“Doc, How Long Do I Need to Be on Dialysis?”
A patient recently asked me this question, one that I interpreted to be one about sessional duration. The full question read as follows:
“What is a good amount of time to be on dialysis? I am on for 3 hours and it feels like forever. I often suffer from low BP and I'm exhausted and cold after every treatment.”
My response goes to the core of all that is wrong with dialysis—at least dialysis as it is all too frequently prescribed and practiced—though, that said, I sense that I sound rather like a cracked record as, over and over, and over again, year on year, I have been asked the same question…and over and over again, my responses have always been the same:
(1) There are no shortcuts in dialysis
(2) Symptomatic dialysis is ONLY encountered when treatment time is too short
(3) Inadequate treatment time is invariably the core threat to most dialysis patients
My frustration at repeating this same mantra, again and again, implies no criticism of the question or questioner, rather it is lays bare my frustration that many treatment providers just do not seem to get it. Whether due to their lack of understanding of the basic principles of dialysis, or whether due to self-denial driven by shorter time = greater profit…that is another question.
However, the answer to “how can I shorten my chair-time” is always the same, and I have yet to find a way or a reason to answer any differently from …
The slower, the more gentle, the longer and the more frequent your dialysis treatment is ... the better you will feel, the less symptomatic your treatment will be, the more stable you will find your blood pressure will become, the less will be your pill burden, the more healthy you will feel, the longer you will live, and as you move towards an acceptance of your (sadly essential) treatment, the more at peace with both the dialysis process and yourself you will become.
No one wants to be on dialysis… No one. And, dialysis is a hard load to have to bear! But, the sad fact is that if dialysis is needed, it is because of one single inescapable reason: the kidneys are no longer working.
In that event, only three choices remain:
- Transplantation (the best option)
- Dialysis (the next best)
And, while the latter will come to us all, sooner or later, a postponement of that choice appeals to most of us!
Transplantation is a luckily a choice and option for some and, when it is feasible, it is the best choice. But...and this is something the general public and the media often don't understand, transplantation is NOT an option for the majority of dialysis patients where age, frailty, co-morbidity (other co-existing illnesses or health issues), or immune system factors prevent listing. For example, in Australia, only about 1 in 4 dialysis patients are suitable for listing for transplantation. And the same is true, all around the world, whatever the country of origin. It is a sad but simple fact that more than 75% of dialysis patients will remain on dialysis for the rest of their lives...that is, unless a seismic shift occurs in transplantation medicine in the decades ahead.
Dialysis is thus the long-term lot for most but, if you work with it and not against it, dialysis can be made to work for you. Accepting that dialysis maybe your only choice is hard. Very hard. There is no doubt of that. But, if you can move through and past the natural anger and resentment that is often directed at both your dialysis and those associated with it, then understanding dialysis and how to make it work for you is the essential next step.
The key to understanding dialysis is to understand the necessity of time. There is an old saying "Rome wasn't built in a day," and it aptly applies to dialysis! Dialysis is NOT a fast, wham-bam, get-it-over-quickly therapy. Dialysis patients would like it to be. So, seemingly, do some dialysis clinics. But, it is not, and wishing it were so does not make it so.
The slower and, yes, the longer your dialysis treatment lasts, the gentler will be the changes that must be made to your biochemistry and circulatory volume, and the less symptomatic those recurrent modifications become. In particular and of core importance, the slower the rate of removal of any excess fluid, the more stable will be your blood pressure and your circulation.
Dialysis cannot be, no, it must not be hurried. The constant self-delusion and false reassurance that the shortening treatment times that have dominated the last 4 decades are in some way OK has not been OK. Short, “bazooka” dialysis was the wrong premise at the start—and it remains the wrong premise.
And, yes, I do get it. To ask a patient to sit for longer in a chair does (on the surface) seem a hard thing to ask of any patient. And, yes, I really do get it that chair-time sucks. It numbs the bum, it numbs the mind, and it wastes the hours that “living” might otherwise occupy.
But, that is the very reason why I (and others) encourage as many dialysis patients as possible to embrace self-care, home dialysis, and overnight, during- sleep treatment so that:
(1) Longer time can be easily accessed, while at the same time…
(2) Day-time hours are freed up for life and living, and …
(3) At the very least, alternate day (or better, alternate night) treatment can be used to exclude the dreaded and lethal long break (2-day weekend with no dialysis).
Other blogs in this now long series attest to the benefits of longer and slower treatment: the lower ultrafiltration rates; the greater middle molecular clearance; the better phosphate clearance; the lower burden of pills; the faster recovery time; the better sleep patterns; the abolition of on-dialysis symptoms; the day-time freedoms and return to work or school (for nocturnal patients); the improved well-being; the cleaner, brighter skin; the lesser or loss of need for EPO or iron … the list goes on.
See some of my previous duration-relevant blogs at this site. Click the titles to read them.
- The Dialysis Waterfall (Forget Urea: It’s Fluid that Kills) – Part 1
- The Dialysis Waterfall – Part 2
- The “Volume-Safe” Dialysis Duration KPI
- Slaying the Water Dragon
- From Blog to Dialysis Chair: Implementing Volume 101
- “How Much Can I Drink, Doc?”
But, all that said, it is true that a small majority of patients are unlikely to be suited to home dialysis —whether PD or HD—though in many countries, more than 35% of all patients at home is the normal and seems easily achievable, and achieved.
For those where facility dialysis is the only option, we should not be “selling” the message that a short time in the chair is enough when we know it is not, and when we know that longer time is simply better. In Australia, for example, in-centre treatment duration is ±5 hours—from the start—and is the common and promoted ethic for most dialysis services.
While 5 hours may seem a long time for patients erroneously persuaded to accept short chair runs, our patients here accept longer duration dialysis as normal. But, this clearly raises the question: can we be smarter about how we use and structure on-dialysis time?
Structured learning (e.g. through programs like the University of the 3rd Age), on-dialysis exercise programs, interactive entertainment…all these and more have been reported as successful. Time can be passed gainfully, if thought is given to how. Much more thought must be given to improving the gainful use of chair-time for those who cannot dialyse at home, or dialyse overnight. This is a qualitative imperative, going forward.
But, back to the original question, my short answer to “how long do I need to be on dialysis?” is: as long as is logistically possible.
And what of her stated “3 hours”? Well, 3 hours every day (and who would or could) might just about do it—for only a few. But ,I suspect the 3 hours she mentions in her question is not daily. Further, each and every patient is different, and the differences are legion: age, sex, weight, body mass index, racial origin, underlying disease and co-morbidity profile to name just a few. Yet dialysis prescriptions are commonly identical, in duration and frequency, regardless of whether the patient is a 78 year old white female weighing 46 kg, or a 25 year old black diabetic male weighing 150 kg. Clearly, these patients are vastly different—yet they are commonly shoe-horned into a single treatment profile.
Many national bodies state that 1 in 4 dialysis treatments are likely to be associated with hypotension, going “flat”, nausea, vomiting, cramps, restless legs, poor sleep quality, itchy skin, and other horrid ‘complications’ of dialysis.
One such reputable US national body even blandly states that dialysis patients should limit their fluid intake "to no more than a quart (= 32 ounces or by conversion = 0.95 litres) each day" ...end of instruction! This extraordinary instruction, given, it seems, for all/any dialysis patient, takes no account of differences in age, body weight, BMI or surface area, activity levels, ambient external temperature, residual urine output, inter-dialytic interval, or any ultrafiltration rate implication that might arise for the next dialysis session. Fluid intake can and must be individualised. The two patient examples given above clearly qualify for differing intakes, simply based on age and size, regardless of the added differences between other variables. To think otherwise is to reveal no thought at all.
This time, dangerous piffle! Who on earth wrote those “instructions”?
Good dialysis (in-centre) should be variable and varied to the needs of each individual patient. Similarly, good interdialytic management should also be individualised. No blanket instruction like the example above should ever be given. We can be smarter than that!
At home (in home haemodialysis), and wherever else possible (e.g. centre-based nocturnal treatment), my clear personal preference is to strive for 8-hour duration treatments at a minimum of an alternate night frequency, or, even better, a two nights on, one off regimen, abolishing the dreaded long break.
Just ask any patient who undertakes longer dialysis whether they “go flat”, need saline, vomit or cramp, or have sallow, itchy skin and they will answer, “no, I don’t!”
All these ‘listed complications’ are not the side-effects of dialysis. They are the side effects of BAD dialysis.
As for so-called short daily treatment (2-3 hours x 5-6 x week), I am NOT and have never been a fan, except when used in-centre to “rescue” patients with very damaged hearts and narrow volume windows—the only use of short hour treatments in ANZ.
To come to the second part of her question, the feeling of coldness, of chill, there has been a recent long and interesting patient-based discussion about the interrelationship between “chill” and dialysate temperature at the HDC Facebook page. Indeed, Dori Schatell, the group moderator, asked me to add some comments to that discussion.
Sadly, another unpalatable truth about dialysis is that lower dialysate temperatures are beneficial —even though by lowering the dialysate temperature, there is no doubt that the sensation of coldness during treatment increases in a small but significant number of patients. An excellent review of this was recently published by Gihad Nesrallah and his Canadian group that confirmed the advantages for circulatory and blood pressure stability, while noting that the feeling of being cold was reported nearly 3 times as often by the low temperature groups. The FaceBook group listed a number of user ways to counter this feeling of coldness.
At the end of the day, while longer treatment lengths and lower dialysate temperatures clearly have their negatives too—undeniably these are (1) chair-time and (2) a feeling of coldness or chill—both also undeniably improve clinical, cardiovascular, health and survival outcomes. So, as is often the way in life, a choice must be made between discomfort and outcome. Here, both longer duration and lower dialysate temperature do potentially add some patient frustration and process discomfort —but the alternatives to both are far worse.
Clearly, the ultimate choice remains to be negotiated between each patient and his/her treating team but, I know that if I were to need dialysis, I would dialyse for as long as possible, and I would don a Geelong CATS beanie, and snuggle down under a warm rug to counter my choice for a lower dialysate temperature.
As there are no better advocates for longer time than those who have embraced it, hopefully some longer hour patients will (a) read this blog and (b) add their voices; their “been there, done that” experiences to mine to attest to the one single and overriding principle in dialysis: the longer, the slower, the more frequent and the more gentle the dialysis treatment, the better.