Discovering

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					Discovering
  Dialysis
a manual for kidney and dialysis
            patients




                        Provided By:
    Kidney Foundation of the Greater Chattanooga Area
                      423.265.4397
               http://www.kidneyfoundation.com
Revised 2004
printing for this publication has been provided by:
  A Manual for
Kidney & Dialysis
    Patients
                             courtesy of

 THE KIDNEY FOUNDATION OF THE GREATER CHATTANOOGA AREA




                           423.265.4397
                  http://www.kidneyfoundation.com



          printing for this publication has been provided by:
                                                       Table of Contents

Part 1 – Clinic Information
  General Introduction .......................................................................................................................             2
  A Typical Day On Dialysis .............................................................................................................                  3

Part 2 –Kidney Disease
   The Normal Kidney ........................................................................................................................              7

Part 3 –Renal Failure and Dialysis
   Causes of Kidney Failure ................................................................................................................ 11
   Problems of Kidney Failure ............................................................................................................ 13
   Common Questions Asked About Complications .......................................................................... 15

Part 3 – Medical Needs
   Medications ....................................................................................................................................       19
   Lab Tests .........................................................................................................................................    24
   Blood Chemistries ...........................................................................................................................          26
   The Renal Diet ................................................................................................................................        29
   Helpful Hints to Stay on your Diet .................................................................................................                   30
   Hepatitis ..........................................................................................................................................   32
   Hepatitis Vaccine ............................................................................................................................         34
   Vascular Access ..............................................................................................................................         35
   Common Questions About Vascular Access ..................................................................................                              37

Part 4 – Treatment Options
   Treatment Options ..........................................................................................................................           41
   Common Questions About Hemodialysis .......................................................................................                            42
   High Flux Dialysis and High Efficiency Dialysis...........................................................................                             45
   Home Hemodialysis ........................................................................................................................             46
   Continuous Ambulatory Peritoneal Dialysis (CAPD) ....................................................................                                  50
   Continuous Cycling Peritoneal Dialysis (CCPD) ...........................................................................                              53
   Transplantation ...............................................................................................................................        55

Part 5 – Social Services
   Social Work Services ...................................................................................................................... 63
   Common Questions About Social Work Services .......................................................................... 63
   Other Facilities and Organizations of Interest to Kidney Patients .................................................. 70

Part 6 – Definitions
   Glossary .......................................................................................................................................... 75
                        EMERGENCY CONTACT INFORMATION

UNIT NAME: _____________________________________________________________________

UNIT ADDRESS:__________________________________________________________________

_________________________________________________________________________________

UNIT PHONE NUMBER: ___________________________________________________________

HOSPITAL: ______________________________________________________________________

HOSPITAL PHONE NUMBER: ______________________________________________________

DIALYSIS DAYS: _________________________________________________________________

DIALYSIS TIME: _________________________________________________________________

DOCTOR: ________________________________________________________________________

DOCTOR PHONE NUMBER:________________________________________________________

PRIMARY NURSE: ________________________________________________________________

PRIMARY NURSE PHONE NUMBER: ________________________________________________

SOCIAL WORKER: ________________________________________________________________

SOCIAL WORKER PHONE NUMBER: _______________________________________________

DIETITIAN: ______________________________________________________________________

DIETITIAN PHONE NUMBER: ______________________________________________________

24-HOUR CALL NUMBER: ________________________________________________________


OTHER INFORMATION AND INSTRUCTIONS:
PART I
CLINIC INFORMATION




                     page 1
                   General Information about the Dialysis Clinic

Your dialysis treatments should not be skipped. Try not to schedule other appointments on the days
you have dialysis. If you are not able to come for your appointment, call the Dialysis Clinic and talk
to the nurse in charge.

   Bradley Dialysis                  Cleveland, TN                          423-476-6166
   Chattanooga Kidney Center         Chattanooga, TN                        423-648-4900
   Dialysis Clinic, Inc.             Third Street, Chattanooga, TN          423-698-0927
   Dialysis Clinic, Inc.             Lyerly St. (Glenwood), Chattanooga, TN 423-698-6422
   Dialysis Clinic, Inc.             East Ridge, TN                         423-894-8134
   Dialysis Clinic, Inc.             Hixson, TN                             423-870-0020
   Dialysis Clinic, Inc.             Broad Street, Chattanooga, TN          423-756-8808
   Dialysis Clinic, Inc.             Dayton, TN                             423-775-3386
   Dialysis Clinic, Inc.             Ft. Oglethorpe, GA                     706-861-6668
   Dialysis Clinic, Inc.             Lafayette, GA                          706-638-6553
   Dialysis Clinic, Inc.             Jasper, TN                             423-942-9977
   FMC Dialysis Clinic               Athens, TN                             423-507-9712
   Woods Memorial Dialysis           Etowah, TN                             423-263-3666


Report for all your treatments ON TIME. Call if you will be more than one hour late. If you come
late, you may not receive all of your prescribed treatment. If you are late on a regular basis, you will
be scheduled for a conference with your doctor.
Please leave children at home. They are not allowed in the treatment area. There is no place for
them to stay while you are receiving dialysis.
Dress in comfortable clothes. You will sit in a reclining chair for your treatment. You may bring a
blanket, an extra pillow, and something to do (a book, handiwork, etc.) while you are here.
Unless you have problems with nausea and vomiting, it’s a good idea to eat something before
coming to dialysis. You are not allowed to bring food or drinks into the clinic.
No drugs are given out at the Dialysis Clinic. If you run out of a medicine, tell your nurse. He or
she will have your doctor prescribe a refill.
Only take medicines prescribed by your kidney doctor, even if they are over-the-counter drugs.
Aspirin, milk of magnesia, and other common medicines can have harmful effects on kidney
patients.
The clinic will give you Medical ID tags or order them if you ask.
Please make sure that the clinic has your correct address and telephone numbers. Let the clinic
know immediately of any changes. This allows your doctor or nurse to contact you if any significant
problems come up.
When you come for your first dialysis treatment, bring ALL your medicines, including any
medicines that you received when you were discharged from the hospital. These will be reviewed.
If necessary, changes might be made. Your nurse will check your medicines every month, so bring
ALL your medicines to the clinic the FIRST week of each month.
Please do not bring expensive items to the clinic. If they become lost or stolen, the clinic is not
responsible for them.
page 2
                                  A Typical Day on Dialysis

You will receive detailed instructions during your first dialysis treatment. There are general steps to
follow for each time you receive dialysis. We have listed the things you need to do each dialysis to
familiarize you with the procedures of the clinic. You may want to come a little early on your first
day to sign forms and meet the staff.


1. When you arrive at the clinic, wait in the lobby until the nurse calls you.

2. When you are called into the dialysis area, first go to the scales. The nurse or a technician will
   check and note your weight.

3. Find your name on the board and the number of the chair you are to sit in.

4. Get all necessary items (magazines) that you may need during dialysis.

5. When you get to your chair, make sure your name is correct on your artificial kidney.

6. If you have a graft, wash your arm or thigh with the Betadine scrub provided on the table next to
   your chair.

7. Several procedures will be carried out throughout the dialysis including:
      blood pressure reading
      pulse rate
      blood flow rates (how fast your blood is moving through the artificial kidney)
      machine adjustments

8. A nurse will take your blood pressure (sitting and standing), your pulse, and temperature and
   note them on your chart.

9. The nurse will place a cleansing solution on your graft or fistula and let it set for three minutes.

10. If you have a graft or a fistula, the nurse will insert two special needles into your arm. A
   medicine to numb your skin can be used, if you want.

11. Once the needles are inserted, the nurse will connect the blood lines to the needles and turn on a
   pump. The pump pulls blood from your body, sends it through the artificial kidney, and returns
   it to your body.



                                                                                                   page 3
12. The machine alarms and equipment are checked to insure your safety. Don’t be frightened if you
   hear the machine beep. This is a necessary test.

13. The machine is adjusted for your fluid weight.

14. While you are dialyzing, two blood samples are removed from the blood lines to test how fast
   your blood clots. The results of this these tests determine how much medicine (Heparin) that
   you need to prevent clotting of your blood within the artificial kidney.

15. Near the end of dialysis (15 minutes to an hour before the end of the process), the heparin is
   turned off so your blood can return to its normal clotting time. This will keep you from bleeding
   too long after your dialysis.

16. If you have a fistula or graft, the blood line carrying the blood from the body is disconnected
   from the needle and the remaining blood in the machine is returned to you. The needles are then
   removed, and pressure is placed over both needle holes. If you are able to hold pressure on your
   needle sites, the nurse will instruct you on how to do this. Continue pressure on this area for 10
   minutes or longer to make sure that all the bleeding is stopped. When the bleeding has stopped,
   band-aids or pressure dressings are placed over the two needle holes.

17. Your blood pressure, pulse and temperature will be taken and recorded on your chart.

18. Have your nurse weigh you again.

19. Put away your magazines and place your linens in the laundry hamper. Gather your belongings
   before you leave.




page 4
PART 2
KIDNEY DISEASE




                 page 5
page 6
                                      The Normal Kidney

To understand kidney failure, you need to know something about the kidneys and how they work.

       The urinary tract contains two kidneys, two ureters, a bladder, and one urethra. The kidneys
are small. Each kidney is about the size of your fist. They are located in the middle of your back, on
each side of your spine just below the ribs.

       When the blood enters the kidney, it is cleaned when it passes through lots of blood “filters,”
known as nephrons. The waste materials filtered out of the kidney go through the ureters--tubes that
connect the kidneys and the bladder. Urine is made in the kidneys and moves from the kidneys
through the ureters to the bladder, where it is stored. When this waste (urine) reaches the bladder, it
is stored and then sent out through the urethra, a tube that takes the urine from the bladder to outside
of your body.

       Urine is constantly flowing from the ureters into the bladder. However, the urine goes out of
your body from the bladder through the urethra only when you go to the bathroom. Any remaining
urine is stored in your bladder. Since urine eventually leaves the body, it is a waste product.




                                                                                                  page 7
         The kidney is usually only thought of as producing urine. Actually, the kidney performs
many other extremely important functions.


1.       Controls Blood Pressure
         The kidneys play an important role in controlling blood pressure. When blood pressure is
         high, the kidneys get rid of excess salt (sodium) and water. When blood pressure is low, the
         kidney saves salt and water. The kidney also produces a hormone called renin. Renin affects
         a protein in your bloodstream, which helps raise blood pressure.

2.       Helps Produce Red Blood Cells
         Another function of the kidneys is to control the formation of red blood cells, which are
         usually produced in bone marrow. The kidneys produce erythropoietin that helps to produce
         red blood cells by stimulating the bone marrow.

3.       Helps in Absorbing Calcium
         The kidneys also activate vitamin D, which is produced in the skin based on what you eat in
         your diet and from sunlight. This vitamin is changed by the liver and by the kidneys. When
         changed, vitamin D helps your body absorb calcium, which is important to prevent your
         bones from becoming soft.

The kidneys are vital organs that play many roles. When kidney failure occurs, your body’s systems
are disturbed, causing many changes.




page 8
PART 3
RENAL FAILURE &
DIALYSIS




                  page 9
page 10
                                  Causes of Kidney Failure

There are many causes for kidney failure: high blood pressure, diabetes, hereditary disease, drug
abuse and infection. A few of the more common ones are outlined in this booklet.


                        COMMON CAUSES OF KIDNEY FAILURE




       Uncontrolled High Blood Pressure

                                                                        Drug Abuse




                                                                          Infection



         Hereditary Polycystic Kidneys



       There are two main types of kidney failure: acute and chronic. Acute failure usually
happens suddenly and often is reversible. In comparison, chronic renal failure develops over a
longer period of time, is usually not reversible. This means the kidneys will never regain their
function with chronic renal failure.
       Acute renal failure can happen because of a trauma (such as a wound or an injury), disease,
ingestion of poison or drugs, shock, or infection. As a result of this trauma, the kidney is
temporarily damaged and stops producing urine. Poisons build up in the bloodstream, which causes
                                                                                               page 11
the person to become confused or unconscious, and overloaded with fluids. Often the patient is
placed on a special diet, fluid restrictions and temporary dialysis. After a few weeks, the patient’s
kidney function usually returns to normal.
    Chronic renal failure usually requires dialysis treatment for the rest of a patient’s life. The most
common causes of chronic renal failure are: chronic glomerulonephritis, pyelonephritis, polycystic
kidney disease, diabetic renal failure, and hypertensive nephrosclerosis.


   Chronic glomerulonephritis — Glomerulonephritis, which has several causes, is an
    inflammation of the glomeruli-small structures in the kidneys. The inflammation interferes with
    how your urine is cleaned or filtered. As the disease develops, scar tissue replaces the inflamed
    areas and causes the blood circulation to slow down. The nephron is starved of its blood and
    withers.


   Chronic pyelonephritis — Pyelonephritis is an inflammation of the kidney that affects the
    tubules of the nephron and eventually the glomerulus. The infection causes the kidney to lose its
    ability to produce urine. The cause of the infection may be from the bloodstream or the bladder.


   Polycystic kidney disease — Cysts on the tubules is called polycystic kidney disease. The
    tubules don’t develop properly and the cysts begin to grow. Over time, the cysts get bigger and
    put pressure on the tissues close to them. This pressure can affect the job of the normal
    nephrons. The kidneys soon stop producing enough urine to get rid of the body’s waste.


   Diabetic renal failure — Diabetic renal failure happens when diabetes causes the renal arteries
    to scar. This interferes with the proper filtration of urine.


   Hypertensive nephrosclerosis — This type of renal failure happens when a patient has high
    blood pressure over a long period of time. This causes the blood vessels of the kidney to scar.
    When enough of the blood vessels are scarred, the kidneys can no longer filter enough of the
    body’s waste.


    There are other causes of kidney failure and the above descriptions are by no means inclusive.
For more information about your type of kidney failure, talk with your doctor.

page 12
                                 Problems of Kidney Failure



When kidney failure begins, you may see a number of signs and symptoms. Some of these are
alarming and baffling. Some of these problems are discussed here. We hope this will relieve any of
your concerns and increase your understanding of your condition.
       As kidney failure progresses, the amount of urine you pass will probably go down. Because
the kidneys no longer filter as much fluid, the extra fluid remains in your bloodstream and tissues.
The increase in fluid in the bloodstream leads to high blood pressure and puts an increased workload
on your heart. An increased workload on the heart can cause an irregular heart rate and congestive
heart failure. After dialysis is started and the fluid is removed, your blood pressure may drop. Your
doctor may be able to decrease the blood pressure medicines you take. Symptoms of congestive
heart failure also improve with dialysis.
       Kidney failure may also affect your heart by causing pericarditis, a swelling and redness of
the sac around the heart. Pericarditis can cause chest pain and weakness. Once dialysis is started,
pericarditis should get better. Occasionally, dialysis patients receiving regular kidney treatments
will get pericarditis. Usually increasing dialysis treats this condition.
       Kidney failure can also cause shortness of breath and pulmonary edema (swelling of the
lungs), because of extra fluid in the bloodstream and lungs. This should go away once regular
dialysis treatments are started, but it may come back if you drink too many liquids between
treatments.


Most kidney patients have low blood counts (anemia) due to three main reasons.
1. A decrease in a hormone that helps the body to produce red blood cells. This hormone is called

   erythropoietin.

2. A decrease in how long the red blood cells live.

3. Loss of blood while on dialysis.

   If your blood count stays low and causes you problems, your doctor may order a blood
transfusion. But, transfusions are avoided, if possible, because of the following reasons.
1. Transfusions may transmit hepatitis.
2. Although it has not been proven, a high number of transfusions may interfere with a future
   transplant. However, they may also be beneficial to transplant patients.
                                                                                               page 13
3. Transfusions may prevent your body from making blood for itself.


Kidney failure also affects the stomach and G.I. tract in various ways:
1. Nausea and vomiting,
2. A decrease in appetite,
3. Weight loss,
4. Mouth and stomach ulcers.


These symptoms are caused by the build-up of waste (poisons) in the blood. These symptoms
improve with regular dialysis, but may occur off and on while you are on dialysis or in between your
treatments.
        Sometimes your feet may tingle or feel numb because your nerves are damaged. This is
called neuropathy (nerve damage used by kidney failure). These symptoms should get better with
dialysis. When nerve damage occurs, you may feel tried, drowsy, or excited. Or you may have
headaches, poor memory, confusion, seizures, or a coma. These symptoms should improve when
dialysis treatments start.
        Itching is a common problem of dialysis patients. It usually is worse when the waste
products in the blood are very high. When phosphorus is high, itching may be much worse, and the
doctor will probably increase your binders. It’s important to take the binders correctly because a
high phosphorus level results in low calcium. When calcium is low, the bones become weak and
break easily.
        Other minor problems caused by renal failure include muscle cramps, arthritis, and blurred
vision. Psychological problems may include decreased ability to concentrate, depression, and
difficulty sleeping. Other problems may also occur. If you have any questions about these or other
problems, ask your doctor or nurse about them.




page 14
                 Common Questions Asked About Complications


1. What if I don’t feel like coming for my treatments?
   If you think you are too sick to come for your dialysis treatment, it may be that you need the
   treatment so much that you are beginning to be sick with uremia. Do not miss a treatment
   because you feel sick. Call your nurse or doctor, and tell them about your symptoms. They may
   want you to have an emergency treatment. If you must miss a treatment because of work, call
   your nurse as soon as possible. This way the necessary laboratory tests can be done to make sure
   your blood levels are still safe and another treatment time can be set up.


2. Why do kidney patients continue to have nausea and vomiting after they have been on
   dialysis for some time?
   Usually, nausea and vomiting improve after dialysis is started. However, some patients still have
   occasional attacks of nausea and vomiting between treatments. This happens sometimes because
   the kidney machine cannot keep their blood chemistries at normal levels by only working 9-12
   hours a week. Many patients have nausea and vomiting while they are on dialysis because their
   blood pressure falls suddenly or because their blood urea nitrogen (BUN) level drops quickly. A
   drop in the BUN can also cause headaches. You can minimize these symptoms by following
   your diet closely so that the BUN is not high at the beginning of dialysis.


3. Is constipation a problem for dialysis patients?
   Yes. This is because vegetables and other sources of roughage are limited in the diet. Physical
   activity is usually reduced and binders (such as Phos-Lo, used to control your phosphate levels)
   can also cause constipation. If you are constipated, your doctor can prescribe a mild laxative.


4. Does blurred vision happen very often?
   Yes, it is quite common before your first dialysis is performed. It may also happen near the end
   of a dialysis treatment, especially if the level of waste products in your blood were high at the
   beginning of your treatment. Vision usually clears up after the first several dialysis treatments.




                                                                                                page 15
5. Is it unusual to have problems falling asleep?
   Not at all. Many patients with kidney failure have difficulty going to sleep. If this bothers you,
   mention it to your doctor, who can prescribe a mild sedative.


6. What can I do for the itching?
      Regular dialysis.
      Take your binders regularly.
      Use skin lotions.
      Ask your doctor about medicines to relieve the itching.


7. Is there a reason why I might feel tired at times?
   Most patients with kidney failure are anemic even after they start dialysis. Being anemic means
   their red blood cell count is a lot lower than normal. This low blood count can make a patient
   feel tired.


8. Will my sex life change?
   Many patients on dialysis notice that their interest in and enjoyment of sex is decreased.


9. Can anything be done about this change in my sex life?
   In some cases, hormone treatments will improve the situation. Like all other problems, mention
   any difficulty you have to your nurse or doctor so that proper treatment can be started.


10. Can a woman dialysis patient have a baby?
   A few such cases have happened. Most women do not ovulate while they are on dialysis, so it is
   unlikely they can get pregnant. To be safe, we recommend that you continue to use your usual
   means of birth control. We recommend that female dialysis patients do not try to have children.


11. Can a male dialysis patient still father children?
   The sperm count is low in many male dialysis patients, and some have difficulty with impotence
   (inability to have intercourse). However, many male dialysis patients do father children.




page 16
PART 3
MEDICAL NEEDS




                page 17
page 18
                                           Medications


All kidney patients have to take some medicines. Most patients have to take vitamins and iron pills.
Some patients also need medicines to meet their specific needs. Because your pills are based on
what you need, take only the medicines prescribed for you by your kidney doctor.
       If another doctor prescribes a medicine for you, check with your kidney doctor. Never take
pills that belong to your family, friends, or other patients. Kidney patients should never take over-
the-counter drugs without the asking their doctor first. These medicines may contain harmful
ingredients.
       Follow all of the directions for each medicine. Each has a special purpose to meet your
special needs. Problems may occur if you don't take them as prescribed.
       Learn the names of all your medicines and why you are taking them. This can help you, and
your doctor and nurses. You must bring ALL of your medicines to the dialysis clinic during the first
week of each month. The nurse will check each medicine and review the correct dosage and
schedule with you.
   If you have not started on dialysis at the outpatient clinic, please bring your medicines with you
on your first clinic visit. The nurses will write down your medicines on your chart and make sure
you are taking them correctly. Kidney patients often ask the following questions about medications.


1. How long will I need to take medications?
   You will have to take some of the medicines as long as you are on dialysis. All patients take
   certain medicines, and some patients take additional medicines to meet their specific needs.


2. What happens if I don't take the medicine?
   We will explain the purpose of each medicine and the effects of not taking them. In some cases,
   not taking your medicines can destroy your bones and cause heart failure. In other cases, you
   could become very anemic and weak. If you find that a certain drug bothers you in any way, do
   not stop it. Instead, tell your nurses and doctors. Your doctor may be able to prescribe another
   drug that works better for you.


3. Why must I take a binder?
   You must take a binder to protect your bones from becoming weak and to avoid getting calcium
   deposits in your heart and other vital organs. These are very serious problems. Take the binder
                                                                                               page 19
   with your meals, so it mixes with your food and prevents the phosphorus in the food from being
   absorbed.


4. Why must I take vitamins?
   Vitamins are limited in the renal diet for kidney patients. Many vitamins are removed during
   dialysis. All dialysis patients take vitamins.


5. Why must I take iron?
   Some blood is lost during each dialysis. Iron tablets will replace the iron lost during the
   treatment process.




page 20
                                      Medications

MEDICATIONS THAT MOST PATIENTS TAKE

          Medicine                        Reason                  Special Instructions
Phosphorus Binders              Controls how much             Take with meals and with
 Phos-Lo (calcium acetate)     phosphorus is absorbed        snacks (except a fruit snack).
 Os-Cal 500 (calcium           from foods.
   carbonate)                                                 Do not skip dosages.
 Tums carbonate                Too much phosphorus can
 Tums E-X carbonate            cause kidney-related bone     Don’t take iron at the same
 Magnebind 400                 disease.                      time.
 Renagel 800 mg
 Renagel 400 mg

Iron supplements                Prevents iron deficiency.     Take between meals.
 Ferrous sulfate
 Ferrous fummerate (various    Helps build blood, replaces   Do not take at the same time
   brands)                      the iron lost with blood in   as phosphorus binders.
 Niferex-150                   the dialyzer and when blood
 Nu-Iron 105                   samples are drawn.            If stomach upset occurs, you
   (polysaccharide-iron                                       may need to change the type
   complexes)                                                 of iron you take.

                                                              Polysaccharide-iron complexes
                                                              are usually tolerated best.

Vitamins                        Replaces the water-soluble    Take any time.
 Nephrocap                     vitamins C and B-complex
 Nephrovite                    that can be lost during the
                                dialysis treatment.
(These vitamins are specially
designed for patients with
kidney disease).




                                                                                       page 21
MEDICATIONS THAT SOME PATIENTS TAKE

       Medicine                    Reason              Special Instructions         Possible Side
                                                                                        Effects
Blood pressure             Controls blood             If blood pressure is low   Tiredness,
medicine                   pressure when proper       for you, do not take       weakness dizziness,
                           control of sodium and      blood pressure             lightheadedness.
                           water does not bring       medicine.
                           blood pressure down.

Digoxin or Lanoxin         Increases the force of     Take your pulse before     Weakness,
                           the heart when it          taking digoxin.            hypotension,
                           contracts, increases                                  nausea and
                           cardiac output.            Do not take digoxin        vomiting, diarrhea,
                                                      unless your pulse rate     slow heart rate.
                                                      is 60 or higher.

Itching Medicines          Decreases the amount       Take as prescribed.        Drowsiness, dry
 Benadryl                 of itching.                                           mouth, dizziness.
 Temaril
 Atarax

Stool softeners            Prevents constipation.     Take as needed,            Diarrhea.
 Metamucil                                           usually one every day.
 Dulcolax
 Pericolace
 Sorbitol

Pain reliever              Relieves pain.             Should be used only        Taking too much
 Tylenol                                             when necessary.            may result in
 Darvon                                                                         dependence.

Hormones                   To raise hematocrit        Take as prescribed.        Slightly increased
 Male hormones            (blood count)                                         risk of forming
 Nandrolone                                                                     blood clots.


WARNINGS
   DO NOT take any medicines not approved by your kidney doctor.
   Antibiotics are not given for colds. Some antibiotics cannot be used for people whose kidneys
    have failed.
   Over-the-counter drugs can be dangerous. Never take new medicines of any kind that are not
    prescribed by your kidney doctor. Never take home remedies unless approved by your doctor.
   DO NOT change your dosages on your own.
   Some medications can be habit forming. Take only as directed.
   When having prescriptions filled, never allow the pharmacist to substitute a drug without first
    talking to your physician.

page 22
HELPFUL HINTS ABOUT MEDICATIONS
   Learn the name of each medicine you take, the dose you should take, and its purpose. Ask your
    nurses or doctors whenever you have questions about your medicines.
   Get all of your medicines at one drug store. The pharmacist will get to know you and your
    medications and help you when you need it.
   Carry an updated list of your medications with you at all times. This is very important in
    emergencies.
   Establish a routine. Pick specific times to take your medications.




                                                                                                 page 23
                                 Your Numbers -- Lab Tests
                                    (Blood Chemistries)

You will have lab work checked once a month in the dialysis clinic. This lab work is referred to as
your panel. The results of the lab work are called your “numbers.” The nurse or dietitian will
review results with you each month and explain them to you.


Numbers
      Are done monthly.
      Tell if your diet is in order or if you are well dialyzed.


You will be especially interested in a few of the numbers that the doctors and nurses will check
closely. They might need to adjust your diet or dialysis to improve some of your lab test results.


The following tests will be covered in more detail:
           A.      Potassium
           B.      BUN (blood urea nitrogen)
           C.      Phosphorus
           D.      Hemoglobin and Hematocrit


POTASSIUM
Potassium is a particle in your cells and bloodstream. It is important to the function of your cells,
muscles, and heart. Most kidney patients have a high potassium level before dialysis because almost
all foods contain potassium, and the kidneys can't get rid of the excess. Potassium can collect in
your bloodstream and make your heart beat irregularly or even stop. Some foods that are high in
potassium are: oranges, bananas, chocolate, and potatoes. Many high protein foods are also high in
potassium and must be limited. Some foods must be totally eliminated due to their high potassium
content. The dietitian will tell you more about how much potassium you can have in your diet and
what foods to eat and not to eat.


BUN (Blood Urea Nitrogen)
BUN stands for blood urea nitrogen. Urea is the waste product that comes when your body
processes protein from what you eat. How much urea is in the blood is measured by the BUN test.

page 24
When you are off your diet, the BUN will usually be higher. If you follow your diet and dialyze the
right amount of time, your BUN should stay in a satisfactory range.


PHOSPHORUS
Phosphorus is usually excreted by the kidneys. Due to kidney failure, phosphorus builds up in the
blood and causes the calcium to drop. This leads to a breakdown of the bones. Phosphorus can be
controlled with adequate dialysis and medicine (binders) that bind the phosphorus so that it will be
excreted by your bowels. When your phosphorus goes up, the doctor will probably increase your
binders.


HEMOGLOBIN AND HEMATOCRIT
Kidney patients are usually anemic, so we will keep a close check on your hemoglobin and
hematocrit. These two tests measure the amount of oxygen and the number of red blood cells in
your blood. If your blood count gets too low, your doctor may order a blood transfusion for you. He
may want you to take iron pills or iron shots to build up your blood count. If you should need a
blood transfusion, you will get it while you are on the kidney machine.


There are other tests that are checked with your monthly panel. If you have questions about any of
your lab work, ask your doctor or nurse.


YOU WILL BE ENCOURAGED TO PARTICIPATE IN THE REVIEW OF YOUR NUMBERS.




                                                                                              page 25
                                           Blood Chemistries
 (This guide was put together by the staff of Good Samaritan Hospital Chronic Dialysis Center, Bay Shore, New York)

    Blood          Normal Values      Accepted Normals For          Causes of Abnormal        Signs and Symptoms
  Chemistry                             Dialysis Patients                  Levels              of Abnormal Values
                                                                  (Refers to increases in,
                                                                     unless otherwise
                                                                          noted)
Glucose            80-120mg/dL        80-120mg/dL                Diabetes, persistent         Excessive thirst
                                                                 uremia. Will be
                                                                 slightly higher within
                                                                 1-3 hours after eating
                                                                 a meal.

BUN                10-26mg/dL         60 -100                    Eating too much              Fatigue, nausea,
                                      Depends on how             protein-containing           insomnia, dry and
                                      much protein you eat.      food.                        itching skin, taste
                                                                                              and smell affected,
                                                                 Or could indicate the        urine-like body odor
                                                                 need for more dialysis       and breath.
                                                                 time, higher blood flow
                                                                 of a larger dialyzer.

CO2 Bicarb         21-30mEq/L         Not less than 15-16        Eating too much              Rapid breathing,
                                                                 protein, creating a          shortness of breath
                                                                 more acid blood and
                                                                 lowering C02

Sodium (Na)        133-145mEq/L       133-145mEq/L               Eating too much salt,        Thirst. Leads to
                                                                 e.g., potato chips,          drinking more fluid,
                                                                 ham, pickles.                causing fluid weight
                                                                                              gain, elevated blood
                                                                                              pressure and
                                                                                              shortness of breath.

Chloride (CL)      95-108mEq/L        95-108mEq/L                Same as Sodium               Same as Sodium
Creatinine         Below              10-20. Varies with         Inadequate dialysis          Non-specific
                   1.2mg/dL           how much muscle            time or addition of          symptoms
                                      mass you have.             muscle                       associated with
                                      Should remain about                                     inadequate dialysis.
                                      the same as at start
                                      of dialysis from
                                      treatment to
                                      treatment.
                                      Only the most
                                      muscular of patients
                                      should have values in
                                      the upper range.

Potassium          3.5-5.4 mEq/L      4.0– 6.0                   Eating too many foods        Extreme weakness
(K)                                   Few symptoms below         high in potassium            that can lead to a
                                      7.0 in dialysis                                         heart attack (cardiac
                                      patients                                                arrest).




page 26
    Blood      Normal Values   Accepted Normals For     Causes of Abnormal       Signs and Symptoms
  Chemistry                      Dialysis Patients             Levels             of Abnormal Values
                                                      (Refers to increases in,
                                                         unless otherwise
                                                              noted)
Calcium (Ca)   8.5-10.5        8.0-10.0               Low calcium: eating        Low: Muscle
               mg/dL           Should be near upper   too much high              twitching and
                               range if normal to     phosphorus food. Not       cramping, seizures,
                               prevent overactive     taking phosphate           varying degrees of
                               parathyroid glands.    binders. Calcium will      depression, hair loss,
                                                      go down if phosphorus      cataracts and
                                                      goes up.                   conjunctivitis.

                                                      High calcium:              High: Muscle
                                                      Medications such as        weakness, fatigue,
                                                      Rocaltrol may cause        constipation,
                                                      sharp increase. Check      abdominal cramps,
                                                      blood regularly.           nausea, vomiting,
                                                      Parathyroid gland          loss of appetite,
                                                      removal may be             coma.
                                                      indicated.

Phosphorus     3.0-5.0 mgldL   3.0 – 6.0              High: Not taking           High: Causes
(Phosphate)                                           phosphate binders,         elevated parathyroid
(PO4)                                                 eating high-               hormone by lowering
                                                      phosphorus foods,          calcium.
                                                      e.g., milk, cheese,
                                                      organ meats, beans.        High and low:
                                                                                 Breaking of bones
                                                      Low: Taking too much       without specific
                                                      phosphate binder.          injury (spontaneous
                                                                                 fractures),
                                                                                 continuous bone pain
                                                                                 especially hips,
                                                                                 knees and ankles,
                                                                                 heels.

Calcium-                       Multiply calcium and                              High: calcification of
phosphate                      phosphorus blood                                  blood vessels
product (Ca                    values—should not                                 including coronary
XPO4)                          exceed 55.                                        arteries.
Magnesium      1.7-2.3 mg/dL   1.7-2.3 mg/dL          Elevations due to          Decreased mental
(mg)                                                  taking phosphate           function ranging
                                                      binders containing         from drowsiness to,
                                                      magnesium or other         in severe cases,
                                                      medications such as        coma. Decreased
                                                      milk of magnesia or        tendon reflex leading
                                                      citrate of magnesium.      to paralysis. Nausea
                                                                                 and vomiting,
                                                                                 hypotension due to
                                                                                 dilation of blood
                                                                                 vessels.
Hematocrit     36-45%          Will be lower varies   Decreased production       Fatigue, shortness of
(Hct)          [% of total     with patient           of red blood cells,        breath, chest pain on
               blood volume                           blood loss during or       exertion (if
               made up by                             after dialysis,            underlying heart
               red cells]                             shortened survival of      disease is present).
                                                      red cells.
Enzymes        Check normal    Check with your        Check with your            Check with your
               for your lab.   doctor.                doctor.                    doctor.

                                                                                              page 27
    Blood         Normal Values     Accepted Normal For       Causes of Abnormal       Signs and Symptoms
  Chemistry                           Dialysis Patients              Levels             of Abnormal Values
                                                            (Refers to increases in,
                                                               unless otherwise
                                                                    noted)
SGOT              10-50 U/mL        10-50 U/mL              Hepatitis                  None, or nausea,
                                                            Some medicines             vomiting, abdominal
                                                                                       cramping, fatigue if
                                                                                       severe liver damage.

SGPT              7-33 U/mL         7-33 U/mL               Hepatitis                  None, or nausea,
                                                            Some medicines             vomiting, abdominal
                                                                                       cramping, fatigue if
                                                                                       severe liver damage.

Alkaline          30-115 IU/L       30-115 IU/L             Comes from bone or         Painful joints,
Phosphatase                                                 liver                      weakened bones that
                                                                                       could lead to severe
                                                            From bone: A marker        pain and or
                                                            for how bad                deterioration
                                                            parathyroid-caused         requiring surgery
                                                            bone disease might be.     (hyperparathyroid-
                                                                                       ism).
                                                            From liver: Marker for
                                                            diseases involving the
                                                            liver or gall bladder.

Parathyroid       Check normals     150- 300                Long-term imbalances       Same as evaluated
Hormone           for your lab.                             of calcium and             phosphorous.
(PTH)                                                       phosphorus.




A brief explanation of other tests that are drawn monthly or quarterly.

      Blood            Normal Values                              Reason For Test
    Chemistry
Australian               Negative        Test for serum hepatitis (Hepatitis B)
Antigen
Hepatitis                Negative        Antibody test to determine if you have ever had hepatitis. Past
Antibody                                 episodes of hepatitis would give a positive result. If you have
                                         ever had a vaccine for hepatitis B, then you could also have a
                                         positive result.
Total Protein           6-8 gm/dL        Observed for abnormally low levels due to intake of protein foods.
Albumin               Above 4 gm/dL      Measure of nutritional adequacy.
Red Blood Cells             4-6          Test for anemia due to decreased RBC production when there is
(RBCs)                 millionlmm3       little or no kidney function.
Ferritin              76-155 ng/mL       A measure of ―stored‖ iron.
Total Bilirubin        0.2-1 mg/dL       Elevated level indicates liver damage, e.g., hepatitis, or
                                         obstruction of bile ducts.




page 28
                                         The Renal Diet

Managing your diet is an important part of the overall treatment of kidney disease. A special diet is
usually prescribed for renal patients to reduce the production of wastes (and the effects) on your
body. You will be on a special diet as long as you are on dialysis.
       When the “wrong” foods or too much of the “right” foods are eaten, waste products can build
up in the blood and cause nausea, vomiting, itching, and weakness. Headaches, shortness of breath,
or swelling of the legs may occur also. These may be present some of the time in all patients. Many
occur most of the time in patients who do not follow their dietary and fluid restrictions. The kidney
machine cannot do as much work in three to four hours, two to three times a week, as your kidneys
did working 24-hours a day. You must reduce how hard the artificial kidney must work by
following a diet restricted in protein, sodium, potassium, and certain other nutrients. The dietitian
will carefully explain your diet to you. Following it is essential to your care because the diet helps
reduce production of wastes in the body.
       Specific waste products that accumulate in the blood include excessive amounts of nitrogen
(BUN), phosphorus, sodium, potassium and fluids. Monthly lab values show which waste products
may be high in the blood and indicate how well you are following your diet.
       Although there are some similarities among patients’ diets, each diet is set up specifically for
you. Your diet is made for your particular needs and the type of dialysis you are receiving. You
may have different diet restrictions or allowances from other patients. You must be responsible for
controlling your own diet. A dietitian will help you with what you should eat, how you can prepare
meals on the special diet, and will explain how blood chemistries are affected by sticking to your
diet. However, it is up to you to actually eat the correct amount and types of foods. No one can do
this but you.




                                                                                                page 29
                        HELPFUL HINTS TO STAY ON YOUR DIET


      Learn about kidney disease so that the importance of the diet is clear. Talk with your
       dietitian. It is easier to follow a diet if you understand it.
      It is your responsibility to ask questions about your diet.
      Get your family or close friends involved in learning about your diet. They can help and
       support you if you need it.
      You should be honest about food that you like or dislike. Your dietitian can help with
       recipes and can adjust your diet so it includes food that you like.
      Learn what foods to avoid, the proper amounts of foods you can eat, and how to measure
       food portions.
      You should not adjust or change your diet without first talking with your dietitian.
      Don’t compare your diets with other patients. Your size, weight, and diagnosis determine
       which foods your can eat and how much you can eat.


Below is a list of questions that may help you. Remember: Talk with your dietitian if you have any
questions.


   1. How much will I be able to drink on my diet?
       If you have no urine output, you will be able to consume only 500-1,000 cc of fluid a day. If
       your kidneys still produce urine, you can drink 500cc plus the amount your kidneys produce.
       The doctor and dietitian will discuss your fluid intake with you.


   2. I have been told to limit how much fluid I drink. How can I avoid being thirsty?
       Excess salt is the main cause of thirst. You can limit how thirsty you are by limiting how
       much salt you eat. Patients who do not eat too much salt (sodium) are not thirsty, even if
       they are only allowed to drink 500-1,000 cc of fluid a day. Sweets also may make you thirsty
       if you are a diabetic.


   3. I just can’t eat food without salt. What can I do?
       Patients say that it takes two to three months to get used to eating food without salt. After
       that, food with salt tastes strange to them, just as salt-free food did at first. There are many

page 30
   other spices that you can use to add flavor to food. Talk with your dietitian about spices that
   might be good to use.


4. What is high-quality protein?
   High-quality protein is protein of animal origin. It is called high quality because it has a
   higher percentage of the components that are necessary to build strong muscles and other
   tissue. High-quality protein produces fewer waste products than does low quality protein,
   which is derived from vegetables sources such as beans, corn, and peas.




                                                                                            page 31
                                                Hepatitis


Hepatitis is a big danger to all dialysis and transplant patients, and for those who are in close contact
with them, such as family members and staff who work in the dialysis unit. We do not want to cause
excessive concern about this, but we want to see that you are fully informed about the dangers of
hepatitis and about the measures that you can take to prevent spreading it.
         Hepatitis is a virus infection of the liver. In most cases, it causes an acute illness that
gradually clears up in two to three weeks or a month or two. In some cases—more often in dialysis
patients—hepatitis can lead to a chronic infection that can seriously damage the liver. It is important
that you try to prevent the spread of hepatitis.
         The form of hepatitis most commonly seen in dialysis units is called serum hepatitis because
it was once believed that it could only be spread by the transfer of blood or blood products from one
person to another (for example, by blood transfusions). Now we know that this form of hepatitis can
be spread by other means but it occurs less easily than by contact with the blood.
         To identify patients and/or staff who have been infected with hepatitis, we do a blood test
each month known as the Australian antigen test.
         The Australian antigen is a factor that can be found in the blood of patients who have had
serum hepatitis. A positive test for this factor does not mean that the patient has a serious case of
hepatitis, but it does mean that he or she has been infected with the virus at some time and could
possibly spread the infection to someone else. Once an individual has had hepatitis, he or she cannot
be infected with the same type of hepatitis again, but may carry the virus and possibly can transmit it
to others several years after the initial infection.
         Most kidney patients who develop hepatitis have mild cases. The most common symptom is
being more tired than usual. Other symptoms are: skin rash; pain in the hands or joints; yellow
color of the whites of the eyes or skin; dark yellow urine (almost brown) or light colored stools; loss
of appetite; and nausea, vomiting or diarrhea.


To protect patients as well as staff, the following safeguards against contracting hepatitis will be
followed at the clinic.
    1.       Contact with the blood of potentially infected patients should be avoided. Because the
             test for Australian antigen is not 100 % perfect, we regard all blood as being potentially
             infected with the hepatitis virus. Our personnel wear disposable gloves when working

page 32
           with dialysis patients. This reduces the chance that blood will enter a small cut on their
           hands or fingers, or be spread to other patients.
   2.      Use care when you handle used needles. This means discarding them in proper
           containers and seeing that no one is carelessly stabbed with a used needle.
   3.      Avoid blood transfusions unless they are very necessary. Blood Assurance tests every
           unit of blood for Australian antigen, but this testing is not 100 % perfect. Transfusions
           should be kept to a minimum.
   4.      Use care when cleaning up or getting rid of vomit, urine, stool and other secretions from
           all patients, particularly those who are known to have a positive Australian antigen test.
   5.      Patients who are known to be positive for Australian antigen will be isolated from those
           who are negative. They will dialyze on a special machine set aside for only positive
           patients.


We hope that all patients and visitors will understand the need for regulations that help increase
safety of all patients, visitors, and staff. Please understand that staff members are exposed to
hepatitis every working day, and that some rules are necessary to see that they, as well as the
patients, are protected from an accidental hepatitis infection. For this reason, patients should follow
the policies given to them.
   You also can take the following precautions at home to protect yourself and your family from
becoming Australian antigen positive.
   1.      Wash dishes and eating utensils thoroughly with hot water and plenty of soap.
   2.      Wash pans or sheets contaminated by blood, vomit, or diarrhea, etc., thoroughly in hot
           water and with plenty of soap before using them again.
   3.      Do not share razors, clippers, and personal articles used by a person who is positive for
           hepatitis.
   4.      Practicing personal cleanliness will decrease the chances of spreading hepatitis.
   5.      If you are positive for hepatitis, tell others who may come in contact with your blood
           (e.g., dentists, barbers).


A positive Australian antigen is no cause for alarm. If you have a positive antigen, or if you have
questions about hepatitis, talk to the nurses and your doctor. They will explain more about how
important this problem is and the meaning of the tests that are done.


                                                                                                   page 33
                                         Hepatitis Vaccine


There is a vaccine that can help prevent you from getting hepatitis. Your doctor may order this
vaccine for you. The vaccine makes your body produce antibodies that kill the hepatitis virus. The
vaccine is a total of four injections at different times; one shot at the beginning, one shot after one
month, another after two months, and another shot six months from the first. After all the shots are
completed, your blood will be checked to see if you have the antibodies. The medicine does not
produce antibodies in everyone and if you are a kidney patient, you have a greater chance of not
developing antibodies. If you do not develop antibodies, your doctor will order another series of
shots for you. If you have more questions about this medicine or if you want to get it, talk with your
doctor or nurse.




page 34
                                          Vascular Access


To start you on dialysis, you need a vascular access to your blood. This is a way of getting your
blood from your body, through the artificial kidney, and back into your body. You need to have
special surgery to create an access. Your doctor will determine the type of access that is best for
you. The most common accesses are listed below.
      A-V Fistula
      Gortex Graft
      Dialysis Catheter


Each type of access has advantages and disadvantages. One will probably suit your needs better
than the others.
       You may hear doctors and nurses refer to arteries and veins. Arteries are blood vessels that
carry blood from your heart to all parts of your body. Veins are blood vessels that carry blood back
to your heart. Veins are usually closer to the skin than arteries are.
       During dialysis, you will hear the nurses using the words “arterial” and “venous.” An arterial
needle in a fistula or graft leads the blood away from the heart just as an artery does. A venous
needle takes blood toward the heart, as does a vein.


A-V FISTULA
A fistula is a direct surgical connection between an artery and a vein that allows blood to flow
directly from the artery into the vein. Because of this fast flow of blood, the vein gradually gets
larger and becomes stronger and tougher. This allows the nurses to easily insert large needles to
remove blood from your body, pass it through the artificial kidney and return it to your body. An
ordinary vein would not be strong enough for this, since it would not provide the amount of flow
needed for efficient dialysis.
       A fistula is created by first numbing your skin with a local anesthetic (similar to what the
dentist uses). The surgeon makes a small cut (usually about one inch long) over the artery and the
vein at the wrist. The surgeon then attaches the vein to the side of the artery and closes the incision.
Nothing is actually placed in your arm except the stitches that hold the vein to the side of the artery.




                                                                                                 page 35
GORTEX GRAFT
The Gortex graft is a man-made graft like plastic. The graft can be placed under the skin as a
substitute for your own blood vessels. The graft is connected to an artery at one end and to a vein at
the other, so that blood flows constantly from the artery into a vein. After the area has healed,
needles can be placed in the graft just like in a normal fistula.
       One advantage of a graft is that it may be used soon after dialysis. The graft can be used
after a day or two, but we prefer to let it heal for at least two weeks.


DIALYSIS CATHETER
When you first start on dialysis you may need to have a catheter placed. This is a temporary access
that involves putting a small catheter below your collarbone into the large blood vessel going to your
heart. The catheter is stitched in place and stays there until your permanent access is ready to use.
After the nurses start using your graft or fistula, the catheter can be removed. Sometimes, these
catheters may still clot or kink, or get infected, and it may be necessary to replace the catheter.




page 36
                    Common Questions About Vascular Access


1. After the access is created, what will happen to the rest of my hand?
   The rest of your hand has plenty of blood supply from other arteries, so nothing will happen
   to it. Some patients get numb over the thumb. This usually goes away in two to three weeks.


2. Can I use that arm?
   After the incision heals--usually in 7-10 days--you can use the arm freely. You can do
   anything with your fistula arm that you could do before the surgery. We suggest that you
   exercise your fistula arm often.


3. What happens if I cut my arm?
   If you should cut the fistula vein or the graft, it will bleed more than a normal vein. Putting
   pressure over the cut will control this bleeding.


4. When can the fistula be used?
   It can be used after five or six weeks. The vein can sometimes be used within a week, but we
   prefer letting it develop for a longer period.


5. When can a graft be used?
   Usually after two to four weeks.


6. What can I do to help the fistula vein develop more rapidly?
   After the incision heals, you will be given a rubber tourniquet. The vein will develop faster
   if you put the tourniquet on for three to four minutes several times a day. While the
   tourniquet is on exercise the arm by squeezing a rubber ball or by lifting a moderately heavy
   weight.


7. How is the access used?
   One needle is placed in the vein to remove blood from your body, and a second needle is
   used to return the blood to your body. The arterial needle takes blood away from your heart.
   The venous needle returns blood toward your heart.

                                                                                            page 37
   8. Does it hurt when the needles are put in?
      A small amount of local anesthetic can be used to numb the skin where the needle will be
      placed, so that it’s not very painful. In time, your skin will become less sensitive to the
      needle sticks.


   9. Does it hurt during the time the needles are in?
      Usually there is no discomfort once the needles are placed, although you must be careful
      when moving your arm. If you feel pain, tell your nurse or doctor. Changing position will
      usually stop the pain.


   10. How long are the needles left in?
      They are left in for the length of the dialysis treatment, which varies between three and five
      hours depending upon your size, the blood flow rate, and a number of other factors.




page 38
PART 4
TREATMENT OPTIONS




                    page 39
page 40
                                      Treatment Options

Once the doctor tells you it is time to begin dialysis treatment, you may feel overwhelmed with all

the things happening to you, and all the decisions that you have to make. You may not know or

understand the different options possible to you. Once you start dialysis, you can decide what type

of treatment you would like to use. Not all of the treatments are right for everyone. Ask your doctor

or nurse to help you pick the one that best suits your medical situations, and takes into account your

lifestyle. Your doctor will tell you which treatments you will be able to do. It is up to you to make

the choices that will be best for you and your family.



YOUR CHOICES MAY INCLUDE:

      • Hemodialysis at a clinic

      • Home Hemodialysis

      • Continuous Ambulatory Peritoneal Dialysis (CAPD)

      Continuous Cycling Peritoneal Dialysis (CCPD)

      Transplant




                                                                                               page 41
               Commonly Asked Questions About Hemodialysis

   1. Does the artificial kidney machine have an effect on my kidneys?

      No, it neither helps nor hurts your kidneys. Whether you put out urine or not, your kidneys

      have failed. Kidney machine treatments will not fix your kidneys. The treatments will not

      harm them either.



   2. Will I always need to use a kidney machine?

      Kidneys rarely recover after they have deteriorated to the point that dialysis is necessary.

      The need for the kidney machine is permanent once dialysis has been started. In many cases,

      a kidney transplant can be performed. If the transplant is successful, dialysis will no longer

      be needed.



   3. Will dialysis make me feel any better?

      Even though the artificial kidney will not make you well, it will make you feel much better.

      Many patients actually say they feel normal between treatments, but most do still feel some

      effects of kidney failure. Some of the effects you might feel are decreased strength and

      endurance.



   4. How does dialysis feel? Is it painful?

      The treatments are not painful. You may experience some discomfort. The first treatment

      often causes a headache, and sometimes you may throw up or feel like you might. Some

      patients have headaches, nausea, and vomiting even during later treatments. These

      symptoms are less likely if you follow your diet closely and dialyze regularly for the right

      length of time.


page 42
5. What can I do during a dialysis treatment?

   You may read, watch television, knit or crochet, play checkers or cards, talk to the nurses and

   the patients near you, or simply take a nap. Time will pass quicker if you plan some activity

   during the dialysis treatment.



6. Can I have a normal life while using the kidney machine?

   Your life may not be perfectly normal, but you can do most of the things you used to do

   before you developed kidney failure. Reasonable amounts of work are suggested. You

   should exercise as much as your physical strength will allow. The more you do, the better

   you will feel.



7. When can I expect to feel better?

   Improvement may be slow. Most patients find they feel a great deal better after the first three

   months. Many patients continue to gain strength slowly for up to two years after dialysis is

   started.



8. How long can I live on an artificial kidney?

   Patients have lived many years on dialysis. Some of the first patients treated by dialysis in

   the early 1960s are still living. How long you live depends on how carefully you follow the

   treatment program prescribed for you, and your overall medical condition.



9. Will I have to dialyze at the center from now on?

   We encourage all patients to consider home dialysis. Many other patients have dialyzed at

   home. Dialysis is more convenient at home than in the center, and you can arrange your

   treatments when you desire. You will also begin to know that you are responsible for your
                                                                                           page 43
      own treatment. If home training is not possible, you may wish to consider Continuous

      Ambulatory Peritoneal Dialysis (CAPD). Refer to that section if you are interested.



   10. Can I go back to work or school?

      We encourage patients to return to work or to school, and we’ll make every effort to arrange

      your dialysis schedule to accommodate your schedule.



   11. Can dialysis patients travel?

      Yes, we can help you set up dialysis in other cities, if you wish.



   12. Will I always be under a doctor’s care?

      Yes, although patients who go on home dialysis can become quite independent and require

      occasional visits to the doctor. Patients who have a successful transplant eventually become

      quite independent, also. Learning all about your condition can increase your level of

      independence, so you can take some responsibility for your own care.



   13. Is dialysis dangerous?

      Dialysis is a complicated procedure. Some risks are involved. Nurses who perform dialysis

      are trained especially in that area. They know the possible dangers and are careful to avoid

      them.



   14. Is a wearable artificial kidney ready for use?

      A lot of research has been done on several types of wearable artificial kidneys. When these

      become available for regular use, they will be assessed for use by our patients.


page 44
   15. Will I have cramps while I am on dialysis?

       Some patients do have cramps during the dialysis treatment. This usually happens when

       dialysis removes a lot of fluid. To keep from having cramps, avoid taking on large amounts

       of fluid between treatments by staying within your fluid limits. If you do experience cramps,

       your nurse can give you something to ease them.



                    High Flux Dialysis & High Efficiency Dialysis

High flux dialysis and high efficiency dialysis are fairly new procedures. These types of dialysis are

sometimes called shortened dialysis because the dialysis time can be reduced when started on this

type of therapy.

       This type of dialysis works because a very large artificial kidney is used for the treatment.

The larger kidney needs a special machine to control the fluid removal so that too much fluid is not

taken off. This type of treatment is not right for everyone. Patients who have high flux dialysis

must have a good vascular access because very high blood flows are needed. The high blood flows

also present another problem. Some patients cannot physically bear rapid blood flows. Patients also

must be very good with his or her diet and fluid restriction. Since the dialysis time is shortened, the

nurse cannot take off large amounts of fluid safely with this treatment method.

       How much this reduces dialysis is different from patient to patient. Some patients may be

able to run two hours while others require four hours. Dialysis time is very different for each

patient. Every patient does not have the same level of kidney failure. Also, your size, level of

activity, and diet affect the amount of time patients needs to dialyze. By evaluating you as an

individual, your doctor knows how much time you need to dialyze. If high flux or high efficiency

dialysis interests you, ask your doctor if you qualify for this type of treatment.




                                                                                                  page 45
                                     Home Hemodialysis

Once you have started on dialysis, you may want to do your own treatment at home. This is an

option that offers several advantages to the patient. If you select home hemodialysis, you would use

a kidney machine at home in the same way as your treatments are performed at the clinic. This

method of dialysis requires that you and a partner (usually a family member) learn how to work the

kidney machine. This training takes place over a period of six to eight weeks, and can be done while

you are receiving your dialysis treatments. You do not need to purchase your kidney machine.

Medicare will help pay for it. Once you take the machine home, you will need to come back to the

clinic once a month to have lab work drawn and to be assessed by your doctor. During this monthly

visit, you can ask your doctor or home training nurse questions about any problems you might have

with the process.



ADVANTAGES:

      You can do the procedure yourself with the help of a partner or friend.

      You use your own machine.

      You can dialyze at times that work for you.

      If you are eligible for Social Security, Medicare reimbursement begins the day you begin

       training.

      You don’t have to travel to the clinic for treatment.

      You can have more independence and control of your life.



DISADVANTAGES:

      May cause additional family stress.

      Requires a partner or friend to help.

page 46
The following questions and answers will give you more information regarding home dialysis.



   1. Who will dialyze me at home?

       You dialyze yourself, with help as needed from your partner or friend. You should take

       responsibility for your own treatment, because this will help you to be more independent.

       However, we will train both you and a partner or family member, since it is important to

       have proper assistance while performing home dialysis.



   2. Why is the patient expected to be in charge of his or her own treatment?

       It is important for you to feel independent. It is also important that you understand

       everything related to your treatment. You have more reason than anyone to do things

       correctly. It lightens the load on family members, and patients are happier and do better at

       home if they learn to accept responsibility for their own treatment.



   3. Can I learn home dialysis if I am not a nurse or doctor?

       Yes. Very few of the home dialysis patients have any medical background. Despite this,

       they learn the method in a short time, and most do quite well at home with help from their

       medical team.



   4. What is the home dialysis training including?

       The training has two parts: technical and medical. In the technical phase, you learn about the

       equipment and the artificial kidney. You also learn how to carry out the dialysis safely and

       efficiently. In the medical part of the training, you learn about any medical treatments you

       need to stay in good health. The training sessions occur with your dialysis treatments.


                                                                                               page 47
   5. How can I be sure that I am ready to go home with a machine?

      During the training sessions, the nurses will gradually move the responsibility to you and to

      your partner. Eventually, you will do all work involved in your dialysis, with help from your

      assistant. You will be allowed to go home with your machine only after you have shown that

      you can do the technique safely.



   6. How do I handle emergency situations at home?

      In your training, we teach you to avoid emergencies by following the proper and safe

      technique. However, we also teach you to handle all emergencies that you may encounter.

      We teach you and your assistant what to do immediately to protect you. After you have

      stabilized the emergency, you may want to call the clinic or your doctor for additional

      advice.



   7. What happens if the machine breaks down?

      If you think you are having trouble with your machine, call the Dialysis Clinic and talk with

      the home dialysis nurse. Usually the machine can be fixed quickly, sometimes with simple

      directions over the phone. The service person from the company that made your machine

      may have to repair it.



   8. What if my assistant gets sick?

      If your assistant is sick or is not able to help you, you can come back to the Center on a

      temporary basis for your dialysis.




page 48
   9. Are home dialysis patients also on the transplant waiting list?

       Yes. Home dialysis patients are on the transplant waiting list if they want a transplant and if

       their medical condition would allow a transplant. We evaluate a patient’s suitability for a

       transplant prior to training him or her for home dialysis and will contact the patient when the

       first suitable kidney is available. One patient is as likely to be called as any other patient,

       since the decision about who gets a kidney is based on tissue typing, not on where the patient

       receives dialysis.



   10. How can I find out more about home dialysis?

       Talk with your doctor or nurse about home dialysis. We continually train patients to dialyze

       at home, and will be happy to discuss this treatment method with you.



If you are interested in home training, you may want to talk with the home training nurse. Contact
information is listed below.
                               Dialysis Clinic, Inc.
                               1425 East Third Street
                               Chattanooga, Tennessee 37404
                               (423) 698-0927




                                                                                                  page 49
               Continuous Ambulatory Peritoneal Dialysis (CAPD)

Continuous Ambulatory Peritoneal Dialysis (CAPD) is one of two treatment methods available for

end stage renal disease patients who want to do treatments at home. CAPD is a type of dialysis, or

blood cleansing. A liquid mixture is put into the abdominal cavity through a soft plastic tube—a

catheter—that has been permanently fixed in the abdomen by a surgeon. CAPD is a seven-day-a-

week, 24-hour-a-day procedure and provides continuous dialysis. The dialysis solution is always

present in the abdomen. It is a machine-and-needle-free form of dialysis. No assistants or helpers

are needed.

       The dialysis solution “runs into” the abdominal cavity and remains there for four to six hours

during the day and eight to twelve hours at night. The time the solution is in your system is called

the dwell time. After the “dwell” time, the solution is manually drained from abdomen and fresh

solution is again “run” into the abdominal cavity. This procedure is called “exchange” and is

performed four times a day. Each exchange usually takes about 30 minutes. The patient choosing

CAPD can plan to spend an average of two hours a day performing dialysis, or 14 hours per week.

       To “run” the solution into the abdominal cavity, one end of a plastic tube is connected to the

catheter. This tube is called the “transfer tubing.” There are different kinds of “transfer tubing’s.”

Each has a spike or a connector that lets the solution go in for each exchange. The “bag” and the

“tube” are made of a soft, flexible plastic. Many of the new tubings allow connections from the

“bags” in between exchanges with only a short transfer tubing in place. This is easily hidden under

clothing. There are also tools to help patients that may have vision or manual dexterity problems.

       Extra fluid and waste products are cleaned from the body continuously with CAPD. Because

of this, people doing this method of dialysis usually have a different diet than those using

hemodialysis. The diet usually lets you eat more fluids, potassium, sodium, and protein. But, each

patient is an individual and the dietitian creates a diet specifically for each CAPD patient.


page 50
ADVANTAGES:

      No machine

      No needles

      No helper or assistant needed

      Rise in hematocrit

      Improved taste and appetite

      Increase in strength

      Better control of blood pressure

      More stable blood chemistries

      Freedom to travel

      Shorter training period than for hemodialysis



DISADVANTAGES:

      • Infection

      • Increase in body weight

      • Constipation

      • Muscle cramps

      • Occasional nausea/vomiting

      • Loss of appetite

      • Abdominal hernia




   The greatest disadvantage of CAPD is the risk of infection. Performing each exchange is a

sterile procedure. If contamination occurs during the exchange, germs may get into the abdominal
                                                                                           page 51
cavity and cause an infection. This infection is called “peritonitis.” The CAPD technique is simple,

but must always be kept sterile, or germ-free. Peritonitis can be serious and painful, if it is not

treated. Therefore, you should always call your doctor if you see signs of an infection.

   CAPD has many advantages; but it is not for everyone. The choice to use CAPD is reached only

after looking at the individual’s needs and emotional and physical capabilities.


For more information, contact:
      Dialysis Clinic, Inc.
      (423) 698-0927




page 52
                         Continuous Cycling Peritoneal Dialysis

Continuous Cycling Peritoneal Dialysis (CCPD) is another kind of peritoneal dialysis, or a reversal

of CAPD exchanges. CCPD takes the exchanges normally done during the daytime and moves them

into the night, while the patient is sleeping.

        CCPD is another kind of dialysis, or blood cleansing. A solution is put into the abdominal

cavity through a soft plastic tube (catheter) that has been permanently fixed in the abdomen by a

surgeon. CCPD is also a seven-night-a-week, 24-hour-a-day procedure. Dialysis solution is always

present in the abdomen. It is a needle-free form of dialysis. A machine is necessary, but an assistant

isn’t needed.

        The procedure is done with a cycler (machine), which measures and warms the solution,

sends the solution to the patient and allows the solution to drain after the completion of the “dwell”

time. The cycler also watches each drain cycle to make sure it is drained enough. The cycler has

warning alarms to let the patient know if not enough solution is drained. The cycler uses gravity and

works quietly, offering the patient a non-threatening home dialysis treatment.

        The procedure usually takes eight (8) hours each night. Within this eight-hour period, three

(3) exchanges are done during the night and the fourth (4) exchange is carried in the abdomen during

the day. After finishing dialysis each morning, the patient disconnects at the catheter end. There is a

short transfer tubing, but no bag is worn on the body.

        Extra fluid and waste products are cleaned from the body continuously with CCPD. This

allows a more liberal diet, especially more protein, potassium, sodium and fluids. But each patient’s

diet will be different, and the dietitian prepares a diet specifically for each CCPD patient.




                                                                                                page 53
ADVANTAGES:

      No Needles

      No Helper

      Rise in Hematocrit

      Improved Appetite

      Better control Blood Pressure

      More stable Blood Pressure

      Freedom to travel

      Shorter Training Period than for Hemodialysis

      Fewer Connections than CAPD



DISADVANTAGES:

      Machine

      Infection

      Increase in Body Weight

      Constipation

      Muscle Cramps

      Occasional nausea/vomiting

      Loss of Appetite

      Abdominal Hernia



The biggest problem with CCPD is the risk of infection. Performing each dialysis treatment is a

sterile procedure. If contamination occurs during first or last dialysis, germs get into the abdominal



page 54
cavity and can cause an infection. This infection is called “peritonitis.” The CCPD technique is

simple, but must always be kept germ-free.

       Even though CCPD has many advantages, it is not for everyone. The choice to use CCPD is

made only after assessing the individual’s needs and emotional and physical capabilities. Usually,

this decision is one in which both the patient and the doctor agree upon and share.



                                        Transplantation

Kidney transplantation is the process of placing a kidney from another person (donor) into a patient

with kidney failure using surgery. The donated kidney can perform all the functions that the

patient’s damaged organs are unable to do.

       The transplanted kidney is put in near the patient’s hipbone rather in the location of the

patient’s kidneys, which are higher and more to the side. Sometimes, the patient’s own kidneys have

to be removed to control chronic infection or high blood pressure.

       The patient with a functioning transplant kidney doesn’t need dialysis treatments. Because

kidney works more effectively than dialysis, the transplanted patient generally feels better and has

more energy. Some patients, whose sexual activity declined during dialysis, find their sexual

interest returning. Many limits are ended after transplantation, including food and liquid limits.

       The transplanted kidney comes from a donor, who may be a living related member of the

patient’s family, or from a person who recently died. Needing a donor places some patients in an

uncomfortable position. Their need and desire is to be transplanted, but it is hard to ask another

person to make the sacrifice of donating a vital organ. Patients who must wait for a kidney from

someone who has died are placed on a waiting list. Usually these patients have to wait longer for a

kidney because it is harder to find a good “match.” Our kidney transplant programs maintain files of




                                                                                                page 55
patients wanting to be transplanted. When kidneys from people who have died become available,

patients who “match” the donor are called for transplantation.

        The kidney transplant surgery is considered major, but low risk surgery. Rejection of the

kidney by the body is possible. The patient is treated with drugs to lower the body’s resistance to

foreign objects. If rejection does take place, the transplanted kidney is removed, and in most cases

the patient returns to dialysis.

        The drugs that are needed to keep the body from rejecting a transplanted kidney cause some

problems. The renal patient may become prone to infections. There may be damage to the liver and

skeletal systems. Salt tends to be retained by the body; and the patient may develop ulcers. Some

cosmetic effects of drugs may cause the patient difficulties. These changes include fullness of the

face, weight gain, acne, facial hair, stretch marks, fat pads on the back, and darkened skin. Not all

patients have these problems. Most of the side effects can be made less noticeable through the use

of make-up, diet and other means. Most patients prefer the risk of side effects to having to be on the

kidney machine.

    A transplant allows kidney patients the chance to return to a normal lifestyle. Many transplant

patients return to work and to their pre-dialysis activities. Although there are risks involved, most

patients feel that the rewards are worth the risk. You must weigh your choices and decide what

option is best for you. Below is a list of questions frequently asked about transplantation.



    1. How long will I have to wait for a kidney transplant?

        You will receive a kidney as soon as a proper tissue match can be found. In some cases, the

        wait is only a few weeks or a few months, but in other cases the wait may be one to two

        years, or even as long as five years.



    2. How many kidneys are transplanted?
page 56
   Only one kidney is transplanted, because one good kidney is all you need to be healthy. In

   this way, two patients can receive transplants when one cadaver donor becomes available.



3. How long do patients stay in the hospital after a transplant?

   A transplant patient usually stays in the hospital for two to four weeks. Some may have to

   stay longer if any problems develop.



4. How long does it usually take to recover from the operation?

   The transplant patient is usually out of bed in two to three days. The incision usually heals

   within 10-14 days. The patient will be completely able to walk and move around the hospital

   before the incision completely heals.



5. Will the transplant make me normal again?

   A successful transplant will provide you with essentially normal kidney function. However,

   the extent to which you return to a normal life depends on you.



6. Will I need to use the kidney machine after the transplant?

   About half of the patients who receive a kidney from someone who has died need dialysis

   after their transplant while they wait for the kidney to begin working. This period of dialysis

   can vary from one week to several weeks. Dialysis is only rarely needed for patients who

   receive a kidney from a live donor.



7. Will I be on a special diet?




                                                                                           page 57
      If the transplant is a success, you will be on a special diet that will give you large amounts of

      protein to prevent muscle wasting from the medicine you will have to take. The diet will be

      limited in carbohydrates and calories and will usually be limited in salt.



   8. Will I be able to drink as much as I want?

      If the transplant is successful, you will generally be able to drink all the water you want.



   9. Will I have to take medicines?

      Yes, you will have to take medicines to prevent rejection as long as you have your transplant.



   10. What is rejection?

      Rejection is when your body tries to get rid of any foreign tissue. Almost all transplanted

      kidneys go through some rejection attempts, but usually they can be controlled with

      medication.



   11. Can more than one transplant be done?

      Yes, if the first transplant fails, the kidney will be taken out and you will return to dialysis.

      After you recover from that operation, you will be placed on the active transplant list again if

      you wish, and a repeat transplant will be done. Some patients have had three or four

      transplants before they receive one that is a success.



   12. How long will the transplanted kidney last?

      There is no known limit to how long a transplanted kidney will last. Many kidneys, both

      from live donors and from cadaver donors, have lasted ten years or more and are still

      working normally.
page 58
13. What is a live-related transplant?

   A live-related transplant is a kidney transplant in which the kidney is taken from a member of

   your immediate family, or a relative. This could be a parent, brother or sister, or child.



14. Are there advantages to receiving a live donor kidney?

   Yes, the two main advantages are that the success rate is better (because the kidney is more

   nearly like your own tissues than an unrelated kidney would be), and the transplant can be

   done immediately.



15. If I take a kidney from a relative, how will that affect my relative?

   The donor’s health should not change. After recovery from surgery, he or she should be able

   to return to work or school and be as strong as ever. The kidney that is left will do the same

   work that two kidneys did.



16. How long will the donor be in the hospital?

   Usually 5 to 7 days.



17. What about the costs of live donor transplantation?

   Medicare covers most costs for both the patient and donor. The few patients not eligible for

   Medicare should discuss questions about costs with their social worker.



18. How can I learn more about transplants?

   Ask your doctor or nurse.


                                                                                            page 59
page 60
PART 5
SOCIAL SERVICES




                  page 61
page 62
                                        Social Work Services


Living with chronic renal failure usually means a major change in your lifestyle and that of your
family. These changes may occur in social, environmental, and psychological areas. The
nephrology social worker in a dialysis or transplant unit is a professional member of the health care
team trained to help you and your family adjust to these changes. Your psychosocial situation can
affect both your physical condition and your ability to benefit from your treatment.
       The social worker offers services that can be sorted into two big categories: resources and
referrals for well-defined problems that require a specific solution, and counseling services.
Experience in counseling qualifies the social worker to provide emotional support, problem-solving
techniques, and psychotherapy to those patients and families who express a need for such assistance.
               Blackburn, Sue. “Social Work Services for the Patient with Chronic Renal Failure.” National Kidney
               Foundation, Inc. 1978.




                     Common Questions About Social Work Services


   1. Will I ever get used to life on “dialysis”?
       In the beginning, many patients feel overwhelmed by dialysis and the medical routine. You
       may feel shocked that you need dialysis, or you may have a hard time believing that it’s true.
       You may feel angry and ask “Why did this happen to me?” You may feel depressed. It is
       natural to have these feelings. Often it helps to talk about these feelings and learn to
       understand and manage them. Your social worker will talk with you about adjustment to
       dialysis.


   2. How much does dialysis cost?
       Dialysis reimbursement is set by Medicare and changes depending upon the fee they set. At
       this time, the cost is around $250.00 per treatment or $39,000 per year. Dialysis cost varies
       from city to city and depends on in what part of the country you live. Hospital dialysis costs
       more than dialysis in a clinic. Local dialysis clinics accept Medicare assignments.




                                                                                                        page 63
   3. How can I afford to pay for dialysis?
      There are many ways to pay for dialysis, if you meet the eligibility requirements. Medicare,
      Medicaid, Major Medical, TN. State Renal Disease Program, Veteran’s Program, Medicare
      Supplement Policies, or Comprehensive Health Benefits Pool are all programs to look into as
      are using personal funds.


   4. Who is eligible for Medicare?
      If you have worked long enough in a job under the Social Security system or are the husband,
      wife, or dependent child of a worker with enough Social Security credits, or if you are a
      divorced spouse married 10 years, you are eligible for Medicare. Only the person on dialysis
      is eligible, and coverage begins three (3) months after you have your first treatment.
      Medicare pays 80 % of the cost of dialysis.


   5. Will Medicare begin earlier if I home dialyze?
      Yes. Medicare will begin the month you start dialysis, if you home train.


   6. Where do I apply for Medicare?
      At your local Social Security office.


   7. What is Medicaid?
      Medicaid benefits vary considerably from state to state. In Tennessee, if you have no income
      or if your income is low enough to qualify for SSI (Supplement Security Income), you will
      also be eligible for Medicaid.


      Medicaid helps pay for dialysis and some medicines. Medicaid benefits may change from
      year to year depending upon the money allocated from the state and Federal governments.
      You can apply for SSI and Medicaid at your local Social Security office.


   8. Is there any other way to qualify for Medicaid?
      In Tennessee, there is a program called Medicaid for the medically needy--for persons whose
      medical bills are greater than their income, based on a formula used by the Tennessee
      Department of Human Services (DHS). You can apply at your local DHS office. This type
      of Medicaid may help pay for dialysis, but will not help pay for medications. The program is
page 64
   also subject to changes in governmental spending. You must reapply every three months for
   this type of Medicaid.


9. What is “Major Medical” insurance?
   If you or your spouse is employed, you may be covered by a Major Medical insurance that is
   part of your group insurance through work. Most Major Medical policies help pay for
   dialysis, some medicines and transplantation. For specific benefits, contact your insurance
   counselor at your place of employment.


10. What is the Tennessee State Renal Disease Program?
   The State of Tennessee has a program under the Department of Public Health to help pay for
   dialysis and some medications for patients who qualify. Submit your application to your
   nephrology social worker. State Renal monies vary depending upon how much money the
   State legislators allocate to the program.


11. What is the Georgia Kidney Program?
   In Georgia, there is a program that may help with the cost of dialysis for a year, if you
   qualify. If you are interested, submit your application to your nephrology social worker.
   This program will also help pay for home dialysis.


12. Will the Veteran’s Administration help me?
   If you are a Veteran with a service-connected disability for kidney disease, or if you wish to
   home train, the Veteran’s Administration may help you. You need to discuss this with your
   physician before you begin on dialysis. If accepted, VA pays the full cost of treatment and
   medications.


13. Personal Funds
   Different clinics have various policies regarding personal payment of dialysis expenses. If
   your financial situation is adequate, you may be asked to pay any of the rest of your expenses
   after Medicare or Major Medical insurance. Most hospitals expect you to pay for your bill
   somehow. If you plan to travel and dialyze in another town, most clinics expect you to pay
   the balance after Medicare. Ask the bookkeeper in the business office at your clinic about
   any expected payment. Ask your social worker for help finding resources for payment.
                                                                                               page 65
   14. What are Medicare supplement insurance policies?
      If you are 65 years old, there are Medicare supplement policies for which you may apply.
      Some of these can help pay the 20 % of the cost of treatment that Medicare does not pay.


   15. What is the Comprehensive Health Benefits Insurance Pool (CHIP)?
      In July 1986, a health insurance law was passed for people who, due to medical reasons, find
      it difficult to be accepted by an insurance company. This law includes Medicare supplement
      provisions. There is a deductible, a 6-month waiting period for pre-existing medical
      conditions, and the cost may be high. Ask your social worker for more information about the
      program.


   16. If I dialyze at home, will these programs help pay?
      Yes. Medicare, Medicaid, State Renal and Major Medical insurance will help pay for the
      rental of the machine and supplies for home dialysis.


   17. How much does a transplant cost?
      A transplant costs about $50,000. Fortunately, the programs just outlined cover most costs.


   18. My brother plans to give me a kidney. Who will pay his hospital bill?
      Your Medicare will pay the full cost of care for a person who donates a kidney for your
      transplant surgery. If not previously eligible, Medicare will begin the month you go into the
      hospital for the transplant.


   19. After I get a kidney transplant, will Medicare still be available to me?
      Medicare will provide coverage for 36 months after your transplant.


   20. Is there any help to pay for medicine costs while I am a dialysis patient?
      Medicaid and Tennessee State Renal help pay for some medicines. Major Medical insurance
      from your work may help pay for medications. Medicare does not pay for medicines for
      dialysis patients.



page 66
21. Is there help with the cost of medicines after a kidney transplant?
   State Renal can help pay for some medications for a year after transplant. Medicaid, if
   eligible, will also help pay. If you are taking Cyclosporin, Medicare will pay 80% of the cost
   for the first year after a transplant.


22. Is there help available for transportation to dialysis?
       A. Rural Transportation
           If you live in the county, you may be eligible for “rural” transportation services. Call
           757-2610 in Hamilton County. Call 942-5946 in Marion County.


       B. CARTA
           If you live in the Chattanooga area, you may be eligible for CARTA Care-A-Van
           Transportation. The present cost is $4.00 round trip. Call 698-9038.


       C. Kidney Foundation of the Greater Chattanooga Area:
           The Kidney Foundation of the Greater Chattanooga Area, Inc. has a grant for
           financial assistance for transportation for patients who qualify. Ask your social
           worker for information.


       D. Medicaid:
           If you are eligible for Tennessee Medicaid it can help pay for certain types of
           transportation. Ask your social worker.


23. Will I have to quit working when I begin dialysis?
   We hope you can maintain any of your pre-dialysis activities. Many employers understand
   their employee’s medical needs, especially if he or she has been a dependable, productive
   employee. A lot depends on how you feel. If your job requires strenuous physical work, you
   probably can not return to work. If your job is largely inactive or does not require a great
   deal of physical work, we encourage you to continue working.




                                                                                             page 67
   24. If it is impossible for me to continue to work, am I eligible for any disability payments?
      You may be eligible for the following disability benefits:


          A. Sick leave benefits through work
             Talk with your employer regarding sick leave and disability benefits at your job.


          B. Social Security Disability:
             If you have worked enough quarters under Social Security, you may be eligible for
             Social Security Disability payments. You must have been not working for five (5)
             full months before you can draw a check, but you can apply any time you feel you
             cannot return to work. Apply at your local Social Security Office. Your doctor will
             be asked to verify your disability.


          C. SSI (Supplemental Security Income):
             If you do not have enough quarters of work under Social Security, and if you do not
             have enough assets, you may be eligible for SSI. SSI will pay you each month and
             provide Medicaid benefits. Apply at your local Social Security Office.


          D. VA compensation may be available if you are service-connected:
             VA pension may be available if you had an honorable discharge, and served 90 or
             more days in the armed forces in wartime.


   25. I am in school and on dialysis. Can I stay in school?
      Yes. If you are in elementary or high school, we will work with you and your school to
      make sure you still get an education. We prefer that you attend school rather than having
      homebound instruction, since there are many benefits in going to school and interacting with
      other children.


   26. I want to go to college or vocational school and cannot afford it. Is there any help for
      me?
      Yes. Right now, the office of Vocational Rehabilitation in your state can provide financial
      resources for school. Call your local Vocational Rehabilitation office for information.


page 68
27. Can I travel now that I’m on dialysis?
   Yes. There are facilities all over the world. Your social worker and nurse can help you make
   the necessary arrangements to get dialysis while out of town. You must plan in advance.
   Many facilities require a month’s notice or more.


28. Who pays for dialysis when I travel or when I am out of town?
   If you are traveling in the United States, Medicare will pay 80 % of treatment. Usually, the
   patient is expected to pay the other 20 % at the time you dialyze, and then bill your insurance
   later. Some other insurance plans will pay for dialysis when traveling out of the United
   States.




                                                                                          page 69
          Other Facilities and Organizations of Interest to Kidney Patients


Camp
DCI sponsors a camp each summer for children and teenagers who are on dialysis or have a
transplant. The camp is held near Nashville for one week each June. Doctors, nurses and
technicians are the counselors, and the young people on dialysis go to Nashville for their treatments.
Often the Kidney Foundation helps to pay the fee for families who cannot afford it. Please let
someone in your facility know if you would like to go to camp.


Kidney Foundation
The Kidney Foundation of the Greater Chattanooga Area, Inc. is a voluntary health agency. Services
vary depending on funds available. The Kidney Foundation of Chattanooga is able to help with
some emergency needs; such as medicines, phone installation, and medical supplies that patients
need, but are unable to afford. They also offer, as a last resort, limited funding for transportation and
emergency food baskets. The Foundation also offers dietary supplements needed by patients unable
to pay, as well as medical alert tags. For further information, contact the Kidney Foundation at 265-
4397. The Kidney Foundation also welcomes volunteers to help with many fundraising projects.
Please contact them about how to help.


Kidney Kare
Kidney Kare is a program offered through the Kidney Foundation to provide visitation for new
patients, social activities, educational programs, and group therapy for interested transplant patients.


American Kidney Fund
The American Kidney Fund is a nonprofit organization that offers direct help to kidney patients. It
does not have funds to help pay for treatment, but can help with the cost of medicines,
transportation, and emergency needs of patients on a one-time basis. The American Kidney Fund
establishes a small emergency fund for patients at the Clinic. This Fund is based in Washington,
D.C. Ask your social worker for more details.


PLEASE NOTE: Some drug companies have programs for patients who are needy. Ask your
social worker for further details.

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If you have access to the Internet, here are some web pages that make also have information about
kidney disease and dialysis.
      American Association of Kidney Patients: http://www.aakp.org/
      American Foundation for Urologic Disease: http://www.afud.org/
      American Kidney Fund: http://www.akfinc.org/
      American Nephrology Nurses' Association: http://www.annanurse.org/
      American Society of Nephrology: http://www.asn-online.org/
      American Society of Pediatric Nephrology: http://www.aspneph.com/
      American Society of Transplantation: http://www.a-s-t.org/
      American Urogynecologic Society: http://www.augs.org/
      Interstitial Cystitis Association: http://www.ichelp.org/
      Life Options Rehabilitation Program: http://www.lifeoptions.org/
      National Black Nurses Association: http://www.nbna.org/
      National Kidney Foundation: http://www.kidney.org/
      Polycystic Kidney Disease Foundation: http://www.pkdcure.org/
      Renal Physicians Association: http://www.renalmd.org/
      The Simon Foundation for Continence: http://www.simonfoundation.org/
      Society of Urologic Nurses and Associates: http://www.suna.org/
      United Network for Organ Sharing: http://www.unos.org/
      American Urological Association: http://www.auanet.org/
      Urology Health: http://www.urologyhealth.org/
      Transplant Living: http://www.transplantliving.org/




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PART 6
DEFINITIONS




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                                         Glossary

Acidosis              Abnormal buildup of acids within the body.
Acute Renal Failure   Sudden stopping of the kidney functions. Usually occurs for a few days or
                      weeks. Normal function usually comes back, unlike in chronic renal failure.
Albumin               A type of blood protein that helps keep fluid within the blood vessels.
                      Albumin also can indicate adequate nutrition and diet.
Anemia                A condition where there is a decrease in the number of circulating red blood
                      cells. Anemia can cause fatigue, weakness, and paleness, among other
                      symptoms.
Antibiotic            A drug that kills or stops the growth of bacteria.
Antibody              A natural defense against infection and other foreign substances in the body,
                      including transplanted kidneys.
Antigen               Part of the chemical make-up that makes each person unlike anyone else.
Antihypertensive      A drug that lowers blood pressure.
Anticoagulant         A drug used to prevent blood from clotting. Example: Heparin
Antiseptic            A solution that stops the growth of bacteria but does not necessarily destroy
                      them.
Artery                Blood vessel that carries blood away from the heart to other parts of the
                      body.
Arterial              Related to arteries; in dialysis it refers to blood leaving the patient and going
                      to the artificial kidney.
Artificial Kidney     A mechanical device that removes wastes from the blood and restores
                      chemical balance in the body. It does this by flowing across a semi-
                      permeable membrane.
Aseptic               The same as sterile-free from infection organisms.
Bacteria              Germs that can cause infection.
Bladder               The sac that collects and stores urine produced by the kidneys until it is
                      released from the body.
Blood Cell            One of the non-liquid parts of whole blood. Two types of blood cells are the
                      red blood cells that carry oxygen and the white blood cells that fight
                      infection.
Blood Pump            A special pump that moves blood through tubing to the dialyzer without
                      hurting the blood cells.
Blood Pressure        The pressure inside the arteries. Blood pressure gets to its peak during heart
                      beats (systolic) and drops to its lowest level between beats (diastolic).
Blood Volume          Relates to the amount of blood. The normal amount of blood in the body is
                      11-12 pints.
Bone Marrow           The soft material that fills the hollow spaces of the bones. It produces red
                      blood cells, white blood cells, and platelets.
BUN                   Stands for blood urea nitrogen. The BUN measures the amount of waste
                      products produced when protein breaks down. Normal BUN is 10-20 mg.
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Cadaver                 Body of someone who has died.
Calcium                 A mineral found in the blood that is important to the body’s functioning.
Cardiac                 Refers to the heart.
Catheter                A plastic tube that allows fluid to enter or leave the body.
Chronic                 Developing over a long period of time or reoccurring often.
Chronic Renal Failure   Serious, gradual decrease in kidney function. The kidney does not return to
                        normal function.
Clearance               In dialysis, the amount of blood cleared of certain waste products by the
                        artificial kidney in a specific amount of time.
Clot                    A nearly solid mass of blood; the result of the body’s effort to protect itself
                        from loss of blood.
Coagulate               To clot or to become clotted.
Concentration           The amount of material dissolved in a given amount of liquid.
Conductivity            The ability of a solution, such as dialysate, to conduct an electrical current.
                        Determined by the strength of chemicals such as sodium, potassium, and
                        chloride. A conductivity check is a simple means of checking the
                        concentration of the dialysate mixture.
Contaminate             To make dirty or impure; adding foreign material such as bacteria.
Creatinine              One of several nitrogen waste products removed by the normal or artificial
                        kidney. Normally below 2 mg.
Delivery System         A machine that mixes concentrate and water in correct proportions to form
                        dialysate, and delivers it to the artificial kidney at the correct temperature,
                        flow rate, and conductivity.
Dialysate               The mixture of water and chemicals that flows on the outside of the artificial
                        kidney to remove waste products from the blood.
Dialysis                The process of cleaning the blood of built up waste products. May refer to
                        hemodialysis or peritoneal dialysis.
Dialysis Concentrate    A solution of chemicals to be diluted for use in dialysis treatment. The
                        diluted solution is called dialysate.
Dialyzer                Artificial kidney that removes unwanted material from the blood.
Diastolic Pressure      The pressure that remains in the arteries between heart beats. The lower
                        value when blood pressure is measured with a blood pressure cuff.
Diffusion               The route of particles through a semi-permeable membrane from a solution
                        of high concentration (blood) to one of lower concentration (dilysate).
Dilute                  Weaken, thin out; to dilute a solution is to decrease its strength.
Disinfectant            An agent that destroys most infection-producing bacteria and other
                        microorganisms.
Distal                  Away from the center of the body.
Distended               Swollen or stretched out.
Edema                   Build up of excess water in the body tissues that results in swelling of a

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                     specific area of body, or over all swelling.
Electrolyte          Refers to Sodium (Na), Potassium (K), Chloride (Cl), Bicarbonate (H03) that
                     are normally found in blood. A solution that is able to conduct an electrical
                     current.
Embolus              A small particle floating through the circulatory system. May be composed
                     of fat, clotted blood, or air.
End Stage Renal      (ESRD) The stage of kidney impairment that requires dialysis to maintain
Disease              life and health.
Fibrin               A thread-like protein forming the basis of a blood clot.
Fistula              A connection of an artery and vein usually in the arm, that causes the vein to
                     toughen and become larger so that large needles can be put in to provide
                     enough blood supply for dialysis. Fistulas are made by an operation.
GI                   Gastrointestinal.
Glomerulonephritis   A disease involving inflammation of the tissues of the kidney.
Hematocrit           How much of the blood that is red blood cells. Normal Hematocrit is 40-45
                     %. Most dialysis patients run hematocrits of 24 - 36 %.
Hemodialysis         The process of removing waste products from the blood and restoring
                     balance in the body by using the artificial kidney.
Hemoglobin           The red pigment of red blood cells that carries oxygen to the body.
                     Normally the hgb. is about 1/3 of the hematocrit. If your hematocrit is 24,
                     then a normal hemoglobin would be 8.
Hemolysis            Destruction of the red blood cells.
Hyper                Higher than normal. Example: Hypertension is abnormally high blood
                     pressure.
Hypercalcemia        High serum (blood) calcium.
Hyperkalemia         High serum potassium (K).
Hypernatremia        High serum sodium (Na).
Hypo                 Means lower than normal. Example: Hypotension-abnormally low blood
                     pressure.
Intravenous (IV)     Within a vein.
Kidney               One of two organs located at the back of the abdominal cavity; one on each
                     side of the spinal column. Their function is to maintain the chemical balance
                     of the body.
Kidney Transplant    The taking of a kidney from the body of one person and implanting it
                     surgically in the body of someone who has lost kidney function to perform
                     the function of that person’s kidneys.
Liter                1,000 cc’s; in liquid measure, slightly more than a quart and equals 2.2
                     pounds in weight.
Membrane             A semi-permeable surface used in dialysis to filter waste products out of the
                     blood.
Monitor              A device used to check, remind, or warn. The hemodialysis machine has its
                     built-in monitoring system to help prevent serious problems from occurring
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                      during dialysis.
Negative Pressure     Suction applied to dialysate by the delivery system. When the suction is
                      increased, it increases how fast water crosses the dialysate to the drain
Nephrectomy           Surgical removal of a kidney. “Bilateral nephrectomy” means removing
                      both kidneys. Often nephrectomy is helpful to control blood pressure.
Nephrologist          A doctor who treats patients with impaired kidney function.
Nephron               The part of the kidney that maintain the body’s chemical balance. There are
                      approximately 1,000,000 nephrons in each kidney.
Occlude               To close.
Oral                  Refers to the mouth.
Osmosis               Passage of water through a semi-permeable membrane. Water flows from an
                      area of lower concentration of dissolved substances into an area of higher
                      concentration until the two solutions are equal in concentrations.
Patent                Open; not blocked, unobstructed.
Pericardium           The sac that surrounds the heart.
Pericarditis          Inflammation of the sac surrounding the heart.
Peritoneal Dialysis   When dialysate is introduced into the abdominal cavity. The peritoneal
                      membrane in the abdomen works the same way that the cellophane in the
                      hemodialysis machine functions.
Peritoneum            The membrane lining of the abdominal cavity.
Plasma                The fluid portion of the blood.
Platelets             Small particles in the blood stream, produced in the bone marrow that helps
                      to clot the blood.
Polycystic Kidney     A hereditary disease that slowly destroys the kidney tissue over twenty or
Disease               forty years.
Potassium             A mineral necessary to the body but may be harmful if you get too much or
                      too low. It affects the heart muscle. Normal serum K is 3.5 -5.
Protein               A basic substance found in food; high quality protein is found in poultry,
                      meat, fish, eggs, and milk; low quality protein is found in all other food.
Proximal              Toward the center of the body.
Pulmonary             Refers to the lungs.
Pulmonary Edema       A state where the body holds on to excess fluid, causing the heart to pump
                      harder. This can result in excess fluid in the lungs.
Pyrogen               A substance that produces fever. May be due to bacteria that grow in water.
Renal                 Refers to the kidney.
Saline                A solution of sodium chloride and water that can be used to replace fluid
                      removed by dialysis, and to correct hypotension.
Semi-permeable        A thin material that has tiny pores, through which particles small enough can
Membrane              moves across the membrane.
Serum                 The fluid part of the blood that stays after a clot has formed.

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Shock               Extreme hypotension; on dialysis caused by fluid loss, corrected by elevating
                    feet and administering normal saline.
Shunt               Plastic tubing that connects an artery and a vein.
Silastic            Soft, flexible plastic material used in shunts.
Sphygmomanometer    Cuff used for measuring blood pressure.
Subcutaneous        Beneath the skin.
Systemic            Affecting the body as a whole.
Systolic Pressure   The high point of blood pressure reached in the arteries at the time the heart
                    beats; the high value when blood pressure is measured with a blood pressure
                    cuff.
Tissue Typing       Laboratory procedure used to determine the degree of compatibility between
                    the donor organ and the recipient of the kidney transplant.
Thrombus            Clot in a blood vessel.
Transplantation     The surgical procedure that involves taking an organ from either a cadaver,
                    or from a living relative of the patient and putting it in the patient.
Ultrafiltration     The method used to remove extra fluids from the blood during dialysis.
                    Pressure of the blood is raised above that of the dialysate,
Urea                Waste left over after the body breaks down protein.
Uremia              A poison (toxin) condition because of kidney failure.
Ureter              One of the two tubes in the body that carries urine from the kidneys to the
                    bladder.
Urethra             Canal that takes urine out of the body.
Urologist           A doctor that works mostly with patients that have disorders of the urinary
                    system.
Vein                Blood vessel that carries blood toward the heart.
Venous              Refers to veins; in dialysis the blood leaving the artificial kidney and
                    returning to the patient.
Venous Pressure     The resistance to blood flow within the venous side of the fistula. An
                    increased VP increases the rate of fluid loss during dialysis.




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