How timely treatment can mitigate the challenges of common complications like anemia and peripheral neuropathy in dialysis patients, leading to better health outcomes.
BY DR. T VISHNU MURTHY
Peritoneal dialysis is a well-established and widely recognized medical technique found in most general hospitals. Traditionally, its application has primarily been reserved for the treatment of reversible renal failure. However, it has not been extensively implemented as a recurring treatment option for patients with chronic renal failure. Recent advancements, particularly the development of permanent peritoneal catheters that eliminate the need for repeated punctures of the abdomen with each treatment, along with the ability to produce dialyzing fluid in an economically feasible manner, have revitalized interest in using this method for the long-term management of patients.
The procedure itself necessitates the careful insertion of a catheter into the peritoneal cavity, typically in the midline of the abdomen. When permanent catheters are utilized, efforts are made to position the entrance site for the catheter at a sufficient distance (subcutaneously) from the exit site on the skin to minimize the risk of infection. Although the insertion point of the catheter does not have to be strictly midline, it can be placed in various locations on the abdominal wall under certain special circumstances. Maintaining strict aseptic techniques during catheter insertion and throughout the entire dialysis procedure is of utmost importance, as peritonitis remains the most common complication associated with peritoneal dialysis. Research indicates an indirect relationship between the frequency of infections and the meticulousness of the techniques employed in handling the catheter.
A typical peritoneal dialysis session lasts anywhere from 12 to 48 hours, depending on the specific needs of the individual patient. During this procedure, one or two liters of commercially available peritoneal dialyzing fluid, which contains electrolytes in appropriate concentrations, is introduced into the peritoneal cavity as quickly as possible—usually within five to ten minutes. Once the dialysate fluid is in the abdomen, it remains there for a designated period known as the “dwell time,” which can range from 15 to 60 minutes. This dwell time is crucial for allowing the transfer of solutes to occur effectively. After this period, the fluid is drained out of the peritoneal cavity through gravity flow, and the cycle is repeated. This process continues until the desired therapeutic effect is achieved.
Some patients are trained to perform peritoneal dialysis at home, typically undergoing treatments for 12 to 18 hours twice a week. When maximally automated, this procedure can even be conducted overnight while the patient is asleep. Although a few centers have successfully employed this home dialysis method repeatedly with the same patient over the course of several years, it remains unsatisfactory in the hands of many practitioners. The various prosthetic devices available for gaining access to the peritoneum are often limited by their susceptibility to infection.
Hemodialysis
The technique of hemodialysis was first applied to animals by researchers Abel, Rountree, and Turner in 1913, utilizing a collodion dialyzing membrane. However, it was not until more recently that its clinical application became widespread. Despite the successful use of hemodialysis for treating acute renal failure over several years, it was not routinely applied for chronic renal failure until significant advancements were made in its technology. A major breakthrough for patients suffering from end-stage kidney disease was the development of a synthetic arteriovenous bypass, which enabled repeated access to the circulatory system for dialysis treatments. Before this innovation, each dialysis session necessitated a new arterial and venous cutdown, making the process much more invasive and cumbersome.
Currently, the methods of accessing the circulation have evolved, and there are two primary techniques in use today. One common method involves constructing arteriovenous shunts made from Teflon, which are connected subcutaneously to a Silastic tube. This Silastic tube exits the skin and remains external to the body, allowing for easy attachment to the dialysis machine. The second, and increasingly popular, method is the creation of an arteriovenous fistula. This procedure entails surgically creating a connection—referred to as a window—between a peripheral artery and vein, typically in the forearm. As a result of this surgical intervention, the peripheral veins become arterially enlarged and more prominent, facilitating easier identification for venipuncture.
Both arteriovenous shunts and fistulas can be placed in various locations, although the forearm is the most common site. In some instances, these access points can also be located in the leg. The lifespan of the access tube varies significantly based on individual patient factors; however, some patients have successfully maintained their original access point for several years without complications.
Medical Problems Associated with Chronic Dialysis
Hematologic Issues
Patients who are maintained on dialysis, often referred to as being treated with an artificial kidney, frequently exhibit some degree of anemia. The severity of this anemia can vary significantly among individuals and may be related to the specific type of renal disease affecting the patient. For instance, patients diagnosed with polycystic kidney disease tend to present with higher hematocrit levels compared to those suffering from other forms of renal diseases.
The challenges posed by anemia are further compounded in dialysis patients due to the inherent blood loss that occurs during the dialysis procedure itself. A notable concern is the loss of red blood cells that can be left behind in the dialyzer once the treatment is concluded, which can worsen the pre-existing anemia. Additionally, it is crucial to minimize laboratory evaluations and blood testing for these patients whenever possible, as repeated venipunctures for blood samples can further contribute to their anemia.
Emerging evidence suggests that, in addition to a deficiency in the production of erythrocyte-stimulating factor (ESF), the bone marrow of uremic patients may show an inadequate response to ESF. Consequently, one might anticipate that patients who are severely uremic could benefit from chronic dialysis. Indeed, this is often the case; many individuals can be maintained on dialysis without the necessity for blood transfusions, even if their hematocrit levels do not return to normal ranges. However, the decision regarding the need for transfusions must be individualized, taking into account the specific symptoms produced by the anemia.
In younger patients, hematocrit levels as low as 12 to 14 percent (vol/100 ml) may be tolerated without any significant difficulties. Conversely, in older patients who may have pre-existing cardiovascular issues, it might become essential to administer blood transfusions on a weekly basis. It is important to note that hepatitis can present as a significant complicating factor within a hemodialysis unit; therefore, the decision to utilize transfusions must be approached with careful consideration and clinical judgment.
Peripheral Neuropathy
There has been a growing recognition of peripheral nerve dysfunction as a common complication of uremia. When neurological involvement occurs, it typically presents symmetrically, starting distally at the toes and progressively spreading upwards through the legs. In cases of significant lower extremity involvement, upper extremity symptoms may also develop; however, this tends to occur more insidiously. For the majority of patients, the first noticeable sign is often a reduction in nerve conduction velocity, while overt clinical symptoms usually manifest only in more advanced stages of the condition.
Peripheral neuropathy may lead to various discomforting sensations, including pain and paresthesia in the lower extremities, heightened sensitivity to touch, and a distinct “burning” sensation. While sensory symptoms may initially dominate, there can also be a significant motor component associated with the neuropathy. The presence of peripheral neuropathy serves as a clear indication for initiating appropriate treatment interventions. Furthermore, some experts have posited that peripheral neuropathy can be both a manifestation and a consequence of inadequate dialysis.
A noteworthy percentage of patients who are referred to maintenance dialysis centers already exhibit measurable signs of neuropathy, particularly as determined by assessments of nerve conduction velocity. The incidence and severity of neuropathy are closely tied to the timeliness of the referral for dialysis; generally, neuropathy is considerably less prevalent when patients receive dialysis treatment three times a week, as opposed to the less frequent schedule of only twice a week.
At our facility, we are proud to offer advanced Ayurvedic research and treatment options. We prepare individualized herbal formulations based on a comprehensive assessment of each patient’s unique health condition and the severity of their disease. Our approach aims to address the specific needs of patients undergoing chronic dialysis, fostering improved health outcomes and overall well-being.
The views expressed in this article are solely those of the author and do not necessarily reflect the opinions or views of this Magazine. The author can be reached at [email protected] /9650696341
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