Hemodialysis Management provides kidney replacement therapy to patients with kidney failure either as a regular maintenance or on an emergency basis.

Fistulagram

Fistulagram is also called an artificial graft. Purpose of a fistulagram is to evaluate renal access from a surgical fistula/graft (synthetic connection of an artery and a vein) that is not functioning properly. Upon attempt to access the fistula or graft, the flow rate may not be high enough, pressures in the vein may be too high or the graft may clot off frequently.

The procedure involves placement of a tiny needle (smaller than a dialysis needle) into the fistula / graft and injection of contrast dye, which enables visualization within the fistula/graft from its arterial end to its venous end and all the veins to the heart. Treatments such as venous angioplasty/stent (renal dialysis access) may be performed to treat blockages that are detected.

Fistulagram declotting, angioplasty and stenting

Venous angioplasty is a non-surgical procedure, which can be performed during venogram to open or bypass narrowed veins to prevent clotting. Venous angioplasty can also allow for placement of a small device called a stent, which supports a vessel or tissue in an open or expanded position to allow bypass of scarred tissue and improve blood flow.

For venous angioplasty procedure, an X-ray of the veins using a thin wire tube is performed. Once blocked or narrowed vessel(s) are visualized on the venogram, a balloon tipped catheter is inserted into the blocked vein and guided under fluoroscopic x-ray to the area of concern. The balloon is inflated to correct the blockage and enable blood flow. In some circumstances, a stent is mounted on the balloon tipped catheter. When the balloon is inflated, the stent is expanded and adheres (permanently) to the walls of the vessel to keep it open.

Advanced hemodialysis vascular access including recannalisation of blocked vessels

Patients with advanced kidney failure usually require dialysis. Hemodialysis is one form of dialysis where blood is circulated through a special cleansing machine and returned to the body. For hemodialysis to happen an access site is needed. There are three methods for drawing blood from and returning it to the body:

Arterio-venous fistula - patients own vein is used as a conduit.
Arterio-venous graft - an artifical tube is used as a channel.
Temporary venous dialysis catheter - temporary and emergency method. Catheter is inserted in large vein.
When kidneys fail, function of the kidneys can be partially replaced using a process called hemodialysis.  Hemodialysis involves drawing blood out of the body, filtering it through a large machine that draws off the impurities and then returning the filtered blood to the body. When patients are placed on hemodialysis, they will require placement of a plastic tube into a large vein at the base of the neck. This plastic tube is called a hemodialysis catheter. It is connected to a hemodialysis machine and is a vital connection between the patient and the hemodialysis unit.

Patients in need of hemodialysis access may be sent by their kidney doctor to the Interventional Radiology Division. Here, specialty trained doctors use advanced technology equipment to place a hemodialysis catheter. A combination of machines including an ultrasound machine and a fluoroscope are used to safely access the large vein at the base of the neck and slide a plastic tube into the venous system. Once in place, this catheter is securely fixed to the skin and can remain with the patient for weeks to months. This catheter will need special care and is explained to the patient at the time of catheter placement.

Lifeports hemodialysis ports

Hemodialysis works by circulating the blood through special filters. The blood flows across a semipermeable membrane (the dialyzer or filter), along with solutions that help facilitate removal of toxins. Before hemodialysis can be performed, there needs to be adequate access to the circulatory system. The access needs to support a blood flow of 250 milliliters per minute (ml/min), and a normal IV will not support that volume of blood flow. A special type of arterial and venous access is therefore established.

The access can be either external or internal. External access involves two catheters -- one that is placed in an artery, and one in an adjacent vein, or two catheters positioned within different parts of a large vein. External access is typically only used in emergency situations.

Internal access can be either an arteriovenous (AV) fistula or graft. A fistula involves the surgical joining of an artery and vein under the skin. The increased blood volume stretches the elastic vein to allow a larger volume of blood flow.

After the 4 to 6 weeks the fistula needs to heal, needles can be placed so that arterial blood can be pulled off for dialysis, and the cleansed blood returns through the dilated vein. Turbulent blood flow over the fistula is commonly felt and termed a thrill.

A graft may be used for people whose veins are not suitable for an fistula. This procedure involves surgically grafting a donor vein from the patient's own saphenous vein (in the leg), a carotid artery from a cow, or a synthetic graft from an artery to a vein.

After there is adequate access with two ports, a hemodialysis machine is connected. The port from the artery leads into the machine, and the port returning from the machine leads into the vein. Inside the machine, your blood is run through tubes with semipermeable membranes, and the tubes are bathed with solutions that help remove specific soluble materials from your blood.

In children, hemodialysis is used as preparation for kidney transplant, rather than for chronic care. In adults with chronic kidney failure, hemodialysis is typically performed over 3 to 4 hours three times a week.

Translumbar and transhepatic HD catheter placement

Use of the right internal jugular vein (IJV) to insert a catheter for hemodialysis obviates many of the risks associated with subclavian vein access. However, when IJV access is no longer feasible, catheters at other locations provide viable alternative routes.

Peritoneal dialysis catheter placement

When kidneys fail, waste products such as urea and creatinine build up in the blood. One way to remove these wastes is a process called peritoneal dialysis (PD). The walls of the abdominal cavity are lined with a membrane called the peritoneum. During PD, a mixture of dextrose (sugar), salt, and other minerals dissolved in water, called dialysis solution, is placed in a person's abdominal cavity through a catheter. The body's peritoneal membrane enclosing the digestive organs allows waste products and extra body fluid to pass from the blood into the dialysis solution. These wastes then leave the body when the used solution is drained from the abdomen. Each cycle of draining and refilling is called an exchange. The time the solution remains in the abdomen between exchanges is called the dwell time. During this dwell time, some of the dextrose in the solution crosses the membrane and is absorbed by the body.

Many factors affect how much waste and extra fluid are removed from the blood. Some factors--such as the patient's size and the permeability, or speed of diffusion, of the peritoneum--cannot be controlled. Dialysis solution comes in 1.5-, 2-, 2.5-, or 3-liter bags. The dialysis dose can be increased by using a larger bag, but only within the limits of the person's abdominal capacity. Everyone's peritoneum filters wastes at a different rate. In some people, the peritoneum does not allow wastes to enter the dialysis solution efficiently enough to make PD feasible.

You Emory team will determine all the factors that affect how efficiently your blood is filtered.