Impact of Hemodialysis on End Stage Renal Disease Patients

¶ … 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 treatment program, but increased to 22% for the internal medicine program (P = 0.07). 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 as:

limited efficiency of the dialysis membrane it requires frequent solution change the strict aseptic technique considerable storage needed

Such difficulties maybe also make problems for people who are not patient enough with self-administering treatment.

With this positive result of integrative care study, the combination between hemodialysis and peritoneal dialysis treatments, nurses need to be aware of what best option is for the patients, knowing the symptoms that possibly occur, along with the different time given for each treatment.

Whether the patients are aware or not about their condition, it is advisable that the nurses give enough information about the option they have, along with each consequence related to the taken action. Patients then may take which option they prefer based on their condition, working schedule and daily activities. Also they will need to make option based on their financial constraints, although the government helps in some parts to pay for the expense.

However, in contrary to the research that states for the preference of hemodialysis, hemodialysis treatment does not always give proper result as the patients want. The ESRD article indicated some chronic and acute problems that occur in hemodialysis patients. Some common chronic problems are "hypertension, anemia, malnutrition, fluid and electrolyte imbalance, calcium deficiency, insomnia, sexual impotency, decreased mental acuity and lower energy levels." On the other hand, acute problems include "headaches, nausea, hypotension and asthenia (a general lack of strength and vitality), which are associated with thrice weekly dialysis sessions. This is not to mention, the general decrease of the condition as the result of accumulating toxins, salt and water in the patient's blood. More commonly afterwards, patients will complain for another complication of heart disease.

It is included in nurses' responsibility to give proper explanation and thorough facts to the patients about possibilities they will confront and risks they need to take that go along with each type of treatment. It is not that hemodialysis is the best choice, compared to peritoneal dialysis and kidney transplant, since each treatment brings its own risks. The occurrence of negative response to hemodialysis treatment also happen on special condition the patient bears. It is wise that the patient knows the truth, as long as it is within the range of the patient's emotional acceptance.

While mental condition of the patients sometimes are left behind when carrying out renal thorough check, or in after transplant surgery (during the recovery process) or any other dialysis therapy, Walton (2002) carried out a new study that examines how patients cope up with their daily life, adjusting to dialysis. Hemodialysis patients are critical in their need to face the entire struggle themselves, regardless the care and attention they may get from their family and paramedics who help them get around with the paraphernalia.

Some volunteer participants, consisting of four men and seven women, in the age range of 36 to 78 years old, were invited to join this research. The patients' status were staying out, which means the degree of separation with hospital function increased, unless they were treated properly by visiting nurses or trained family member.

The study was aimed to check or "find a balance" of the most important aspects the patients undergo: "confronting mortality, (b) reframing, - adjusting to dialysis, and (d) facing the challenge." Besides those categories, it was also important to seek the spiritual qualities like "faith, presence, and receiving and giving back." The patients mentioned in their life quality for the surrender from within to face the life with positivism, regaining the private aspects of their life to develop the "balance."

The balanced condition means the patients have good stability in managing their emotion, and look more positively and optimistic to heal the disease. Some people have this attitude since they were born, but most people might be rather shocked knowing that they would live forever with a catheter or tool attached in their abdomen and go through the long processes. Nurses have the capacity to work with this kind of feeling, explore the patients, listen to them, and help them managing the drawback.

Although other expert, Anita E. Molzahn commenting on the research mentioned that it is necessary to confirm the research, like that the samples need to represent the whole community of hemodialysis population (some of hemodialysis patients are not engaged in strong spiritual pursue or religious activities), this study reveals some holes in where nurses can contribute their skills to help the patients. It is necessary to understand the patients' status of self-respect and readiness to cooperate with the given therapy. This aspect has been left behind while attempting a therapy to patients for most cases, and right now should be quite helpful; as nurses can also help the patients cure themselves with the positive attitudes from within.

It is also a certain mark, which opens a possibility for future research, to find out other factors that may contribute to health level of a hemodialysis patient. Those possible factors include: races, socio-economic strata, and spiritual belief systems associated to the researched factors above.

What a nurse perhaps need to keep in mind is that the importance of treating a person as the whole, and not only the disease. Of course, a preliminary conversation is essential to explore the patients' mental condition and personality outlook. With an educated patient, the nurse will be able to help more and communicate what key issues of the disease are, while on the other occasion, the nurse may try different approaches. Molzahn also recommended that this procedure applied in the practice.

How Nurses Develop Themselves

The development of relationship between nurses and patients actually has greater opportunities than just therapy and consultation sessions. As a part of scholarly communities, nurses also bear the responsibilities to grow and always develop their managerial and technical skills. No matter which one is the greater than the other, nurses may learn a lot of the skills by get knowing their patients better.

Counts and Holmes (2002) mentioned that nephrology nurses still have a lot of room to upgrade. As a matter of fact, many medical researches can be conducted just within the time when nurses carry out the daily conversation when they are trying to explore the patients, and also explaining standard procedures to the closest relatives or friends of the patients.

Nurses only need to think a little bit broader than what they should in their profession. There are actually a lot of slight of opportunities that open the mind later after several follow-ups and self-conducted research.

In the case of hemodialysis, there are a lot of different conditions of the patients when they start and during treatment that determine the end result of the treatment. It depends on the patient's background and their information about hemodialysis and their own condition. Many patients tend to be actively involved in their treatments and ask a lot of questions to enrich their knowledge and especially, to make sure that they know what to do when no appropriate person are around to help. Many others are completely helpless, fully dependent to the help from paramedics and other member of the family, and are overwhelmed in their own spurs of fear that very often, encouraged by the stories they overheard upon minimum acquaintance about the disease.

Hemodialysis treatments often take place in nephrology service and clinics that this place could be the center of learning where both nurses and patients educate themselves. Nurses, for example, may take advantage to learn the management of the therapy, like finding ways to increase the effectiveness of the treatment, applying different approaches to create non-threatening environment for the patients, or if possible, encouraging such activities that patients may try to get rid of boredom (such treatments may take hours to carry out).