Until a few years ago, I believed that dialysis was a fairly straightforward process. If your kidneys failed, you went on dialysis until you received a transplant. In my mind dialysis was basically the same as having a kidney. As it turns out, this is a commonly held belief and has people questioning whether dialysis is even better than having kidneys. It wasn’t until I worked on a number of dialysis cases that I realized how wrong I had been. In all actuality, dialysis patients are at risk for a long list of complications, and even at its best, dialysis treatment is life-altering.

The reality is, dialysis only replaces about 10% of a healthy kidney’s function. On average, the life expectancy of a person who starts dialysis is about five years, versus 8 to 20 years with a transplant. Additionally, dialysis is an incredibly complex and lengthy process that removes waste from the patient’s blood and returns the patient’s blood chemistry to healthier levels. One treatment can last anywhere between three to eight hours a day, and is required three to seven days a week.

Hemodialysis is one of the most common, if not the most common forms of dialysis in the United States. The process starts with either a catheter, graft, or fistula. A catheter is basically a large needle that allows the dialysis machine to draw blood from a patient’s vein. A fistula is a surgical creation that combines a vein and artery to allow dialysis access in the same location, but needs time to develop. A graft is similar to a fistula, but created with an artificial implant. While any of these can be used, fistulas are preferred because they have a lower chance of infection and clotting. Regardless of which access is used, when the dialysis treatment is about to start, someone at the dialysis facility, usually a technician, attaches the patient to the dialysis machine through the access port with needles.

After being connected to the machine, the patient’s blood flows into a dialyzer, which is where the actual dialysis occurs. Within the dialyzer, the blood flows through miniscule tubes. On the other side of the tubes is a liquid called dialysate made up of water, sodium bicarbonate, and an acid solution containing electrolytes. The tubes have miniscule holes in them which are large enough to allow some substances to move through them, but not large enough that the blood and the dialysate are mixed together. Some substances, like potassium, calcium, and bicarbonate move from the dialysate into the blood through the wall of the tube.  Other substances, like urea (a waste product naturally removed by the kidneys) move from the blood into the dialysate. After the blood has passed through the dialyzer it is returned to the patient’s body.  During the time the patient is on the dialysis machine, the blood and fresh dialysate are constantly flowing through the dialyzer.

One important-but-overlooked substance removed in dialysis is excess water. Because the kidneys of dialysis patients don’t work, they cannot get rid of excess water like healthy people do through urine. In the time between dialysis sessions, the patient will retain any water consumed and gain weight. Dialysis patients are told they can only drink a certain amount of fluids, and have dietary limits placed on them to prevent water retention and help with their overall health. While everyone knows that not enough water is harmful, too much retained water, called fluid overload is also dangerous with many possible complications including death.

The doctor who oversees the dialysis treatment is the one who writes the prescription for the dialysis treatment. The prescription is complicated with many parts, and typically specifies the rate at which the blood and dialysate flow, the concentration of potassium, calcium, and sodium bicarbonate, the length of time the dialysis will run, the type of dialyzer, the additional medications needed to prevent clotting, how much water should be removed, and other details. I have seen dialysis prescriptions that are close to 10 pages long. Even though the prescription is complex with many details, and research indicates that more visits leads to fewer hospitalizations, patients should not expect to see their doctor at each dialysis treatment. Usually, the dialysis sessions will be overseen by a nurse and set up by a technician. While that may seem fine, becoming a dialysis technician requires very little formal education, only a high-school diploma and dialysis technician certificate. But the technician doesn’t have to be certified right away; they have up to 18 months to complete the certification after they have been hired by a dialysis clinic.

As you would imagine, with a process this complex being set up by well-meaning, but often undertrained, undereducated, and uncertified staff, mistakes can happen (and happen, and happen). Dialysis is scary enough even when everything goes right. If you or your loved-one had an issue at or after dialysis, don’t just trust the clinic to give you answers, make sure you contact an attorney who understands the complexities of dialysis and can help you get to the bottom of what happened, and help you get closure after a bad outcome.