The kidneys are bean-shaped organs found in the abdomen, that are responsible for clearing out bodily waste, maintaining the balance of chemicals in the body, and keeping blood pressure steady. Unfortunately, various diseases such as hypertension or diabetes can lead to irreversible damage to the kidneys resulting in kidney failure. Once the kidneys have failed, a person will need to rely on the process of dialysis to replace the function of the kidneys. Dialysis is a process whereby toxins are removed from the blood, and nutrient-rich blood is put back into your bloodstream. This guide will provide you with comprehensive information on the types of dialysis access in Singapore and dialysis procedure in Singapore.

(https://www.nst.com.my/news/nation/2022/03/778652/only-5-cent-chronic-kidney-disease-patients-are-aware-it)

Overview of Dialysis Treatment

Kidney failure is also called end-stage renal disease (ESRD). It can be caused by high blood pressure, diabetes, lupus, injuries, and other diseases. Kidney failure can be temporary after a severe illness or injury with full recovery of function once the disease has been cured, but it can also be a long-term condition due to irreversible damage from long-standing high blood pressure or diabetes. When you have kidney failure, waste and toxins produced as a byproduct of cellular metabolism builds up in your blood and cannot be cleared. A person is considered to be in the fifth stage of kidney disease when the kidneys function at only 10% to 15% of their normal capacity, and at this stage, dialysis or a kidney transplant becomes essential for survival. Dialysis may be temporary if the kidney failure is due to an acute curable illness or may be life-long if the kidney damage is irreversible. Patients who are relatively fit, with irreversible kidney injury may consider a transplant as an alternative to life-long dialysis.

Dialysis is a treatment that purifies blood using a machine, thus replacing the function of the kidneys. Dialysis requires a conduit via which blood can be easily withdrawn from the body, cleansed, and returned to the body in an efficient way. This conduit is called a dialysis access or vascular access. To avoid significant disruption to a patient’s lifestyle, it is recommended to choose an appropriate healthy vessel to create a suitable dialysis access and regularly monitor it throughout the patient’s dialysis journey to prevent frequent failures and the need for repeated procedures. Engaging an experienced vascular surgeon for the initial creation of an appropriate dialysis access and conducting regular surveillance can significantly reduce the inconvenience and discomfort associated with haemodialysis, ensuring efficient treatment.

Types of Dialysis

There are 2 methods of dialysis, namely haemodialysis and peritoneal dialysis. These can be done either in hospitals or dialysis centres or at home. It is best to discuss your options with your doctor before deciding which option is most suitable to your lifestyle.

(https://www.osmosis.org/learn/Dialysis_care:_Nursing)

Haemodialysis is more efficient at removing toxins and rebalancing the body’s salt content and is performed 2-3 times a week. With haemodialysis, a machine takes blood out of your body, runs it through a dialyzer, and then puts the clean blood back into your body. A dialyzer is a device that acts as an artificial kidney. It contains a filter that separates waste from blood. The haemodialysis process takes around 3 to 5 hours each time. Dialysis access is the entry point into the bloodstream via which haemodialysis can be performed. Examples of dialysis accesses include an arteriovenous fistula, graft, or central venous catheter.

Peritoneal dialysis uses a catheter to infuse a special fluid in your abdomen (more accurately, the peritoneal cavity thus the name). This fluid absorbs waste and extra fluid from your blood, and after a few hours, the toxin comes out with the fluid when it is drained. This method can be done at home but is less efficient and thus must be performed on a daily basis. Prior to starting peritoneal dialysis, patients must have a minor surgical procedure to insert a catheter into the abdomen (peritoneal cavity).

Types of Dialysis Access Singapore & Dialysis Access Surgery in Singapore

Dialysis access is the access point that is used to access the blood stream and effectively remove and return the body’s blood during dialysis. Examples of a dialysis access include an arteriovenous fistula, graft, or catheter.

To achieve efficient haemodialysis, a patient requires a well-functioning arteriovenous fistula, graft or catheter. An arteriovenous fistula (AV fistula) is a surgical connection performed by a vascular surgeon. The surgeon will utilize microsurgical techniques to connect the patient’s own vein to their own artery, and this can be performed either in the arm or occasionally in the leg. Blood then flows from the artery directly into the vein, causing it to increase in size. After 6-8 weeks, once the vein has enlarged to a certain size and the vessel wall has thickened, it can be utilized to perform haemodialysis. On the other hand, an arteriovenous graft (AV graft) is a connection between a vein and artery using an artificial conduit (graft). The graft is a hollow synthetic tube placed just under the skin surface and can be utilized within a couple of weeks of the surgery once the surgical wounds have healed. Another type of vascular access is a central venous catheter (also known as a permanent catheter), which is a method of obtaining blood for dialysis by inserting a Y-shaped catheter into a large vein (typically the jugular or femoral vein). These catheters are at risk of recurrent infection and can cause scarring of the blood vessel if left in-situ for too long. A central venous catheter is typically utilized as a temporary dialysis access while waiting for either and AV fistula or graft to be created and ready for use.

(https://twitter.com/edgarvlermamd/status/1158947453028196355)

An experienced vascular surgeon will be able to advise on the best position to create a fistula, graft, or place a catheter. They will also be able to provide surveillance to ensure that it functions well and doesn’t fail prematurely. If your access is a fistula or graft, during haemodialysis, two needles will be inserted into the access at the start of each dialysis session. The soft tubes that are linked to the dialysis machine are hooked onto these needles. One of the tubes takes your blood to the machine, where it is cleaned by the dialyzer. The other tube brings your blood back to you. If your access is a catheter, you do not need needles to connect it to the dialysis tubes.

Types of Dialysis Machines Used in Singapore

Feature	Haemodialysis Machines	Peritoneal Dialysis Machines
Location	Commonly used in a dialysis centre	Commonly used at home
Duration of Treatment	3 to 5 hours, 2 to 3 times a week	Daily basis, can be done while you work or sleep
Type of filter	Dialyzer (artificial kidney)	Dialysate (cleansing fluid)
Access	Arteriovenous fistula or graft or central venous catheter	Placement of a catheter into the peritoneal cavity
Benefits	More efficient at removing waste products and excess fluid	More convenient, can be done at home

Haemodialysis Machine is used for haemodialysis, a process in which blood is taken out of the body, cleaned through a dialyzer, and transferred back into the body. It handles the flow of blood, checks the pressure, and regulates the dialysis solution. A Peritoneal Dialysis Machine is used to automate and ease the transfer of fluids over the peritoneal cavity, which lines the abdominal area.

Risks and Complications of Dialysis Treatment

Low blood pressure can occur during haemodialysis or soon afterward in some patients. You might feel queasy, lightheaded, or faint. Some may also experience chest pain or back pain, headaches, itchy skin, muscle cramps, and restless legs syndrome. Proper monitoring and adjustments to the dialysis treatment can help minimize these risks. Other risks associated with haemodialysis, include the risk of blockage or infection of the dialysis access. The danger of infection can be minimised through regular cleaning and monitoring of the AV fistula/graft or central venous catheter.

Patients who undergo peritoneal dialysis may experience a feeling of fullness in their stomach. This may lead to an uncomfortable feeling, but it is not generally painful. Another side effect of peritoneal dialysis treatment is peritonitis or the inflammation/infection of the peritoneal membrane that lines the abdominal cavity. The catheter, used to transport the cleansing fluid into and out of the abdomen, is a potential source of infection. Additionally, sugar (dextrose) is present in dialysis solution which may lead to weight gain. Pumping fluid into the abdomen via an abdominal catheter might cause abdominal muscular atrophy over time, and patients may develop a hernia, which is the protrusion of abdominal organs (typically the intestines) through an opening in the muscle or tissue.

(https://www.mncpd.com.au/modules/peritonitis-a-complication-of-peritoneal-dialysis)

Pre-procedure Care for Dialysis access

1. Site Preparation: The access site must be cleaned with an antiseptic solution in accordance with established guidelines. Infection risk is lowered as a result.
2. Hygiene: Dialysis access-related procedures should always begin with a complete handwashing or the use of an alcohol-based hand sanitizer to prevent the spread of infection.
3. Medications: Medications, such as anticoagulants and antiplatelet drugs, should be reviewed with the patient before the surgery to determine if any changes are required. This is done so that uncontrolled bleeding can be prevented.
4. Vital Signs: Blood pressure, heart rate, and oxygen levels should all be measured and recorded before the process begins so that changes may be noted and documented during and after the treatment.
5. Communication: It is crucial for the patient and the healthcare staff to have open lines of communication. The best outcomes can be achieved if the patient is given ample time to ask questions, voice concerns, and get an understanding of the significance of post-procedure care.

Post-procedure Care for Dialysis access

1. Fistula/Graft Care: It is crucial to take good care of the access site to avoid infection and speed recovery. Depending on the instructions given, this may involve keeping the area clean and dry, applying a dressing as directed, and checking for symptoms of infection including redness, swelling, and discharge on a frequent basis.
2. Catheter Care: Keep the catheter dressing dry and clean and have the dressing changed frequently during each dialysis session to prevent infection. Always remember to keep the catheter covered and out of the air and keep an emergency dressing kit on hand in case you need to change the dressing in between sessions.
3. Regular Checks: Looking for a vibration or pulse after your dialysis access procedure is recommended. If you experience any changes, it is important to contact your vascular surgeon. Do not wear tight clothing or jewellery on the access arm, do not put pressure on the access arm, and do not sleep on the access arm.
4. Activity Restrictions: Patients undergoing dialysis may need to limit their activity to prevent strain on or injury to their access site. Tight arm straps, putting too much pressure on the access site, or engaging in other physical activities which can compress the arm may be prohibited unless otherwise permitted by your doctor.
5. Regular Check-ups: By monitoring the patient’s blood pressure and electrolyte levels at regular checkups, doctors can make sure the dialysis treatment plan is working properly. Moreover, regular checkups of the dialysis access allow for the early detection of complications like infections or narrowing of the conduit, and early initiation of preventive treatment to avoid complete blockage of the dialysis access.

Quality of Life After Dialysis

Dialysis patients can lead productive lives. They can continue working, raising families, and exploring the world. If you need dialysis treatment while away from home, your vascular surgeon may be able to make the necessary arrangements for you. Dialysis solution and, if necessary, a portable home dialysis machine can be taken with you while you do either type of self-dialysis.

Those who undergo peritoneal dialysis may need to limit exercise or other physical activities. If the abdomen area becomes too bloated due to the dialysis solution, the patient may need to avoid strenuous activities. Other than this, dialysis patients can usually exercise with no negative repercussions. Your doctor will give you specific instructions for your specific lifestyle and daily activities.

Dialysis is a treatment for renal failure that can improve quality of life, but as with any medical condition, it comes with several challenges to one’s physical and emotional health. A number of patients can experience reduced pain and symptoms, enabling them to live their lives fully. On the other hand, some patients may have difficulties keeping up with their new lifestyle, dietary restrictions, and activity restrictions. There are pros and cons with each mode of dialysis so do discuss your dialysis options with your doctor to see which one is best for you.

(https://www.freepik.com/free-photo/asian-senior-couple-relax-home-asian-senior-chinese-grandparents-husband-wife-happy-smile-hug-talking-together-while-lying-sofa-living-room-home-concept_5820756.htm)

Diet and Nutrition for Dialysis Patients

Dieticians can provide dialysis patients with personalised advice for their diet and meal plan which will be tailored to the patient’s individual needs. Key recommendations include controlling fluid intake, limiting sodium, potassium, and phosphorus consumption, ensuring adequate protein intake, and managing calorie intake to maintain a healthy weight. High-quality protein comes from meat, poultry, fish and eggs. It is also best to avoid processed food which have high amounts of salt. An excess intake of salt causes thirst, leading to increased fluid intake. This aims to regulate the body’s fluid balance and avoid the accumulation of waste.

An increase in potassium intake between treatments have been linked to irregular heartbeats. Meanwhile, too much potassium in the diet is potentially fatal because of its effects on the heart. When blood phosphorus levels increase, the body steals calcium from the bones. Bone fragility and weakness may result from this calcium loss. Maintaining a healthy weight also necessitates paying close attention to both fluid consumption and portion size. The patient’s health and well-being depend on the diet being monitored and adjusted on a regular basis. Due to dietary restrictions, you may not be getting enough essential nutrients. Some vitamins are also lost during dialysis treatment. A vitamin and mineral supplement formulated for those with renal failure may be recommended by your doctor.

Complications of Dialysis Access

Signs of possible complications include:

1. Bleeding from your vascular access site
2. Signs of infection (redness, swelling, soreness, pain, warmth, or pus), a fever of 100.3°F (38.0°C) or higher
3. A decrease or absence of flow (thrill) in your graft or fistula
4. Swelling in the arm
5.  Coldness, numbness, or weakness in your hand

These symptoms could indicate complications with your vascular access, and prompt medical attention is necessary to assess and address the situation appropriately. Possible complications which can occur include:

1. Thrombosis – Blood clots in the dialysis access are called thrombosis. The clot prevents blood from flowing through the access, therefore it must be removed before dialysis can resume. Treatments like thrombectomy or angioplasty may be necessary to restore blood flow and normalise dialysis in the event of thrombosis.
2. Stenosis – Your graft’s or fistula’s blood channels can narrow over time, reducing blood flow through the access. Stenosis is a frequent issue with prolonged catheter usage. Being a foreign object, the catheter might cause inflammation in the vein wall. The vein becomes damaged, preventing blood from flowing freely. Facial, neck, chest, and/or upper limb swelling are reported symptoms of stenosis. It is preferable to treat stenoses early before they lead to thrombosis.
3. Infection – Infection at the access site for dialysis can happen. It is characterised by symptoms such as swelling or redness of the access arm. Antibiotics and, in severe cases, surgery are often necessary to treat infections quickly.

These complications may be treated with the following methods:

1.Venoplasty – This is a procedure to treat narrowed or clogged veins. A balloon is threaded into the vein over a thin wire, where it is inflated to widen the vein. To keep the vein open after balloon dilatation, a stent (a metal supporting strut) may sometimes be inserted. Day surgery is possible with minimal sedation or local anaesthesia for the venoplasty and stent placement.

(https://www.researchgate.net/figure/Balloon-fistuloplasty-on-stenotic-sites_fig4_357382457)

2.Thrombolysis – For completely occluded AV fistulas/grafts, a procedure known as thrombolysis will be necessary. It is also a minimally invasive procedure whereby a microcatheter is introduced via a small puncture in the vessel and special medication is infused into the clot to dissolve it.

(https://www.bostonscientific.com/en-US/products/thrombectomy-systems/angiojet-thrombectomy-system.html)

Latest guidelines recommend creating a dialysis access using the most appropriate vessel followed by regular surveillance to maintain the dialysis access for the patient’s entire dialysis journey. Patients should no longer accept poorly created and poorly maintained dialysis accesses with frequent failure resulting in the need to create new fistulas or insert new grafts every few years. Engaging an experienced vascular surgeon to create the most appropriate dialysis access at the first instance and conducting regular surveillance to prevent premature failure, can significantly reduce the inconvenience and discomfort from haemodialysis.

Patient Support Groups in Singapore

Dialysis patients in Singapore can benefit greatly from the opportunities presented by patient support groups, where they can meet others going through a similar experience and exchange stories and advice. These groups provide patients on dialysis with a sense of community and agency through regular meetings and activities, giving them the courage and fortitude to face the challenges of their treatment. In Singapore, you can join support groups established by The National Kidney Foundation (NKF) and KidneySG Dialysis Foundation. These groups aim to improve the emotional and psychological needs of dialysis patients and their loved ones through social activities and educational talks and seminars. Additionally, you can also find online support groups on social media platforms like Facebook and Instagram. 

Frequently Asked Questions

References

[1] https://my.clevelandclinic.org/health/treatments/14618-dialysis

[2] https://medlineplus.gov/ency/patientinstructions/000591.htm

[3] https://www.kidney.org/atoz/content/hemoaccess

[4] https://www.nephrocare.com/patients-home/living-with-dialysis/access-care

[5] https://www.niddk.nih.gov/health-information/kidney-disease/kidney-failure/hemodialysis/eating-nutrition

[6] https://siouxlandvascular.com/dialysis-access-patients-10-common-terms-you-should-know/

Dr Chen Min Qi profile

Dr. Chen Min Qi is a fellowship-trained Vascular and Endovascular Surgeon who graduated from the National University of Singapore in 2005. He subsequently completed his basic and advanced training in General and Vascular Surgery while obtaining the Member of Royal College of Surgeons of Edinburgh (MRCSed) qualification in 2010, and the Master of Medicine (General Surgery) qualification in 2015. Dr Chen was subsequently successful at the fellowship exams obtaining the Fellow of Royal College of Surgeons of Edinburgh (FRCSed) qualification in 2016.

Upon completion of his advanced surgical training, Dr Chen Min Qi joined the newly opened Ng Teng Fong General Hospital (NTFGH) as a specialist in the Vascular Surgery division. In 2018, Dr Chen was awarded the Health Manpower Development Plan (HMDP) grant from MOH to undergo further subspeciality Vascular training at the internationally renowned St Mary’s Hospital in London, United Kingdom. There Dr Chen gained further experience in surgeries on complex abdominal and thoracoabdominal aortic aneurysms, redo open repair of abdominal aortic aneurysms following failed EVAR surgeries as well as carotid endarterectomy surgery and lower limb revascularization surgeries.

Upon his return in 2020, Dr Chen Min Qi joined the newly formed Woodlands Health as head of their Vascular service, before joining his current practice at the Vascular and Interventional Centre in January 2023.