Hemodialysis Department in Teaneck a standing appointment three days a week and everyone knows his success story.
Mr. Strudwick has always followed instructions, says Anne OReilly, RN, BSN, staff nurse in the department. He follows the diet, takes all his medications, and follows his fluid restriction requirements. I think the fact that he has few comorbidities has also worked in his favor.
Strudwick agrees that following instructions has been an important part of his success. He limits his fluids and cautions other patients who seem to think they can play fast and loose with the rules. OReilly notes that Strudwick is a resource for other patients. When he hears about someone doing something wrong, hell say, Just dont do it, and it carries some weight because hes been so successful, OReilly adds. She says that other patients have a hard time keeping their fluids within the target range, because so many fluids are hidden in foods like soup, pasta, and even rice.
Diet is a crucial part of renal patients regimens, says OReilly. Patients generally have a target of 80 grams of protein per day and electrolyte limitations. Changing habits is difficult and requires some adjusting. Regular blood testing tells the staff how the patient is doing. Elevated potassium levels put the patient at risk for cardiac dysrrhythmia; calcium and phosphorous levels must be maintained to preserve bone health; and albumin levels reveal whether the patient is consuming the optimal amount of protein.
Teamwork is part of success
We work as a team, and that makes a big difference, says OReilly. We have a physician, nutritionist, social worker, and a team of nurses to help every patient with whatever is going on at the time. Maria Linda Pura, RN, BSN, the nurse who is caring for Strudwick, says that it is essential to listen to what patients are saying, to get to know them and their concerns, and to assess their level of anxiety, so that teaching can be individually tailored.
Strudwicks family is his highest priority he loves spending time with his wife, children, and his grandchildren. This and the fact that he has always had other interests are reasons for his long-term success, OReilly says. She adds, There is something in some people that just makes them want to follow the instructions and be successful. Ed has that something.
A story of patience and perseverence
Strudwicks path has not been a straight line, and things have changed over the years. He has had problems with access sites and clotting, infections, fevers, and trips to the ED. However, there has been progress, and the procedure has become more automated.
Strudwick pictured above with (left) Maria Linda Pura, RN, and (right) Anne OReilly, RN, hasnt always been an outpatient. He began treatment in the hospital while his wife was trained in the use of the equipment. After a few months, they began doing the procedure at home. They continued to do so for approximately 25 years, while they worked and raised their two girls. Now his children have children, and approximately 10 years ago, he began coming to the department again for his treatments.
The machine was bigger back then, he says. It had a big tub at the bottom, and my wife had to pour chemicals into it before we started. The procedure took approximately six hours and now it takes approximately three. The advent of erythropoietin-stimulating medications arrived too late for Strudwick; he contracted hepatitis as a result of the many blood transfusions. Now he implements the necessary precautions to prevent exposing others to hepatitis.
Strudwick continued working 8- to 12-hour shifts at the steel mill, fitting treatments in around his shifts. He coped with the problems of clotting and access and he always persevered. In 1977, he underwent an unsuccessful attempt at a kidney transplant and, after his body rejected the donated organ, he returned to dialysis for good. I did well with the dialysis and I didnt want to go through another transplant, although they offered to try it again, he says.
Today, Strudwick receives his regular treatment at Holy Name Hospitals Acute Hemodialysis Department.