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The access is a point for entry into the bloodstream so that the patient can be connected to the machine. It is sometimes referred to as the haemodialysis patient's life line because without it, effective, repeated dialysis would not be possible.

THE COMMONEST TYPES OF CHRONIC ACCESS USED NOWADAYS FOR HAEMODIALYSIS -
1) Arterio-venous (AV) fistula
2) Arterio-venous (AV) graft

Arterio-Venous Fistula
This is created internally and is used for prolonged period of time. This involves a small operation to join an artery to vein, allowing arterial blood to flow directly into the vein. The blood vessels of the arm are usually chosen, e.g. at the wrist or at the upper forearm.

Due to the arterial pressure, the vein would increase in size and its walls would thicken. It takes about 4 to 8 weeks for the fistula vein to mature. It allows for high blood flow rates and repeated needle sticks.


Arterio-Venous Graft
The arterio-venous graft (AVG) is an artificial blood vessel used to join artery and vein. It is used when the patient's own blood vessels are too small for fistula construction. Often, these patients are elderly or have pre-existing diabetes mellitus.

The graft, which may be either straight or looped, is placed close to the surface under the skin. The graft may be of an artificial material such as polytetrafluoroethylene (PTFE) or Gortex, or can be obtained from the patient's own vein e.g. the vein in the thigh.

Grafts are most commonly placed in the upper arm, lower arm or thigh. It can be used sooner than a fistula. Two to four weeks is adequate to allow healing and sufficient growth of tissue to stabilise the graft.


TEMPORARY ACCESS
Sometimes, temporary or immediate access is created for patients who need urgent dialysis or those who are waiting for their new fistula to mature. The types of temporary access are subclavian catheter or internal jugular catheter. The catheter is a hollow tubing inserted into the subclavian (below the collarbone) or internal jugular vein (side of the neck ) which has direct access to the heart. Using these access sometimes tend to have problems like blocked catheter from clots or infection at the insertion site. Therefore, extra care has to be taken with temporary access.

CARE OF ARTERIO-VENOUS FISTULA OR GRAFT
1. Keep the fistula arm raised on a pillow to reduce swelling
2.

The dressing should remain intact and dry at all times. If the dressing is dirty or blood stained, it should be changed.

3. Observe suture line for signs of infection. Report to doctor-in-charge or nurse if any of these following symptoms are present :
• pronounced redness
• warmth
• fever
• bleeding or discharge
• increase pain
• tenderness
4. After the sutures are removed, the fistula arm may be cleansed with soap and water in the usual manner.
5. As soon as post operative pain has subsided, start arm exercises by squeezing a rubber ball or using a rolled up wash cloth for 5 minutes, alternating squeezing and relaxing the hand. Do up to 6 times a day. This helps to develop the fistula.
6. Do not allow blood pressure, blood taking or intravenous administration on the fistula arm.
7. Do not wear constrictive clothing, bangle, watch or hang a bag over the arm or carry heavy objects on the extremity of the fistula arm.
8. The doctor-in-charge will inform you when the fistula is ready for use.

 

GENERAL GUIDELINES
1. Keep fistula or graft site clean and dry.
2.

Feel for thrill or buzzing sensation at both ends of the fistula or graft in the morning when you wake up and at night before you go to sleep. Seek advice from your doctor or nurse if the thrill or buzzing sensation is absent.

3. Inspect fistula for redness, swelling, tenderness or warm to touch to detect infection. Report to the doctor or nurse if any of these symptoms are present.
4. Avoid constrictive clothing, bangle, watch or hang a bag over the arm or carry heavy objects on the extremity of the fistula arm which may block off the fistula.
5. Remember that no taking of blood pressure, blood taking or intravenous administration should be done on the fistula arm. Take measures to prevent sleeping on the fistula arm.
6. Continue arm exercises if the fistula is still not well developed.
7. Wear an arm guard to protect the fistula if participating in contact sport or labour work.
8. Wash the fistula arm thoroughly with antiseptic solution before dialysis.
9. Avoid excessive pressure on the puncture sites after dialysis. Apply digital pressure so as to prevent bleeding.
10. Rotate needling sites to prevent aneurysm and pseudo-aneurysm and also to allow healing of the puncture sites.
11. After dialysis, the dressings should remain intact for about 6 hours . Ensure that the thrill or buzzing sensation is still present on the fistula.
12. If injury or profuse bleeding occurs at fistula site, apply pressure over the bleeding area to stop bleeding and seek immediate medical attention at the nearest A&E department.

 
 
 


1) LOW POTASSIUM DIET
Potassium
Potassium is a mineral found naturally in foods. It plays an important role in normal muscle and nerve activity, especially in the heart.

The kidneys remove excess potassium. People with kidney failure have reduced ability to remove excess potassium, thus causing accumulation of potassium in the blood.It is dangerous when blood potassium level is too high or too low.

Too high a level of potassium can cause muscle weakness, affect the heart rhythm and may even cause death. Too much potassium in the blood can be caused by eating too much high potassium food, fever, surgery, gastrointestinal bleeding and breakdown of body tissue.

Too low a level of potassium can happen when there is not enough potassium in the diet, vomiting, diarrhea, medications such as using potassium binding resins and diuretics preparation that increase the loss of potassium. Eating too little potassium can be dangerous to the heart too. Haemodialysis patients tend to have high levels of potassium while peritoneal dialysis patients tend to have low levels. As Haemodialysis is performed only three times a week while peritoneal dialysis is done on a daily basis and washes out more potassium.

Kidney failure patient should maintain the potassium level at a normal range of 3.5 - 5.0 mmol/L.

Many fruits and vegetables contain potassium. Limit to 2 servings of fruits and 2 servings of vegetables a day. Choose low potassium varieties.

  Medium potassium foods (Limit intake)
  Fruits:
  Lychees Melon Plums
  Strawberries Pineapple  
   
  Vegetables:
  Boiled broad beans Peas Baked beans
  Pumpkin Raw beetroot Lady's fingers
  Carrots Sweetcorn Cauliflower
  Sweet potato Boiled brussels sprouts Radish
  Raw cabbage Boiled broccoli Leeks
  Celery Lettuce Green beans

  High potassium foods (best to avoid)
  Fruits:
  Avocados Peach Apricot
  Pomegranate Cherries Prunes
  Figs Raisins Grapes
  Dates Nectarines Banana
  Orange Sultanas  
   
  Vegetables:
  Ginger root Bamboo shoots Mushrooms
  All kinds of nuts Tomato Potato (jacket chips, roast chips)
  Spinach Lentils (boiled) Yam
  Green leafy
     vegetables		 Lotus root  

  Other foods/drinks high in potassium to avoid
  Coffee Potato chips Milo
  Bottle sauces e.g. tomato ketchup Ovaltine Marmite
  Alcohol Stock cubes Horlicks
  Salt substitutes Chocolate Molassess
  Chocolate products Bran Toffee
  Coffeemate    

  Remember:

  
 

1.


2.


3.

4.

5.

6.

Always remember to cut vegetables into smaller pieces and soak in water for one hour before cooking. Boil and then discard the water. Do not make soup or gravy with it.

Do not steam or use a pressure cooker or microwave oven or to stir fry your vegetables, always boil them in plenty of water so as to remove potassium.

Potato is high in potassium, so potatoes for roasting or chips must be parboiled for 10 minutes first.

Tinned fruit is lower in potassium than fresh fruit but always drain the juice before eating.

Salt substitutes contain potassium and it is advisable to always read labels carefully.

When in doubt about the food products, check with your doctor or dietician whether the products are suitable for you.

  


2) LOW PHOSPHATE DIET
Phosphorus is a mineral needed by the body for healthy bones. When kidneys do not function properly, they cannot remove excess phosphorus. Therefore, phosphorus builds up in the blood, which lowers the level of calcium which is also an important substance for building bones. Most of the body calcium is found in the bones. High blood phosphorus level causes the bone to release calcium into the blood. This will make the bones weak and cause them to break easily. Itching, bone pain and red eyes may occur too.

The normal blood phosphorus level is 0.85 - 1.45mmol/L. A blood test for phosphorus is the way to tell if the phosphorus is too high.

  How can you control phosphorus level in the blood?

  

1.
Avoid high phosphorus products in your diet.
2.
Take phosphate binders. Phosphate binders such as calcium carbonate and aluminium hydroxide preparations such as Alutab combine with the phosphorus in foods and is eliminated in the stool, preventing it from getting into the blood stream. This medication should be taken WITH meals, otherwise it will not be effective.

High Phosphorus Foods
Phosphorus is found mainly in dairy products and other high protein foods.

  Drinks
  Cocoa Malted drinks eg. Horlicks, Ovaltine  
   
  Dairy Products
  Milk Cheese Yogurt
  Ice Cream    
   
  Cereal Products
  All bran Muesli Oatmeal
  Wheat germ Raisin bran Waffles
  Shredded wheat Yeast extracts e.g. marmite, bovril Chocolate cake
  Wholemeal breads Foods containing a lot of baking      powder e.g. rock buns, scones  
   
  Vegetables*
  Beans, peas Lentils Soyabeans
  Pumpkin seeds Sunflower seeds All kinds of nuts
* Beans, peas and soyabeans may be included in the diet if eaten as a substitute for fish or meat.
   
  Meat, Fish and Poultry
  Liver Seafood e.g. prawn, crab, lobster Egg yolk
  Kidney Fish with edible bones e.g. sardine,      ikan bilis  

  IMPORTANT  
1.
Restrict to a minimal amount or avoid food that contains high phosphorus.

  2.
Some of the food may also contain a high amount of potassium, so be careful when selecting them.

  
  3.
Remember to take phosphate binders WITH food. Do not stop taking them on your own. If you have a problem with taking such phosphate binders, discuss with your doctor in-charge, dietician or nurse.

  
  4.
When in doubt about the food products, check with your doctor or dietician whether the products are suitable for you.

  
  5.
Taking phosphate binding medication regularly and avoiding high phosphorus food can help you control phosphorus levels.
  

3) FLUID MANAGEMENT IN DIALYSIS
Healthy kidneys eliminate excess water as urine. People with renal failure usually make little or no urine, so they depend on dialysis to remove excess water. Therefore, in renal failure it is essential to control the volume of fluid intake to prevent the body from fluid overload, which causes complications.

  Fluid overload can cause:

1.
An increase in blood pressure
This increase of blood pressure causes damage to the blood vessels, headache, blurred vision and stroke. Excessive fluid overload causes strain and stress on the heart which will cause it to develop into "big" heart. As a result, the heart becomes weak, which makes a patient unable to tolerate ultrafiltration and has continual heart problems.

2.
Shortness of breath
Excessive fluid can lead to water filling the air sacs in the lungs. This will reduce the air space in the air sacs where gaseous exchange takes place, causing renal patient to complain of difficulty in breathing even when lying down.

  3.
Swollen eyelids and ankles or feet

 
  4.
Distended abdomen
 

To prevent these complications from happening, it is essential to follow the fluid allowance as ordered by the renal physician.

 
TIPS IN FLUID CONTROL

 

1.
Count all fluids (even those sips taken with medications), all ice cubes, gravies, soups, oats, porridge, puddings, etc in your fluid allowance.

2.
It is important to measure all the fluids in the diet accurately. You may like to measure a jug of water every morning containing your restricted amount you can take for the day. As the day goes by, pour from the jug for drinking or even cooking or making ice cubes.

 
3.
Reduce salt intake as this will help to decrease thirst.

 
 
4.
Avoid adding salt, soya sauce, tomato ketchup and any other sauces to meals at the table.

 
 
5.
Avoid salty food e.g. bacon, ham, salted fish, smoked fish, salted vegetables, salted eggs, salted chips, salted nuts, cheese, etc.

 
 
6.
Add garlic, onions, herbs or spices to food for extra flavour in order to reduce salt used in cooking.

 
 
7.
Avoid canned food as they contain high salt content.

 
 
8.
Instead of a few large drinks, divide daily fluid into smaller but more frequent drinks. It may also help if you use a smaller cup each time.

 
 
9.
Ice cubes are more thirst quenching than water. But remember to count them in the daily fluid allowance. It may be helpful to take 100 mls of the fluid allowance each day and make that into ice cubes.

 
 
10.
Take medicine with food. Some medications need little or no fluid to swallow if taken with food. If this is not possible, remember to count the fluid used in taking the medications into the fluid allowance.

 
 
11.
When your mouth feels very dry, rinse with water, gargle if necessary, but do not swallow it. Alternatively, you can suck a slice of fresh lemon as this helps to stimulate salivation.

 
 
12.
Some people find sucking sweets can also help to quench thirst. Choose sugar-free sweets if you are diabetic.

  
 
13.
Save your fluid allowance if you are going out.

 
 
14.
Try to sip drinks or use a straw, as they will last much longer. You can try to squeeze some lemon juice into your water.

 
 
15.
Try to keep yourself busy. You will find it much easier to keep to your fluid allowance if you are busy and not always thinking about your next drink.

 
 
16.
Clean your teeth regularly. Use mouthwash to freshen your mouth and throat.

 
 
17.
Weigh yourself daily and check your weight gain. If you are on haemodialysis, you should not put on more than 1.5 - 2 kg between dialysis.

 
 
18.
Be sure to measure your favourite cup or mug, so that you will not under or over estimate the amount of fluids each time you drink.

1 full tea cup = 200mls

1 scoop ice-cream = 60mls

1 full coffee mug = 300 mls

1 packet drink = 250mls

1 full glass = 200 mls

1 standard ice cube = 30mls

1 tablespoon fluid = 15mls

When in doubt about your fluid requirements, always discuss with your doctor, dietician or dialysis nurses.
  
 
 

CAN PATIENTS ON HAEMODIALYSIS TREATMENT TRAVEL?
Certainly! Haemodialysis patients are encouraged to take a break, go for a holiday and spend some time with their families or spouses. However, before planning for a trip, the patient should be reasonably healthy and also certified fit by a doctor for any trips. Planning for the trip should be 4 weeks prior to departure. If it is during peak time you will need 6 weeks prior to departure

WHAT ARE THE NECESSARY PREPARATIONS BEFORE THE TRIP?
Decide on the destination e.g. countries, cities
Decide on the length of the trip eg: 3 days, 2 weeks
How is the holiday planned :
- Sign up with a tour group
- Free and easy
- Visit friends or family members

Type of holiday: fishing, resort, cruise, sightseeing

The type of activities carried out may or may not be near a dialysis facility. This must be considered during the planning.

WHO TO INFORM?
Doctor in charge:
• You need to consult the doctor on medication and the number of dialysis needed during the trip. This will be    according to the number of days planned for the holiday
• To obtain a medical summary of the current condition. This will give the transient dialysis centres' charge nurse    an idea of your diagnosis, previous medical treatment and current status

Nurse in charge:
• To help you to reschedule your treatment for your departure date & arrival date
• To help with the medical summary

WHAT IS THE BASIC INFORMATION TO GIVE THE DIALYSIS FACILITY?
• Nurse in charge to fill up the 'Patient information data' which the doctor in charge has to sign
• The days which dialysis is needed

HOW DO YOU GET THIS INFORMATION TO THE TRANSIENT DIALYSIS FACILITY?
• You can fax it to them
• If the centre does not have a fax machine, you are to bring the documents to them when you get there

WHAT ABOUT PAYMENT?
• You need to ask the nurse in charge of the transient dialysis facility about the amount to pay for each treatment.    Preferably this should be done before you start your trip to help you with your budget. Note that most centres    differentiate between HepB positive and negative status
• Find out how you can pay e.g. cash, credit card or travelers cheque

DO I NEED TO CONFIRM TREATMENT RESERVATION?
• Yes. Two weeks before the departure to call the facility again to confirm
• When you arrive at the city to call the dialysis centre again to reconfirm appointment

WHAT ELSE I MUST DO?
• You might need Resonium for this trip. Remember, to take the medication according to the instructions
• You may visit the dietician for some advice on food especially if treatment is reduced during the trip

 

 

 

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