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Medical Author:

Pranay Kathuria, MD, FACP, FASN, FNKF

Medical Editor:

Melissa Conrad Stöppler, MD, Chief Medical Editor

Melissa Conrad Stöppler, MD, Chief Medical Editor

Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

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In end-stage kidney disease, kidney functions can be replaced only by dialysis or by kidney transplantation. The planning for dialysis and transplantation is usually started in stage 4 of chronic kidney disease. Most patients are candidates for both hemodialysis and peritoneal dialysis (see below). There are few differences in outcomes between the two procedures. The physician or an educator will discuss the appropriate options with the patient and help them make a decision that will match their personal and medical needs. It is best to choose a modality of dialysis after understanding both procedures and matching them to one's lifestyle, daily activities, schedule, distance from the dialysis unit, support system, and personal preference.

The doctor will consider multiple factors when recommending the appropriate point to start dialysis, including the patient's laboratory work and actual or estimated glomerular filtration rate, nutritional status, fluid volume status, the presence of symptoms compatible with advanced kidney failure, and risk of future complications. Dialysis is usually started before individuals are very symptomatic or at risk for life-threatening complications.

Dialysis

There are two types of dialysis 1) hemodialysis (in-center or home) and 2) peritoneal dialysis. Before dialysis can be initiated, a dialysis access has to be created.

Dialysis access

A vascular access is required for hemodialysis so that blood can be moved though the dialysis filter at rapid speeds to allow clearing of the wastes, toxins, and excess fluid. There are three different types of vascular accesses: arteriovenous fistula (AVF), arteriovenous graft, and central venous catheters.

1. Arteriovenous fistula (AVF): The preferred access for hemodialysis is an AVF, wherein an artery is directly joined to a vein. The vein takes 2 to 4 months to enlarge and mature before it can be used for dialysis. Once matured, two needles are placed into the vein for dialysis. One needle is used to draw blood and run through the dialysis machine. The second needle is to return the cleansed blood. AVFs are less likely to get infected or develop clots than any other types of dialysis access.
2. Arteriovenous graft: An arteriovenous graft is placed in those who have small veins or in whom a fistula has failed to develop. The graft is made of artificial material and the dialysis needles are inserted into the graft directly. An arteriovenous graft can be used for dialysis within 2 to 3 weeks of placement. Compared with fistulas, grafts tend to have more problems with clotting and infection.
3. Central venous catheter: A catheter may be either temporary or permanent. These catheters are either placed in the neck or the groin into a large blood vessel. While these catheters provide an immediate access for dialysis, they are prone to infection and may also cause blood vessels to clot or narrow.

Peritoneal access (for peritoneal dialysis): A catheter is implanted into the abdominal cavity (lined by the peritoneum) by a minor surgical procedure. This catheter is a thin tube made of a soft flexible material, usually silicone or polyurethane. The catheter usually has one or two cuffs that help hold it in place. The tip of the catheter may be straight or coiled and has multiple holes to allow egress and return of fluid. Though the catheter can be used immediately after implantation, it is usually recommended to delay peritoneal dialysis for at least 2 weeks so as to allow healing and decrease the risk of developing leaks.

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