Dialysis is used to remove fluid and uremic waste products from the body when the kidneys cannot do so. It may also be used to treat patients with edema that does not respond to treatment, hepatic coma, hyperkalemia, hypercalcemia, hypertension, and uremia. Methods of therapy include hemodialysis, continuous renal replacement therapy (CRRT; discussed later), and various forms of peritoneal dialysis. The need for dialysis may be acute or chronic.
Acute dialysis is indicated when there is a high and rising level of serum potassium, fluid overload, or impending pulmonary edema, increasing acidosis, pericarditis, and severe confusion. It may also be used to remove certain medications or other toxins (poisoning or medication overdose) from the blood.
Chronic or maintenance dialysis is indicated in chronic renal failure, known as end-stage renal disease (ESRD), in the follow-ing instances: the presence of uremic signs and symptoms affect-ing all body systems (nausea and vomiting, severe anorexia, increasing lethargy, mental confusion), hyperkalemia, fluid over-load not responsive to diuretics and fluid restriction, and a gen-eral lack of well-being. An urgent indication for dialysis in patients with chronic renal failure is pericardial friction rub.
Patients with no renal function can be maintained by dialysis for years. Although the costs of dialysis are usually reimbursable, limitations on the patient’s ability to work resulting from illness and dialysis usually impose a great financial burden on patients and families.
The decision to initiate dialysis should be reached only after thoughtful discussion among the patient, family, physician, and others as appropriate. Many potentially life-threatening issues are associated with the need for dialysis. The nurse can assist the patient and family by answering their questions, clarifying the in-formation provided, and supporting their decision. The lifestyle changes that patients needing hemodialysis eventually need to make are often overwhelming. Sometimes the news that a donor kidney is available for transplantation can be so disruptive to the changes in lifestyle that were made to accommodate hemodialy-sis that the patient may stall the process required for transplanta-tion or refuse the kidney when it becomes available, choosing instead to continue with hemodialysis.
No “gold standard” is available to assess the compliance of hemodialysis patients (Kaveh & Kimmel, 2001), and methods to do so vary from one dialysis facility to the next. Therefore, it is difficult to assess how many deaths are due to natural causes and how many are due to patients’ noncompliance with treatment.
Successful kidney transplantation eliminates the need for dial-ysis. Not only is the quality of life much improved in patients with ESRD who undergo transplantation, but physiologic func-tion, such as heart rate variability, is improved as well (Hathaway, Wicks, Cashion, et al., 2000). Patients who undergo renal trans-plantation from living donors before dialysis is initiated generally have longer survival of the transplanted kidney than patients who receive transplantation after dialysis treatment is initiated (Mange, Joffe & Feldman, 2001).
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