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Nutrition for Home Dialysis vs. In-Center Hemodialysis
Get to Know the Home Dialysis Nurses
Blessings Found and Blessings Shared
Home Dialysis: The Top 10
2011 Patient Satisfaction Survey: The Results
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Karen Schlageter, RN
Did you know that WDI has a Home Dialysis program? Home dialysis is a great alternative for many patients on dialysis. WDI offers both home hemodialysis and peritoneal dialysis. WDI has five nurses that provide training and support to patients and their partners in the home dialysis program.
Let’s take a look at each type of home dialysis and what’s involved.
Home Hemodialysis
Home hemodialysis is done at home very similarly to how it is done in the in-center dialysis clinic. The patient will need a viable access.
The dialysis machine is used to pump your blood through a filter using sterile dialysate or fluid to clean the blood, remove excess fluid and then return the blood to your body.
Patients perform their dialysis five or six days a week for a minimum of 2 hours a day. More frequent dialysis helps the patient feel better since the toxins and extra fluid are not allowed to build up, and as a result, blood pressure and fluid balance are better controlled.
Training is a minimum of three weeks. Patients and their partners come for training Monday though Friday for about 4-6 hours per day. Patients must have a willing and able partner that is present with them throughout the training and the partner must be present at home while the patient is dialyzing. Patients and their partners will perform all aspects of their treatment at home after completion of training. All supplies required are provided. Once training is completed, patients are seen monthly in the clinic at WDI by the home dialysis team: which consists of the nurse, kidney doctor, social worker and dietitian.
Peritoneal Dialysis
Peritoneal Dialysis is a daily therapy that is done using sterile fluid or dialysate that is introduced into the abdomen (belly) by using a flexible tube called a catheter. This process is not done until the catheter site is healed and the catheter is ready to be used, which usually takes about 3-4 weeks.
Training is done daily in the clinic for 4-5 hours per day for 6-8 days. More training will be given as needed. A partner is not required for someone to do PD at home, but the patient must be able to independently perform all aspects of their treatment if there is no partner.
Peritoneal dialysis can be done two different ways. CAPD or Continuous Ambulatory Peritoneal Dialysis requires 4-5 manual exchanges be preformed, spaced throughout the day. Fluid is left in the abdomen over night. Each exchange takes about 30-45 minutes and does not require a machine. The exchanges are portable so they can be done on the go as long as the area is clean and everything is kept sterile. CCPD or Continuous Cycling Peritoneal Dialysis is performed once a day usually at night while the patient is sleeping. CCPD uses a machine called a cycler that performs the exchanges throughout the night. Once training is completed, patients are seen in the clinic monthly at WDI by the dialysis team.
While these options may sound great, it’s important to know that not everyone is a good candidate for home dialysis. If you are the type of person that is highly motivated, detailed oriented and would love the freedom to set your own schedule, then home dialysis may be right for you. The best way to determine if you are a good candidate is to talk to your kidney doctor or nurses practitioner. If they feel that home dialysis may be a good option for you, they can make a referral to the home program.
The home team, which consists of nurses, the kidney doctor, dietitian and social worker, will then review your records, meet with you to answer your questions and determine if you are a good candidate for home therapy. For many people home dialysis is a good option. This option has given patients the freedom and independence they desire. Would you like to follow us home? We’d love to have you join us in the home dialysis program.
Nutrition for Home Dialysis vs. In-Center Hemodialysis
Julie Reavis, Dietetic Intern
As a dialysis patient, keeping your body well nourished is an important part of staying healthy. There are a few nutrition differences between in-center and home dialysis, but everyone has an individualized diet. This is why lab values are monitored monthly. Typically, patients on home dialysis might have a less restrictive diet. This is because they are being dialyzed more often than in-center hemodialysis patients.
With every form of dialysis, the body loses some of the protein that you eat. This is why dietitians make sure you are eating plenty of protein. The highest quality proteins come from fish, chicken, beef, pork and eggs or egg substitute.
Managing fluids can be challenging. Most in-center hemodialysis patients have a fluid allowance of 1 to 1.5 liters of fluid per day. The allowance depends on whether or not you make urine, and how much is produced. For peritoneal and home hemodialysis, patients may be less restricted, as 1.5 to 2 liters of fluid are allowed in most cases.
Phosphorus is a mineral that helps build strong bones. With kidney failure, the kidneys are not able to get rid of extra phosphorus in the blood. This buildup of phosphorous can weaken bones and cause heart disease. Phosphorus is found in many foods.
Phosphate binders taken with meals help to bind some of the phosphorous when it reaches the small intestine, but some phosphorous is still absorbed. Patients on in-center hemodialysis and peritoneal dialysis need a low phosphorus diet, but sometimes people on home hemodialysis can eat a little more.
Potassium is another mineral that is monitored closely. Potassium helps control muscle contraction and heart function, and is found in many fruits, vegetables, and dairy products. For in-center hemodialysis patients, potassium intake should be moderate to low. For home hemodialysis and peritoneal dialysis, potassium intake can be more moderate to normal.
For every type of dialysis, nutrition is key to help you stay well-nourished. This can be achieved by eating a healthy diet with high quality protein, following fluid restriction guidelines, and keeping your lab values in the normal range.
Get to Know the Home Dialysis Nurses
Get to know the five talented nurses that manage the home dialysis program so smoothly and thoughtfully on behalf of its patients and families. They have taken the time to introduce themselves:
My name is Karen and I am the Care Team Leader for the home dialysis program at WDI. I have been a nurse for 31 years and a dialysis nurse for 30 years. This has to tell you how much I love working in dialysis. It has never entered my mind to ever work in a different department. I started working inpatient and outpatient hemo-dialysis units. I have worked in dialysis for the UW for 25 years. About 6 years ago I knew I needed a change and decided to help out the in home dialysis program. I really found my niche in this area and have loved it ever since. I love teaching and helping people to be more independent. Doing home dialysis gives people a better quality of life. I love being a part of that. Our patients are an inspiration to me.
Hi, I am Linda. I graduated from the UW School of Nursing more than two decades ago. The first part of my career was spent working in a neonatal intensive care unit. I have been working in dialysis for the last ten years. I stared as a hem dialysis nurse in the in-center unit at Mertier. For the past six years I have been working in the home dialysis program. I have especially enjoyed the long-term relationships that develop4ed with hem dialysis patients. The benefits they achieve with a home therapy are very rewarding to witness. In my time way from work I like to spend with my family: my husband and our 14-year-old son and 11-year-old daughter. I like to travel, camp, kayak, bike and read.
My name is Lila. I graduated from Methodist Hospital School of Nursing, Madison, many moons ago and have worked in dialysis ever since. When I learned of the "Home/Self Care Dialysis" program that would be opening at Methodist Hospital the same year that I was to graduate, I knew immediately that I had found my career even though I had yet to see a dialysis unit or even a picture. Dialysis units were few & far in-between in those days. The idea of a modality that would allow patients with chronic renal failure to care for themselves in the comfort & familiarity of their homes totally fascinated me & assisting people in gaining this kind of independence continues to be a great reward for me.
Outside of work I love to grow flowers, bike, walk, cross country ski, meditate & travel to see my Grandchildren. I’m usually up for trying almost anything at least once.
Hi I am Dawn. I have been a nurse since 1990. I have worked in oncology, hospice, neurology, and Home Dialysis. I started in the Home Dialysis program in 2000 when it was just pediatric and adult PD. I love the Home program because it allows me to help people with kidney failure take care of themselves. It is a joy to see patients feeling better and able to engage in the activities they enjoy. In addition to crocheting reading and wood working I enjoy spending time with my family and friends, attending auctions with my husband and walking my dog.
My name is Sandy and I am a Nurse Clinician in the WDI home program. My professional career started 20 years ago the year I was married. I was a phlebotomist for 10 years and decided to go into Nursing. I received my degree in Madison in 2001 while raising 2 small children. I have another degree in Human Services. I’ve spent most of my nursing career in Nephrology, first as a Hemodialysis nurse at WDI then in Kidney clinic as the only RN. Most recently I have changed to Home Dialysis. I am a Wisconsinite, in fact, I’ve only moved 30 miles in any direction since I was little. I consider myself an outdoor person, would prefer camping, hiking vacations to luxurious ones. I love to spend time with my two boys, husband and extended family. We have two dogs which are both rescue dogs, our newest one “pugley” has a seizure disorder, so now I not only feel I am a nurse at work but have to be one at home. I love being a nurse and consider it a honor to get to know as many individuals as I have in my career.
Blessings Found and Blessings Shared
Sabine Lobitz, Home Hemo Patient
It has been a long time since I have written an article for the newsletter. Some of you may recall that I was diagnosed 3 1/2 years ago with multiple myeloma (a "terminal" blood cancer) which usually carries a prognosis of five years. My cancer first presented itself through acute kidney failure. So in January 2008, I not only started chemotherapy to try and control my cancer, but also began dialysis due to my kidney problems (end-stage renal failure).
At first this was extremely overwhelming! I had only retired five years earlier from policing at age 50 and had many plans including visiting our adult children spread across five states. I chose early retirement because my husband, David Couper, who had retired from the Madison Police Department five years earlier, was older than I was and I wanted to be able to spend more time with him.
Dialysis, however, complicated everything – or so I thought.
My HMO would only pay for my treatments at the Wisconsin Dialysis Center, so it was not feasible for us to consider doing any out-of-state travel. I was devastated because I knew our children had limited time to get away from their jobs and busy lives.
Six months into our thrice-weekly clinic dialysis schedule we were presented with an alternative – home hemodialysis. It would require training, but would permit us to travel. For the past three years we have gone to Florida for two weeks during the winter season. Home dialysis permitted us to continue to have a winter vacation in a sunny and warm place. So, two years ago, we purchased a slide-in camper for our pickup truck and drove to Glacier Park, hiked, camped, and dialyzed in, perhaps, some of the most beautiful mountain settings. This year we have two more road trips – house boating on the Mississippi with kids and grandkids and, in the fall, going to Branson, Missouri.
All of this, however, has not been smooth sailing. It took three failed fistulas before we were able to button hole and get rid of the tunnel catheter in my chest. I was fortunate enough to be able to receive a stem cell transplant in Spring 2009. This put my cancer under control for a while and I was working toward getting on the kidney transplant list and possible transplant if my cancer behaved itself for 24 months. I didn’t and it returned. I was back on chemotherapy and, again, devastated. I gave myself 24 hours to cry, feel sorry for myself and use words I hadn’t used since our children arrived.
Back on chemotherapy and dialysis, I refused to waste any more of my precious time in such a wasteful, unconstructive way. My husband, David, gave me a great insight recently. He questioned when something terrible happens to us, how do we know it’s not a blessing?
With my original cancer diagnosis, I first assumed it was a disaster. But now looking back at the past 3 1/2 years, I know it was really a blessing. He and I have spent more time together, we choose our travel carefully and deliberately, we both take much better care of our bodies (daily exercise, eating healthy and regular check-ups) as well as improving our minds and cultivating our spirits. He would have continued full-time work in ministry and I would have continued my part-time work at Lands’ End. This would have resulted in us seeing each other after work (usually tired and drained) or on weekends (doing yard work and other domestic chores). Why? Because we all assume there will be more time to do things together (even to work on our relationship) in the future. We all know that a slower day will never come. All we really have is now.
Each of us has a responsibility to live our lives fully and celebrate our life every day.
Health and happiness,
Sabine Lobitz
If you are interested in talking about the home dialysis program and our experience with it, you can contact us through the Wisconsin Dialysis Center.
Home Dialysis: The Top 10
Micah Chan, MD, MPH FACP
Director of Home Dialysis
A famous English poet named Robert Montgomery once said, "Home, the spot of earth supremely blest, A dearer, sweeter spot than all the rest."
Many of us imagine our homes as a place of serenity, a shelter from the elements, a place where we get together with friends and family or even a place we work. But, how many of us could imagine "home" as a place to do dialysis? Well, according to the United States Renal Data System (USRDS) which is the most comprehensive analysis of dialysis patients in the U.S., almost 30,000 patients are doing some mode of home dialysis.
Interestingly, when doctors who were in charge of dialysis centers were surveyed in the U.S., 98 percent would choose to do dialysis at home as opposed to in-center. Again, the USRDS reports that only 7 to 8 percent of dialysis patients are doing home dialysis but up to 50 percent of patients surveyed state they would like to be at home.
The reasons there are such differences in these numbers are debatable but for the most part there is no single reason. As many of you know, there are two forms of home dialysis - peritoneal and home hemodialysis.
Peritoneal Dialysis
Peritoneal dialysis (PD) is a mode of therapy whereby a patient will have a catheter in the abdomen close to the belly button which is used to put in fluid and then drained either manually (CAPD) or automated (APD) which is during the night. In general, patients have 2 liters in the belly during the day or night seven days per week. The fluid has properties which allow the cleaning of the blood and removal of fluid. In general, patients on PD maintain urine output a little longer than hemodialysis patients and feel better overall. There are not as many diet or fluid restrictions and many times medications decrease as well.
Home Hemodialysis
Home hemodialysis (HHD) is a mode of therapy whereby a patient will be at home and dialyze just like in in-center with a catheter or AV fistula (preferably). There are different types such as conventional HHD, short daily HHD (SDHHD), or nocturnal HHD (NHHD). At WDI, we offer SDHHD so patients usually dialyze 5-7 days per week for at least 2hrs. In general patients also have less fluid and dietary restrictions and their labs look better than when on dialysis in-center. Also patients feel better overall and report an improved quality of life.
Acceptance Policy in Home Program
Of course there are always certain factors that must be considered before entering into a home program. For home hemodialysis, there needs to be a partner such as a family member, significant other or friend to be available for every hemodialysis treatment. For PD and home hemodialysis there must be running water, a clean environment, good plumbing, phone service and space to keep boxes of fluid and supplies. Patients will need to be seen once per month by the Home Team (as opposed to three times per week in-center) and be able to keep good records. In addition, peritoneal dialysis candidates will need to demonstrate good nutrition by albumin levels. Overall, however, there are not too many limitations for patients to be accepted in the Home Program.
If anyone is interested in being evaluated for the Home Program at WDI, please let one of your doctors or nurses know. We would be happy to meet you!
Top 10 Good Things About Home Dialysis
10. Save money on gas
9. Save money for the U.S. healthcare system
8. Fewer medications?
7. Fewer diet and fluid restrictions?
6. Now I can finally sleep in
5. Only once per month visits
4. Better quality of life
3. I have time to do other things
2. More freedom
1. I’m HOME
2011 Patient Satisfaction Survey: The Results
Thank you to the 71 patients who completed the annual satisfaction survey in January. Only about 40 percent of all patients filled out a survey, so we hope to involve more of you next year. Your opinion is very important to us since we are always trying to make changes to serve you better.
For each of the 18 questions on the survey, we review the average score (on a 0-to-4 scale) and percent of top scores given for each question (4 is the top score). We also compare results from past years to watch for upward and downward scoring trends.
For all survey questions except the "clinic temperature" and "starting on time," the average score was 3.4 or better. Sixty percent of patients gave a top score of 4 on all questions except for "clinic temperature" and "starting on time." There is always room for improvement but we think overall, these results are once again very good.
As far as the clinic temperature goes, it is an ongoing struggle to keep patients warm and staff members cool. This is the only question rated significantly lower this year than last year. The protective gear worn by staff members to keep them safe is very warm. Conversely, dialysis treatments tend to make patients feel chilled. Each person's comfort level with the room temperature is very subjective. Some people can be very cold while others are very warm - all at the same temperature. The challenge is to find a happy medium that keeps most people comfortable, which we will continue to seek.
Starting and ending your treatments on time is an important issue to you and to us. This score was lower for Fitchburg in-center patients this year. We will be making changes to better define your start time and keep your treatment running on time. One challenge is complications that can occur while starting a dialysis treatment. When there are delays, it affects all subsequent patients on the schedule. One change we are working on is improving the teamwork among the four care teams assigned in the treatment unit. If one team is running ahead of schedule and another is behind, a caregiver will come over and offer to assist when possible. This approach should help keep treatments running closer to schedule.
Responses to four questions were significantly higher this year as compared to last year. They were: 1) "Your impression of how calm and quiet the clinic is." 2) "Feeling of personal safety and security while at WDI." 3) "Nurse Practitioner services." and 4) "Understanding of the best ways to feel good/stay healthy."
The patient check-in process has had a positive effect on keeping the unit organized. This change resulted from feedback in a past patient survey. The same is true of increased Safety and Security scores after your feedback led to hiring an evening shift security guard at Fitchburg.
Your feedback from past surveys also created our focus on patient education, which has led to improved scores for your understanding of how to feel your best while on dialysis. Improved patient education has been a long-term project that is starting to show some benefits.
Thank you for your help with these important efforts. We will continue working together to make positive change in the future. Please participate next year again, or for the first time. We really do listen and want to hear from you.
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