About ESRD & Dialysis

What is ESRD?

Permanent kidney failure is clinically referred to as ESRD. ESRD stands for end stage renal disease (renal means “relating to the kidneys”) — which occurs when an individual loses 85-90% of kidney function.¹  The two main causes of ESRD are Type 2 diabetes and high blood pressure.  The kidneys filter waste, salt, and excess fluids from the blood. In individuals with chronic kidney disease, the kidneys gradually lose the ability to properly filter the blood. There are five stages of kidney failure, and individuals who reach Stage 5 (ESRD) require a treatment called dialysis, or a kidney transplant, to survive.

More than 700,000 Americans have been diagnosed with ESRD. Of these, 494,000 are receiving dialysis treatment. For the remaining 207,000, their ESRD has been resolved by a functioning kidney transplant.²  In 2016, there were approximately 18,000 Ohioans on dialysis.³

What is dialysis?

Dialysis is a treatment that replaces some functions of the kidneys when they are no longer working effectively. The process removes waste, salt and extra fluid from the blood; keeps a safe level of certain chemicals in the blood; and helps to control blood pressure.

Dialysis does some, but not all, of the work of the kidneys, and it does not cure kidney disease.⁴ Individuals with ESRD will need dialysis for the rest of their lives, or until they can receive a kidney transplant.

The vast majority of Ohio dialysis patients (88%) opt for out-patient hemodialysis at a community dialysis clinic. In out-patient hemodialysis, a dialysis machine pulls arterial blood from the body at a high flow rate, filters it through a device called a dialyzer, or artificial kidney, and returns the blood through a vein.  Because dialysis requires a high blood flow rate, patients must have an “access site” created prior to beginning the dialysis. Ideally a surgeon can create a vascular access by joining an artery and a vein under the skin where a needle can be used to access the bloodstream. If a vascular access is not possible, a catheter can be attached to a large vein — typically in the neck. The catheter can then be connected directly to the dialysis machine. The catheter has two sides; one to pull blood from an artery, and the other side to return the blood.

Out-patient hemodialysis is typically performed three times a week, with each treatment lasting approximately four hours. Many ESRD patients receive dialysis for years at the same clinic, developing strong bonds with clinic staff and other patients due to their shared experience, and come to feel that their dialysis community is truly a “second family.”

With training provided by their community dialysis clinic, some patients can do their dialysis treatment at home. Home-based dialysis patients can do hemodialysis or peritoneal dialysis.  Peritoneal dialysis is a type of dialysis that uses the lining of the patient’s abdomen (peritoneum) as the filter through which fluid and dissolved substances are exchanged with the blood.  Home hemodialysis can be performed by a patient along with a partner, while peritoneal dialysis can typically be performed by the patient without assistance.

Importance of dialysis

Dialysis only replaces a portion of the work done by normally functioning kidneys, therefore it is critically important that patients not miss dialysis sessions. Missing dialysis sessions can cause complications that could result in hospitalization or even death. A 2003 study found that skipping one or more dialysis sessions in a month is associated with a 30 percent increased mortality risk (chance of dying).⁵

What does a typical out-patient hemodialysis appointment look like?

Most Ohio dialysis patients (88%⁶) receive out-patient hemodialysis three times a week.  Prior to the procedure, patients are evaluated to ensure they are well enough to undergo treatment, clean their vascular access in order to prevent infection, and to determine how much fluid should be removed.  Patients are weighed before their dialysis starts to determine how much weight they have gained since the last treatment and how much over their “dry weight” they are (“dry weight” is the weight a patient is without any extra fluid). Throughout the course of treatment, the patient’s blood pressure and pulse are monitored to ensure they are tolerating the treatment well.  Patients are also weighed after the treatment to ensure that the proper amount of excess fluid has been removed. Measures are taken to reduce the risk of infection including patient hand washing, and inspecting and cleaning the patient’s vascular access site to help prevent bacterial growth.⁷ Dialysis patients are cared for by an interdisciplinary team including nurses, Ohio Certified Dialysis Technicians, social workers, and dietitians as well as the patient’s nephrologist (kidney doctor).

Data shows that ESRD occurs at a higher rate among veterans than the U.S. population as a whole.  Veterans who get their healthcare benefits through the Department of Veterans Affairs (VA) can receive dialysis services at one of the roughly 70 VA dialysis facilities in the United States⁸, however the majority receive their treatment at a community dialysis clinic.

While some dialysis patients are healthy enough or can tolerate dialysis well enough to drive themselves to and from dialysis appointments, most patients require some transportation assistance. Some insurance programs including Medicaid might provide transportation coverage based on patient need, which can range from a simple cab ride to a wheelchair accessible van, and rarely, ambulance transportation if the patient meets certain criteria.  Many communities offer some type of transportation assistance, but finding adequate transportation to dialysis appointments three times a week can still be challenging for many patients, especially those in rural areas.

Why are people with ESRD at risk for infections?

Like other medical treatments that require the frequent use of catheters or insertion of needles into the bloodstream, hemodialysis patients can have an increased risk for infection. ⁹ In addition, dialysis patients often have underlying conditions such as diabetes that have weakened the immune system. Diabetics may also suffer from nerve damage in their feet, making it more difficult to detect foot injuries, and poor blood circulation, which makes it harder to fight off infection.  Dialysis patients may also require frequent hospitalization, where they might acquire an infection. Dialysis staff and patients follow strict procedures to reduce the risk of infection.

OHIO DIALYSIS FACTS

Current regulation of Ohio dialysis clinics

There are 326 free-standing dialysis clinics in Ohio.¹⁰  All free-standing clinics are licensed by the Ohio Department of Health and certified by the Centers for Medicare and Medicaid, CMS, and highly regulated under current state and federal laws and regulations.  Current laws and regulations require that every dialysis clinic in Ohio must, among other things:

• comply with state and federally-mandated standards of service,
• develop and implement an individualized, comprehensive patient care plan for every patient,
• ensure that staff members are properly trained and if necessary, licensed, and provide a continuing, education and training program for its personnel,
• develop and follow written policies and procedures for preventing and controlling infections, including an equipment maintenance program,
• maintain detailed patient records, ensure environmental cleanliness, emergency preparedness and safety practices and
• conduct ongoing unannounced quality assessments and survey inspections by the Ohio Department of Health (ODH) a minimum of once every 3.5 years, more often if necessary. Complaints to ODH are promptly investigated.

Location of clinics

Out-patient hemodialysis patients must receive treatment three times per week. Clinics are conveniently located throughout the state in urban, suburban and rural areas. While most are out-patient clinics some are located in hospitals. The clinics are typically located in areas with plenty of convenient parking and easy access to public transportation. Dialysis treatment can be tiring and patients often need help getting to and from appointments. Clinic social workers can help patients access low-cost and free transportation resources if available in their community.

Ohio Dialysis patient profile (2016)¹¹

There are approximately 18,000 Ohioans on dialysis:

• 43% women, 57% men
• 62% white, 37% African American; 1% other
• Median age is 64 years old
• Primary cause:
  • 45% diabetes
  • 25% high blood pressure
• 88% use out-patient hemodialysis
• 12% use home dialysis
  • 15% home hemodialysis
  • 85% home peritoneal dialysis

Does insurance cover the cost of dialysis treatments?¹²

In 1972, Congress expanded Medicare coverage to include ESRD patients under the age of 65 who meet certain requirements, and after a waiting period, typically three months.¹³ In addition, Medicaid and all private insurance companies cover dialysis.

Of the 18,000 Ohioans receiving dialysis treatment:

• 82% are covered by Medicare or Medicaid
• 11% are covered by private insurance
• 7% are covered by the VA or other government payers

Some insurance programs and Medicaid may also provide coverage for transportation costs to and from dialysis appointments.

Free-standing and many hospital-based dialysis clinics in Ohio are members of the Ohio Renal Association (ORA), which seeks to enhance the delivery of quality care for Ohio dialysis patients and to educate the public, third party payers, and local, state, and federal policymakers as to the particular problems and needs of ESRD patients and the providers of their care.  The ORA is led by longtime President Diane Wish. Wish, herself a registered nurse, runs Centers for Dialysis Care, an independent Northeast Ohio nonprofit provider of dialysis and related health services to individuals with kidney failure.