State of the Unit - 2008
Home Dialysis: What is it and How Do I Sign Up?
Are there Costs Associated with Home Dialysis?
Prescription for Health: Does Your Skin Itch?
The Future of Dialysis
Is There a Diet for Daily Dialysis?
Why Daily Home Dialysis?
Eat Right With Phil

State of the Unit - 2008
John Hensey, Administrator

Changes are afoot!  The theme for my annual Pathways article this year is change and how to deal well with it. There are generally three types of people when it comes to making changes; 1) those who embrace, promote and are excited by it, 2) those who resist it and are skeptical but eventually are convinced it is okay and 3) those who resist and don’t ever accept it, no matter what. Where do you fall in?  Change is an inescapable part of life. Being able to effectively and appropriately deal with positive and negative changes are an important part of success and happiness, especially in the face of great challenges.

All of you, as WDI patients, are dealing with major changes in your lives that affect you, your friends and family and for some of you, your job. WDI staff members are here to offer information and advice so you can plan for, respond to and accept the changes in your life as best you can. Please use your social worker, dietitian, nurse, doctor and nurse practitioner as important resources for dealing with changes in your health status and life in general. That’s why we are here, as an important part of the WDI mission, to provide high quality and well rounded services to you, your family and your significant others.

There have been many significant changes at WDI this past year too so I thought a brief summary of the major changes we’ve experienced would be fitting:

• Home Hemodialysis is now offered as an option for WDI patients and there are presently 7 patients in this growing program. The other home dialysis program, peritoneal dialysis, has grown to 26 patients. In general, home dialysis patients tend to be hospitalized less, require fewer medications and experience fewer infections. For the highest quality of life, we continue to strongly promote home dialysis for patients who are eligible. If you are interested in a home based dialysis therapy, please talk to your doctor to find out more.
• 30 new dialysis machines were purchased to replace the aging machines that have worked so well for so long. The new machines have many features to help ensure you are getting the best and safest dialysis treatments possible.
• Free wireless internet access is now offered to patients at the WDI-Fitchburg site. For those of you with a laptop, feel free to bring it in and pass the time on your favorite web sites, shopping online or keeping up with your e-mail.We have seen many new faces in the past year among the staff members who care for you during dialysis.  There seems to be a certain pattern with new staff members who either: 1) stay in dialysis a long time, 2) stay for a few years and then feel they need a change or 3) decide rather quickly it is not for them.  We try to hire staff who fit in the first category but there are no guarantees.
• With the staff turnover we’ve experience, we are fortunate that Xinliu Meyer, RN, CNS along with our staff preceptors have  developed a great orientation and training program for new staff members.  They have to prove their competency through testing and skills assessments before becoming independent in providing care to you.  Our efforts are ongoing to ensure you receive only the highest quality care and services from all WDI staff members.
• Last but not least, there was a change this year in nursing leadership as WDI welcomed Michelle Krueger as the new Nurse Manager. Michelle has a long history of experience in dialysis starting as a Patient Care Tech, then becoming a dialysis Nurse Clinician and most recently as the Nurse Manager at the UW Hospital Inpatient Dialysis Unit.  We look forward to her leadership and contributions for many years to come.  Michelle replaced Lila Jorgenson, who has been the Nurse Manager for the past four years.  Lila requested the change into a patient care role to give herself more time to pursue interests in her personal life.  We owe Lila a huge debt of gratitude for her steady leadership and valuable contributions during her tenure as the WDI Nurse Manager.  She played a vital role in WDI becoming the successful dialysis clinic it is today.  We are fortunate Lila is staying at WDI to contribute her skills and knowledge toward the direct care of patients.  Thank you Lila and good luck with all your future endeavors!

In closing, our primary goal as members of your health care team here at WDI is to maximize your health and happiness.  We take our responsibility to provide top quality patient care very seriously and will continue working hard every day to earn and deserve your trust.  Thank you and I hope you have a great 2008!

Home Dialysis: What is it and How Do I Sign Up?
Dawn Foster, RN

Did you know that here at WDI we have a Home Dialysis program?  Home Dialysis is a great alternative for many patients on dialysis. WDI offers both Home Hemo Dialysis and Peritoneal Dialysis. Currently there are 4 nurses that provide training and support for those patients that use Home Dialysis. Let’s look into each type of home dialysis and what is involved.

Home Hemodialysis:  Home hemo is done at home very similar to how it is done in center. There is a machine that you are connected to that pulls your blood through a filter using sterile dialysate or fluid to clean your blood and then return it to you. Patients perform their Home Hemo up to 6 days a week for a minimum of 2 hours a day. This helps them to feel better as the toxin and extra fluid are not allowed to build up with the more frequent dialysis. Thus, blood pressure and fluid balance are better controlled.

Training is a minimum of 3 weeks. Patients come 5 days a week for about 4-6 hours per day. Patients must have a willing and able partner that is present with them at home throughout their treatment because patients and their partners will perform all aspects of their treatment at home after completion of training. All the supplies required are provided to patients. Once training is completed patients are seen monthly in clinic at WDI. They are followed by a dietician, nurse, kidney Doctor and a social worker at each visit. Visits are around 1 hour.

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 catheter requires a minor surgery to have it placed in the abdomen. Once the catheter is placed patients come to the Home Dialysis clinic weekly for catheter care. Care consists of the home nurse flushing the catheter and applying a sterile dressing. This process is done until the catheter site is healed and the catheter is set in the abdomen ready to be used usually in about 2-4 weeks.

Training is done daily in the clinic for 4-6 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 2 different ways. CAPD or continuous ambulatory Peritoneal Dialysis requires 4- 5 manual exchanges be done 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 things can be kept sterile. CCPD or continuous cycling peritoneal dialysis is performed once a day usually at night while patients are sleeping. CCPD uses a machine called a cycler that performs the exchanges throughout the night. Once training is completed patients are seen monthly here at WDI. They are seen by a dietician, nurse, kidney Dr. and social worker each visit. Visits are around 1 hour.

While all of this may sound great not everyone is a good candidate for Home Dialysis. If you are the type of person that is highly motivated, detail oriented, and love the freedom to set your own schedule, Home Dialysis may be for you!   

The best way to determine this is to talk to your Kidney Dr. or Nurse 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 consisting of nurses, the kidney Dr., dietician and social worker will review records and meet with you. The Home Team will make a determination and will discuss this with you.

For many people Home Dialysis is a good option. Is it right for you?  Talk with your team if you are interested.

About the author: Dawn Foster has been a nurse for 17 years. She completed her seventh year as a Home Dialysis nurse and, in her words, " still loving it, I might add."

Are there Costs Associated with Home Dialysis?

The freedom and control with home hemo (HD) and peritoneal dialysis (PD) is one of the hallmark features of these types of treatments. The ability to be within the comfort of your own home and administering your own care, with the help of a partner, can give a person a real sense of accomplishment and empowerment. However, there could be some costs associated with being a home dialysis (HD or PD) patient that you should consider, not to dissuade you, but rather, inform you.

1. Your utility, water or electity bill may increase.
2. You will need a storage area for your supplies. You may need furniture of shelving to accommodate the supplies
3. You may wish to purchase a comfortable chair
4. You will require a home helper
5. You may need a minor upgrade to an electrical outlet
6. You may see rise in telephone costs as you stay in touch with your home dialysis program nurse.

Prescription for Health: Does Your Skin Itch?
Fran Kittell, RD

Does your skin itch?  If so, you are not alone. Many patients with kidney disease have itchy skin, also call pruritis (pronounced proo-RI-tus). Some patients experience itching continuously; others have itching only for a few minutes each day. Sometimes, the itching is worse at night. Many patients say that the itching is worse on their back, but others say they experience itching on their arms, head and stomach.   Why is this problem so common and what can you do about it?

The cause of itching in dialysis patients is not well understood. The problem seems to be more common in men, in patients who have poorly controlled calcium and phosphorus in their blood, and in patients who have dry skin. Itching may be worse during periods of rest, when the temperature is hot, when a person is sweating and when a person is feeling stressed. Itching may improve during physical activity, when the temperature is cooler and during showers. Some hemodialysis patients say that itching is made better by dialysis; others say that dialysis treatments make the itching worse. There are probably many reasons for itchy skin. Unfortunately, there is no “magic bullet” therapy with guaranteed results, but here are some possibilities.

First, you should work hard to keep your blood phosphorus and calcium at the target set for you. In addition, you may wonder, Is there a medication to put on the skin?  Yes, three possibilities exist. The first are non-prescription skin moisturing products that will help relieve dry skin and hopefully reduce itching. The second type of skin product is called capsaicin, found in many creams and lotions. Seek the advice of your pharmacist to purchase this product. You don’t need a prescription. The third possibility is a steroid cream. This is something you should discuss with your nurse or doctor.

For itchiness that does not improve, there are other possibilities to discuss with your treatment team. For example, some patients respond to certain prescription medicines, including antihistamines, given by mouth. For other patients, it may be a good idea to involve a skin doctor who can provide treatment by exposing your skin to certain kinds of light.

If you experience itchy skin, discuss it with your nurse or doctor. There are several treatment options that may work. Anticipate a trial and error approach to find the best therapy for you.

The Future of Dialysis
Xinlou Meyer, RN, MSN, CNS

Happy New Year to All Dialysis Patients and the Families!

New Year is the time to think about resolution, the future improvement and all the New and Exciting stuff. I can’t think about a better time to bring up with this subject.

Before we look ahead, let us take a quick glance at the past, so we can truly appreciate the technological advancement over the years.

The very first dialysis was performed in 1943. It was done through a rotating drum artificial kidney with the size of 42 inches high, 54 inches wide and 28 inches deep. It was developed by a Dutch doctor named Willem Kolff. It literally appeared like a big gas grill on the wheels. In the 1960s, the Kiil dialyzers used were 70-pound flat plates. Dialysis treatments would take up to 14 hours, 3 times a week. In the late 1960s, lightweight, hollow fiber dialyzers were introduced to dialysis industry and they have been much improved over the years. They are the only type of dialyzers on the market today.

Dialysis has become a way of living for 300, 000 Americans with kidney failure, who depend on it to stay alive. Despite all of the advanced technology and great improvement over the decades, conventional dialysis is limited to remove only about 17% of the toxins that a normal kidney removes. A natural kidney works continuously around the clock, but conventional, in-center hemodialysis is done only on an intermittent base at 4 hours each time, 3 times weekly. Consequently, dialysis can be quite stressful on the body due to the rapid chemical and fluid change, and therefore, may cause unwanted side-effects with the treatment. The most common complication with dialysis is low blood pressure. This is directly related to the rapid removal of toxins and water within the short period of treatment time.

Scientists recognize the limitation of current dialysis technology and have been working on inventing devices to simulate normal kidney function. The devices that would provide continuous renal replacement are as gentle as normal kidneys.

There are two types of experimental dialysis devices under development, wearable dialysis and a miniaturized implantable artificial kidney.

Another type of dialysis device for the future is a miniaturized artificial kidney that can be implanted into the human body that mimics the continuous function of normal kidneys. It involves the blood-filtering systems created via nanotechnology-engineering on a scale one-billionth the size of a meter.

This type of dialysis is still in the very infant stage of development.

Is There a Diet for Daily Dialysis?
Fran Kittell, RD

There has been much thought/deliberation for the one who is on daily dialysis and what they can eat. Since dialysis occurs on a daily basis, the more dialysis, the better, right? Getting more dialysis and clearance may allow those to eat more. Can those on daily dialysis get away with eating typically forbidden foods those on in-center hemodialysis are told to forgo? Let’s find out!

Wisconsin Dialysis offers and follows seven people on home daily dialysis. These people we found to be able to eat similarly as the current research suggests. And as with any process, we find some individuals are just that, individually following their own dietary tune!

It has been found those on home dialysis have a less “washed out” feeling, nausea, dizziness, and cramps. As a result those on home dialysis have a better appetite and eat more. This may be due to the more frequent treatments, increasing weekly removal of wastes and fluid, like how your healthy kidneys would have been functioning before becoming sick. It appears to be easier for those on home dialysis to meet their caloric and protein needs.

People on home dialysis are nutritionally healthier and can as a result possibly live longer. We are noting improved serum cholesterol and protein (albumin) levels in those on home dialysis. In fact, weight gain has been observed in this population and as a result exercise is strongly encouraged.

It has been thought with increased weekly removal, people on home hemo-dialysis would be able to eat more high phosphorus containing foods, such as, diary products, chocolate, dried beans and peas, and dark colored sodas. This dialysis could even decrease or even STOP the need for taking binder medications, a 24%-75% reduction in binder medication needs in some people. This has been found to be the case in the majority of those on home dialysis. Some studies have found a ~20-30% reduction in the person’s serum phosphorus levels. HOWEVER, the increased weekly removal of phosphorus has been found to be offset by the increased appetite and intake of food in some people. For these people limiting/watching their phosphorus intake may have to be continued just like those on in-center dialysis. Typically this phosphorus limitation may not be as restrictive as for those on in-center dialysis. AND, in fact, this “feel good” factor has been blamed for having one feeling SO fine, enough to increase their activity THAT it increases the difficulty in remembering to take the binder medications. Sound familiar to you?

What about fluid? Because there is less time for fluid to build between treatment times, there tends to be better blood pressure control, less cramping and a fewer headaches experienced in those on home dialysis. Fluid restrictions are often not needed in the majority of people unless intake exceeds the maximum being removed during the treatment regimen.

Sodium restrictions likewise are often more liberalized than for those in-center. Sodium restrictions are guided by the person’s fluid and blood pressure. In those with low blood pressure more dietary sodium may be needed. Those with normal blood pressures may need to limit their sodium intake to no more than the level of ~2400mg sodium daily. This is a little more than 1 teaspoon of salt for a day’s intake.

Potassium restrictions are rare for those on home dialysis. In people who skip one night per week and have seen high serum potassium levels after their longest interdialytic period, a mild restriction may be needed.

those on home dialysis and it needs to be individualized to your dietary needs, preferences and other medical issues.

Why Daily Home Dialysis?
Lisa Nanovic, DO and Director of the Home Dialysis Program

Dialysis itself is incredibly overwhelming, with the access issues, the procedure itself, and the side effects that can occur in the patient both before and after treatment. Although scheduled for three days a week, dialysis becomes a full time job for most patients, a new and cumbersome part of their lives. So many may question why someone would want to put more responsibility and stress on themselves by taking the modality of dialysis home with them, and even more so, performing this procedure every day.

The proof is in the history of dialysis, and the current literature comparing thrice weekly dialysis with daily home dialysis. When dialysis first came into use in the late fifties, early sixties, it was initially started intermittently, then was found to have better impact on the patient’s health when conducted daily. When the government assumed the cost of dialysis in the early seventies to allow this modality for all those suffering with kidney failure, the costs became astronomical. This prompted studies to find the minimum amount of dialysis needed for adequate care of the dialysis patient, which has led to the now practiced three times weekly dialysis run, lasting three to four hours each time.

Two important facts remain. The first is that three times weekly is the minimum amount needed for dialysis. The second is that we are dialyzing people for a couple of hours, a few days a week, to replace the function of a vital organ that was previously working twenty-four hours a day, seven days a week. In between dialysis days, toxins accumulate in the blood, overall body fluid increases impacting blood pressure and heart function, and levels of essential electrolytes that require specific levels in the blood to help carry out the daily activities of the body become skewed. This all leads to the many medical problems seen in the dialysis population, including fatigue, poor nutrition, high blood pressure, anemia, and heart problems. These persistent predicaments over time lead to an overall poor quality of life.

There have been hundreds of articles since the eighties comparing daily dialysis and thrice weekly dialysis on the above mentioned issues. In those patients transitioning from conventional hemodialysis to daily dialysis, it was found that there is better blood pressure control with an overall reduction in the amount and dosage of blood pressure medications in those patients on daily dialysis. Nutrition also improves on daily dialysis, not only by laboratory measurements, but also by the patient’s appetite and overall food intake. With daily dialysis, there is less time for toxin build up, as well as fluid accumulation. Less fluid means less strain on the heart, and studies have demonstrated this improvement on echocardiography in the daily dialysis patients. Decreased amounts of medications needed for anemia have also been observed in daily dialysis patients when compared to thrice weekly dialysis patients. An improvement in these parameters is a recipe for an enhancement in quality of life which indeed has been observed in daily dialysis patients as well.

While the thought of daily dialysis at home may be daunting to the dialysis patient, the benefits compared with the current practice of dialysis are significant. There is also the luxury of dialyzing according to your schedule instead of set times set by the outpatient dialysis unit. There is also something to be said for taking control of your medical condition instead of it taking control of you. Home dialysis provides the potential to take back some of that control, and at the same time, improving your overall quality of life.

Eat Right With Phil: Salt-free BBQ Sauce

Phil is a former transplant recipient and returns to WDI as dialysis patient. Phil loves to cook and wanted to share some of his ideas for yummy, dialysis-friendly recipes with other dialysis patients and families. Look for Phil’s feature recipe in future additions of Pathways. Phil works with the dietitian to ensure that each recipe meets the guidelines of the “dialysis-friendly” diet.

• 4 red peppers (cut in ½, remove membrane and seeds and rub skin with olive oil; brown in oven under broiler until dark but not burnt; remove skin)
• 6 Roma tomatoes peel and remove seeds
• 1 large Vidalia onion, chopped
• 3 cloves garlic, chopped
• 4 tbsp stone ground mustard
• 1 tsp black pepper
• ½ cup apple vinegar
• Juice of 2 lemons
• 1 tsp fresh oregano
• 1 tsp cumin, more if desired
• 2 tbsp fresh basil, chopped
• 2 tbsp fresh parsley, chopped
• ½ cup honey
• Cayenne pepper

Puree all together, except honey and cayenne. Puree in blender until smooth.  Simmer to desired thickness. Add honey and cayenne to taste.

NUTRITION FACTS: ~3.5oz