What to Expect in Your First Month on Dialysis

Nobody arrives at their first dialysis session feeling ready. Most people arrive frightened, and a lot of that fear is simply not knowing what is about to happen to them. This is what the first month usually looks like, so that fewer things come as a surprise.

We cannot tell you how your month will go. We can tell you what is normal, what is not, and what is worth ringing the unit about.

Your first session is deliberately short and gentle

The first treatment is slower and shorter than the ones that follow. This is on purpose, and it is not a sign that anything has gone wrong.

Removing waste too quickly at the very start can cause a condition called dialysis disequilibrium syndrome, where fluid shifts into the brain and causes headache, nausea, restlessness and confusion. The people most at risk are people having their very first treatment with a high level of waste in the blood. So units go slowly: a short session, a slow blood pump, a smaller filter, and a deliberately modest reduction in the waste level on day one (International Journal of Nephrology and Renovascular Disease, 2019).

If someone tells you your first session is only about two hours, that is the protection working, not a shortcut.

What actually happens in the chair

For in-centre haemodialysis, the pattern is the same every time, and it becomes routine faster than you expect.

You are weighed first, in similar clothes each time. The difference between today's weight and your dry weight, which is your weight with no extra fluid on board, is how much fluid the machine will take off. Being weighed is not a judgement. It is the prescription.

Then observations: blood pressure, pulse, temperature, and a look at your access. Then the chair, which reclines, and which you will be in for the whole session.

If you have a fistula or a graft, two needles go in. They are bigger than blood-test needles. Most units offer numbing cream or a local anaesthetic, and it is worth asking. We are not going to pretend this part is nothing: the first few needlings can hurt, and almost everyone says it gets easier as the skin toughens and as the staff learn your access. If you have a catheter, there are no needles at all; the lines are connected directly under sterile conditions.

Once you are connected, blood is pumped out through the filter and back. Only about a cupful is outside your body at any moment. You are usually given a blood thinner so the circuit does not clot. Your blood pressure is checked regularly through the session. You can read, sleep, work, talk, or watch something.

The machine will beep. It beeps at everyone. It is usually a kinked line or a change of position, not a crisis.

At the end, the blood in the circuit is returned to you, the needles come out, and pressure is held on the sites for ten minutes or more until the bleeding stops. You are weighed again.

How you may feel afterwards

Some people feel fine. Many feel wiped out. That washed-out feeling can last a few hours or the rest of the day, and it tends to be worse when a lot of fluid has been taken off quickly. It usually improves over the first weeks.

Two other things are common. Your blood pressure can drop during the session, which feels like light-headedness, nausea, yawning, sweating, or simply going flat. And you can get cramps, usually in the legs, usually late in the session. Both are managed, and both are made less likely by turning up with less extra fluid on board, which is mostly a matter of salt rather than willpower.

Here is the part that matters: feeling terrible after dialysis is common, but it is not something to accept in silence. It is usually a signal that something in the prescription, such as the dry weight, the speed of fluid removal, or the length of the session, needs adjusting. Tell your team. That is what the conversation is for.

Your access becomes part of your daily routine

If you have a fistula or graft, you will learn to feel for the thrill, the buzz or vibration over it, several times a day. If it stops, that is an emergency and it is time-critical.

The other rules, from the National Kidney Foundation, are short and worth learning by heart. Wash the access with antibacterial soap every day and always before dialysis. No blood pressure cuff on that arm. No blood tests from that arm. No tight clothing or jewellery over it. Do not carry anything heavy with it, and do not sleep with your head on it.

Two things about food that surprise people

First, protein goes up, not down. Before dialysis, many people are told to limit protein. Once dialysis starts, the recommended intake roughly doubles, to around 1.0 to 1.2 g per kg of ideal body weight per day (KDOQI Nutrition, 2020), because dialysis itself removes protein and amino acids. People who carry the old rules into dialysis become malnourished, and malnutrition is more dangerous than most people realise.

Second, the lever for fluid is salt, not willpower. Salt makes you thirsty, thirst makes you drink, and what you drink has to come off in the next session. Eat less salt and you will want to drink less. Ask to see a renal dietitian, not a leaflet.

The long gap

Most people dialyse three times a week, which leaves one two-day gap. That gap is when fluid and potassium build up the most, and it is measurably the riskiest interval of the week.

Which leads to the single most important sentence in this article: never just skip a session. In a European study, in the 48 to 72 hours after a missed session, the death rate rose from 4.86 to 51.9 per 100 patient-years compared with normal attendance, and missing the session after the long gap was roughly twice as dangerous as missing a mid-week one (BMC Nephrology, 2020). If you cannot make a session, ring the unit. They will work something out.

What you feel is not weakness

Grief, anger, exhaustion and a sense of having lost the life you had are ordinary reactions, not character failures. Depression is common in dialysis, affecting roughly 23% of people when properly assessed by interview (Palmer et al., Kidney International, 2013), and it is treatable. It is also linked to missed treatments, which is why it is a medical problem and not just a mood.

Tell someone. Renal units have counsellors and social workers for exactly this.

Get urgent help if

Call your local emergency number for bleeding from the access that will not stop with firm pressure, chest pain, severe breathlessness or waking up gasping, collapse or new confusion, or sudden weakness or numbness down one side.

Contact your unit the same day if the thrill over your access is weak or gone, if you have fever or shaking chills, if there is redness, heat, swelling, pus or discharge at any access site, if bleeding from a needle site takes more than 30 minutes to stop, or if you have missed a session or are about to.

Sources

• KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020 Update, American Journal of Kidney Diseases. kidney.org
• National Institute of Diabetes and Digestive and Kidney Diseases, Hemodialysis. niddk.nih.gov
• National Kidney Foundation, Hemodialysis Access. kidney.org
• Dialysis disequilibrium syndrome: prevention and management. International Journal of Nephrology and Renovascular Disease, 2019.
• Hospitalization and mortality following non-attendance for haemodialysis. BMC Nephrology, 2020.
• Palmer S et al. Prevalence of depression in chronic kidney disease. Kidney International, 2013.

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This article is general information, not medical advice. It does not diagnose, it gives no doses, and it must never be used to start, stop or change a treatment. Your dialysis prescription, your fluid allowance, your diet and your medicines depend on your own blood results, your own remaining kidney function and your own other conditions, and those decisions belong with you and your kidney care team. If you are unwell, contact your dialysis unit. In an emergency, call your local emergency number.