¶ … Hemodialysis on End Stage Renal Disease Patients and the Increasing Role for the Nurse It is a difficult condition of a kidney failure when one's kidney could no longer carry out the proper metabolism system to eliminate waste products. Kidney is the essential organ that is responsible in waste elimination, including others like detoxification process of drugs and toxic materials, also in controlling water balance, salt balance, blood pressures and secrete hormones (Crawford, 2002).

When both kidneys fail to function, which comes to the End Stage Renal Disease, there is suddenly a loss of control to the fluid balance. The kidney cannot filter the fluid and therefore metabolism waste, toxic, salt and water accumulate in the blood, causing swell on the tissues, high blood pressure and heart disease.

Until now, there is no medication offered to cure ESRD. The current treatments to this disease are hemodialysis, peritoneal dialysis, or kidney transplant.

Hemodialysis as The Choice of Treatment

In the article entitled "End Stage Renal Disease" CMS data shows that more people suffer from ESRD in the U.S., indicating the growing requirement for dialysis treatments from 66,000 in 1982 to 260,000 in 2000, or about 8% annual growth. Those patients had spent more than five billion dollars for their therapy. This is quite an outrageous number, and there are three factors that assumed had caused the growth:

The aging of the population

The prolonged life of the patients with diabetes and hypertension

The fast growing frequency of ESRD in certain ethnic groups in the population.

Until now, there are only two methods, hemodialysis and peritoneal dialysis, which are applied to provide enough treatment to the ESRD patients. CMS estimation states about 90% of the dialysis patients in the U.S. undergo hemodialysis treatment, mostly conducted at the hospital as outpatient, and only less than 1% of the community have their treatment at home.

When many of the patients were treated with home hemodialysis in 1973, patients tend to turn to hospital-based treatment as they found a proper funding option. Although many patients have found it more enjoyable to have the cure at home as it has something to do with the positive attitude, they look for more satisfaction with the trained personnel who operates the more sophisticated machine. These practices are not only common in hospitals, but also in outpatients facilities at health clinics.

The Increasing Role of Hemodialysis Nurse

Hemodialysis, according to Crawford (2002) is such method where patient is provided permanent connection in the blood stream (AV fistula). It transfers blood to a machine, which acts as artificial kidney, to eliminate wastes and accumulating fluid from patient's blood, where the kidneys fail to function.

The series of treatment of hemodialysis itself is very time consuming. It requires patients to travel to clinics about three times a week, while each treatment takes about two to five hours. Some patients with willingness to provide their own devices may also take this treatment at home, however it still requires enough supervision from trained officers, mostly nurses.

Kshirsagar, et. al. (2000) showed in their research that hemodialysis patients may find proper treatment while cutting their therapy cost in the hospital with the selected approach. The presence of well-trained nephrologists may offer significant difference in patients' therapy expenses than they have to spend with traditional hospitalization cure.

The study was conducted to 161 hemodialysis patients were arranged to join 219 health services by nephrologists or by internists from July 1995 to March 1996. The study tested the length of stay, costs, risk-adjusted predicted length of stay and costs, and the number of consultations factors as the measurement of comparison between the services, except for nonmedical services and overnight observation, if any.

The research revealed that the patients spent approximately 6.3 days of stay for admissions to the nephrology service (n = 114), while the stay for admissions to internal medicine services (n = 105) took about 8.1 days (P = 0.017). Those lengths of stay spent about $7,925 for admissions under the care of nephrologists while the stay under the care of internists spent $10,773 (P = 0.101).

Similar result was also shown in the frequency of consultation factor. The patients needed about 1.5 consultations to the internists in average for the whole therapy while consultations with the nephrology service only took 0.5 times in average (P = 0.001). Around 24% of risk of readmission was accounted for nephrologists and 30% for internists (P = 0.328). Moreover, the patients might want to know that they had death risk within 90 days of discharge about 12% if they join the nephrologist...

Patients would likely benefit more from the shorter stay they need to have under the nephrologists' care than those of under the internists' care. Overall, nephrologists based therapy could also cut total costs and risk of readmissions, which would benefit the patients, both financially and spiritually.
There is a simple explanation to this case, that because of the proper handling of the system, many patients choose hemodialysis than peritoneal dialysis. Multiple treatments mean that they have to pay more. In some cases, people choose hemodialysis because most have a feeling that they are not familiar with medical treatment and rely on trained practitioner (nurses or nephrologists).

Depends on the patient's condition, hemodialysis is scheduled for two- or three-time visit each week. This is not a good choice while the patient is under the awful condition. The longer he or she waits, the more fluid, toxic elements and metabolic waste build up in the blood that causes dropped condition, high blood pressure and heart disease that risk the death.

Some patients then decide to provide the hemodialysis unit at home, that allow them to have their blood cleaned more frequently, and loose them schedule to visit the nephrology clinics. Although quite costly, patients might consider its value, and it is still quite cheaper than staying at the hospital, or waiting for the new kidney transplant (in the waiting list).

Both choices, home and clinic hemodialysis treatment, give nurses broader role to be the closest people who monitor the patients' condition, make notes on the development or decrease of the patients' situation, give advice on their diet control, and build better relationship with the family and relatives of the patients.

With at-home-treatment option, nurses may also find new schedule for arranged visits, considering that although patients find they prefer to have their blood "cleaned" at home, the end result is still unpredictable. Going under long treatment series for months or years could be frustrating for patients and provoke them to live on their own tolerance of lower standard. It may diminish their restored condition to unstable stages that may even endanger their life. Upon a program arranged by the hospital and the patients (if available), nurses could perform regular visit to check patients' condition and keep it level.

Van Biesen, et. al. (2000) conducted a study about the outcome of integrative care of end-stage renal disease (ESRD) patients, after their post hospital treatment replacement. About 223 hemodialysis and 194 peritoneal dialysis cases of patients starting renal replacement therapy between 1979 and 1996 were measured to meet the objective in finding out what each treatment resulted, and also to observe which approach was better for the patients.

Patients were analyzed for the survival, "first form of modality, for intention-to-treat survival, and for total survival. The result showed that the treatment using hemodialysis had made better response from the patients compared to those given peritoneal dialysis (log rank, P = 0.01). Exactly, it increased success rate after 3-year by 61 to 48%. While patients were undergoing cross treatment transfer (35 transferred from hemodialysis to peritoneal dialysis, and 32 from peritoneal dialysis to hemodialysis), significant result also showed the difference in development of the condition after transfer. The patients transferred from peritoneal dialysis to hemodialysis showed a survival increase that the patients remaining on peritoneal dialysis. On the other hand, transfer from hemodialysis to peritoneal dialysis did not show similar result (log rank, P = 0.17). The patients even showed better survival of their initial modality (more than 48-month), which was not shown respectfully in peritoneal dialysis treatment (log rank, P < 0.01).

The integrative care study emphasized the fact that peritoneal dialysis treated patients would show improvement in their condition when transferred properly (on a given schedule based on the condition). They would even develop better "survival advantage" than the patients who started and continued their treatment in hemodialysis basis. It means that the peritoneal dialysis treatment may be given as the starter therapy and still continued; if the patient shows positive respond to the therapy. However, when problems arise from uncooperative condition of patient's metabolism, he or she may continue to hemodialysis promptly.

The article of End Stage Renal Disease mentioned that although it seems that peritoneal dialysis is quite practical (the patients do not need any machine and able to carry out the dialysis anytime and anywhere they want without extra help from other people), there are several reasons why patients need to turn to hemodialysis, such…