Another form of hepatitis, serum hepatitis, or Hepatitis B, may also occur in people on dialysis. The most common way that serum hepatitis spreads is through contact with blood. People receiving dialysis treatment are at a higher risk of acquiring Hepatitis C and (serum) Hepatitis B than others because of the nature of the treatment, possible contact with an infected needle (which should not occur) and because of blood transfusions. A test, known as the Hepatitis B Antigen test, determines who is infected with serum hepatitis. The spread of Hepatitis C and serum hepatitis may be prevented when the dialysis staff members practice universal precautions, as recommended by the Centers for Disease Control and Prevention (CDC), and when they isolate patients known to have a positive Hepatitis B Antigen test or abnormal liver enzymes. In addition, a Hepatitis B vaccine is available that is very effective in preventing infection with serum hepatitis.

These Medicare benefits consist of two types of insurance: Part A, or hospital insurance, and Part B, or medical insurance. Almost everyone who is eligible for Medicare is covered by hospital insurance without paying any monthly premium. Hospital insurance covers medically necessary inpatient hospital care and, under certain conditions, medically necessary post-hospital inpatient care in a skilled nursing facility, and home health care provided by a home health agency. The hospital insurance part of Medicare, for example, helps pay for an inpatient stay in an approved surgery. Hospital insurance has an annual deductible, and Medicare payments for services are made directly to the participating facility providing services.

When a person becomes entitled to Medicare hospital insurance because of chronic kidney failure, they are also enrolled for medical insurance or Part B of Medicare. Although they do not have to take this part of Medicare, most of the services and supplies required by chronic kidney failure are covered only by the medical insurance and not by the hospital insurance. The monthly premium for medical insurance protection covers physicians’ services; outpatient hospital services; outpatient maintenance dialysis treatments in an approved dialysis facility; durable medical equipment for use in the home, such as dialysis machine; and almost all items necessary for home dialysis, as well as many other health services and supplies. In addition to monthly premium payments, medical insurance also carries a small annual deductible payment and a 20 percent co-insurance liability.

Note: There is no minimum age required to receive Medicare benefits under the kidney disease provisions, as long as all other eligibility requirements are met.

How to Find Out if You’re Eligible for Medicare Benefits

The law states that you must be a Social Security or Railroad Retirement beneficiary or be “fully or currently” insured in order to be eligible for the kidney disease provisions of Medicare. You are currently insured it you have at least six quarters of coverage during the full 13-quarter period ending with the calendar quarter in which dialysis or a transplant occurs. A patient is fully insured when they have one quarter of coverage under the Social Security program for each year elapsing after 1950 (or after the year the patient attains age 21, if later) to the year in which dialysis or transplant occurs. In no case is more than 40 quarters of coverage required. The spouse or dependent child of an insured individual is also eligible. For more information on eligibility, contact your local Social Security office. A social worker is best suited to assist you in determining whether or not you are eligible for Medicare benefits.

• better understand the causes of kidney diseases and kidney failure
• develop new strategies for the treatment and prevention of kidney diseases and kidney failure
• improve dialysis therapies
• increase success rates for kidney transplantation
• find alternative treatment methods for kidney failure

Important Research Accomplishments

As a direct result of intensive research and technological advances, the treatment of kidney failure has changed and expanded. Many advances have made it possible for people with kidney failure to live longer and with fewer complications. Some of these research developments include:

• the use of recombinant erythropoietin to treat the anemia of chronic kidney failure. Erythropoietin has reduced the need for transfusions and has improved the exercise endurance and feeling of well-being of many people who suffer from kidney failure
• a better understanding of the immunology of transplantation that has led to the ongoing development of new medications and tissue typing techniques to prevent the rejection of transplanted kidneys
• the effective use of calitriol, the active form of Vitamin D, for the treatment of a common form of bone disease that occurs with kidney failure
  the identification of another form of bone disease in hemodialysis patients called amyloid bone disease and the development of methods to detect and diminish the accumulation of amyloid in bones and joints
• a major reduction in the occurrence of aluminum bone disease through the use of preventive interventions
  the continued improvement of continuous ambulatory peritoneal dialysis (CAPD) so that the risk of infection has been significantly mitigated

Recent Research Developments

There have been several recent research developments that have led to new ways of preventing kidney failure and treating people with kidney failure.

Recent research has demonstrated that the progression of diabetic kidney disease, a major cause of kidney failure, may be slowed by the use of blood pressure lowering medications called angiotensin-converting enzyme (ACE) inhibitors and by very good control of the blood sugar. In addition, the use of new tests for the early detection of kidney disease in diabetic patients permits earlier intervention with prevenentive measures.

The development of new and more effective antihypertensive medications now offers more treatment options for people with hypertension, which remains a major cause of kidney failure.

The continued development of high-flux dialysis membranes and new biocompatible membranes has improved the efficiency and safety of hemodialysis. The development of new CAPD systems has dramatically reduced the incidence of peritonitis the most common complication of CAPD.

Improvements in the use of immunosuppresive medications in preventing the rejection of transplantations and in tissue-type matching have increased the success rate of kidney transplantation.

Blood is made up of fluid (plasma or serum) and contains many different kinds of cells. Red cells, which are called erythrocytes, are the most common type. The average person has over thirty-five trillion erythrocytes. If a person has anemia, they have a reduced number of red blood cells. A doctor can tell how many red blood cells a person has by doing a blood test of the hematocrit or a red blood cell count. The hematocrit tells what percent of the blood is red cells. A normal hematocrit level is between 38% and 48%, but a level of 24 to 30 is still satisfactory for a dialysis patient. The doctor may also measure the hemoglobin level. Hemoglobin is the molecule that carries oxygen in red blood cells. A normal hemoglobin level is between 12 grams and 16 grams per deciliter. A normal red blood cell count is between 4.4-5.8 million per microliter.

Purpose of Red Blood Cells
Hemoglobin in the red blood cells carries oxygern to all parts of the body. The red cells are the oxygen transport system. The body uses oxygen as a fuel or source of energy. When a person is anemic, and does not ahve enough red blood cells, parts of the body do not get enough oxygen to work properly and the person may feel exhausted and out of breath. People with anemia may feel like they have no energy. The hemoglobin in red blood cells also serves to transport carbon dioxide, a waste product from the cells or tissues throughout the body to the lungs where carbon dioxide is excreted.

Symptoms of Anemia
Along with lack of energy, other symptoms of anemia include fatigue, depression, and inability to concentrate or exercise normally. Shortness of breath, palpitations (rapid or irregular heart beat), impotence (failure to achieve adequate penile erection), dizziness, light-headedness and constantly feeling cold are also symptoms of anemia.

Can Dialysis Help with Anemia?
Normally, the kidneys remove fluids and toxins from the blood stream. For people with kidney disease, dialysis does much of this work for the kidneys. However, dialysis cannot replace erythropoietin. Nevertheless, some dialysis patients are not anemic, even without being given erythropoietin.

How can Anemia be Treated?
Dialysis patients may receive blood transfusions if they are anemic. When patients are transfused, they receive red blood cells from a blood donor. They might also receive anabolic male-type (androgenic) hormones, such as decadurabolin. These substances may help raise the hematocrit to some degree.

Now there is an effective way to treat anemia in people with kidney failure. Scientists have found a way to produce erythropoietin in a laboratory using recombinant DNA technology. This erythropoietin is called recombinant human erythropoetin, or simply “EPO”.

Why is Fluid a Problem?

Properly functioning kidneys prevent the fluid in the body from building up by removing the excess body fluid as urine. When your kidneys are not functioning, fluid may accumulate in your bloodstream. A large amount of fluid in your blood can cause high blood pressure and it also places a strain on your heart. Although fluid can also collect in your lungs, making it difficult to breathe properly, this can be controlled by bringing the body to a dry weight or a weight at which the blood pressure is normal and no swelling is present. You should achieve proper fluid balance by watching your diet and fluid intake between dialysis treatments.

Will I Experience Muscle Cramps?

Muscle cramps are most likely to occur if you are overweight due to the excess fluid in your body. A major cause of muscle cramps is the removal of a large amount of fluid during treatment. The best way to avoid muscle cramps is to limit salt and fluid intake.

Will Itching be a Problem?

You may experience some itching as a result of kidney failure (uremia), the level of phosphorus in the body or allergies to medications you may be taking. If the itching symptoms are related to uremia, your doctor may increase dialysis or prescribe medications, and, in some cases, recommend ultraviolet light treatments. Your physician adjusts the intake of phosphorus through diet and medication if the itching is related to phosphorus. Your medications may be adjusted if the itching is a result of an allergic reaction to medications.

Prior to the advent of human recombinant erythropoietin, anemia in these dialysis patients was treated with androgenic steroid hormones and, if necessary, transfusions of red blood cells.

Both of these treatments had important drawbacks. Androgen (male) steroids were administered by weekly injection into the muscle. Their mode of action was to stimulate cells in the bone marrow to produce more red blood cells. Unfortunately, androgens had limited effectiveness and, as a side effect, promoted the development of masculine sexual characteristics such as facial and body hair and even deepening of the voice. Blood transfusions are a more effective way of treating anemia. Their usefulness is limited by the danger of transmitting certain viral diseases, such as hepatitis. Furthermore, blood transfusions contain a large amount of iron. Some of the iron is deposited in the liver and other organs. After many units have been given, the iron may potentially cause disease of these organs.

Benefits of Treatment with Recombinant Human Erythropoietin
The most important benefit of treatment with recombinant human erythropoietin is an increase in the number of red cells in the blood. Once the number of red blood cells available to carry oxygen to all parts of the body increases, you may not require transfusions, unless you have sudden or substantial bleeding, such as from an ulcer of the stomach or intestine.

Dialysis patients with anemia who have received EPO also commonly experience improved quality of life and sense of well-being. After treatment with EPO, many patients notice an improvement in their ability to work, and their sexual performance, appetite, ability to exercise, social activity, sleep, ahir texture and skin color.

Questions in the values history ask about your living environment; your family and friends; your religious background and beliefs; your attitudes toward life in general and toward independence and control, health, doctors, illness, death and dying, and finances. They ask whether you have wishes regarding specific medical procedures, such as dialysis, artificial ventilation, artificial nutrition and hydration and organ donation, and regarding a funeral, eulogy, and obituary. The questions also ask if you have any written documents, particularly advance directives.

Can I be required to have an advance directive?
According to the Patient Self-Determination Act, a federal law, you cannot be required to have an advance directive. This law specifically prohibits health care facilities or providers from conditioning admission or provision of insurance or services upon whether or not you have executed an advance directive.

Why do so few people elect to have advance directives?
Many individuals do not know what an advance directive is, or if they know, do not realize it would be appropriate for them to have. Many others do not have an advance directive because the subject raises unpleasant or frightening issues.

Why should a dialysis patient have an advance directive?
For the same reasons that everyone should have one-and for additional reasons. Dialysis is very effective in prolonging lives of those who would otherwise die of kidney failure. Fortunately, the quality of health and life for the great majority of people on dialysis acceptable and for many substantially better than that. Most people are able to work and can do most of the activities that they wish to do, but as many as 10% of chronic dialysis patients discontinue dialysis because the burdens of illness and treatment outweigh the benefits of continuing to live. Perhaps half of those who discontinue dialysis are no longer able to make decisions for themselves and the time dialysis is discontinued because of inter-current illness with altered consciousness or because of dementia.

By having an advance directive, they are assured of having their own preferences for health care respected, including the continuation of dialysis or of other life-sustaining treatment if that is their preference (or discontinuation, if that is their preference). Furthermore, it is a great relief to family members and to physicians to know a patient’s preferences and to feel secure that they are doing what this person would have wanted them to do.

The venous pressure monitor and the arterial pressure monitor measure the pressure of the blood as it flows through the dialyzer. If there is a break, kink, or any type of obstruction in the blood lines or in the dialyzer, the pressure changes and the monitors send out an alarm to alert you and the staff.

The temperature monitor indicates an alarm if the dialysate solution becomes too hot or too cold. Because the blood normally cools when it leaves the body through the blood lines, it must be rewarmed to the normal body temperature before it is returned to the body. This is accomplished by heating the dialysate solution, which, in turn, rewarms the blood.

The negative pressure monitor shows the amount of suction or negative pressure used to remove the excess fluid from the body. An alarm sounds if this pressure changes.

Another very important device on the artificial kidney machine is the blood leak monitor, which sets off an alarm if any blood leaks in the dialysate solution through a tear in the dialyzer membrane.

The conductivity monitor indicates the concentration of substances in the dialysate solution.

The air detector detects any air or foam that might pass through the system. This detector not only indicates an alarm, but also features an automatic device that clamps the blood line returning to the body to prevent air from being pushed into the vein. It may be frightening when an alarm sounds, but the monitors are designed to protect you and to make your treatment as safe and as comfortable as possible.

• Wear protective gear such as gloves, scrub suits, lab coats or aprons
• Wear gowns and protective eyewear and masks when blood splashes are likely
• Put on a fresh pair of gloves for each direct patient encounter
• Wash hands when entering the patient area, when starting or completing patient care, before leaving the work area and between patients
• Dispose of needles or other sharp instruments in purchase-resistant containers located close to dialysis area
• Never recap needles

Similar safety procedures are currently in use to control the spread of infection of Hepatitis B in dialysis units. The HIV/AIDS virus is spread much less readily than Hepatitis B in dialysis unites because the blood of a person infected with HIV/AIDS has fewer infectious viral particles than does the blood of someone with Hepatitis B. In addition, all blood donations are being screened for the HIV/AIDS antibody making any blood transfusion as safe as possible.