DIALYSIS

Hemodialysis (HD)
Peritoneal dialysis (PD)
 Absolute Indications for
Dialysis
 Presence of uremic syndrome
 (intractable fatigue, anorexia,
nausea, vomiting, pruritus).

 Presence of hyperkalemia
unresponsive to conservative
measures
Extracellular volume expansion
refractory to diuretic agents.

 Acidosis refractory to medical

therapy.

 Bleeding diatheses.

 Creatinineclearance of 10
ml/minute per 1.73 m2.

 Encephalopathy
 Factors to be considered in
choosing HD or PD
 Patient’ age.
 Ability to perform the procedure.
 Patient’s own perception about
the therapy.

PD – is favored in younger patients

because of their better dexterity
and greater visual acuity.
HD – preferred in:

 Larger patients (>80kg).

 Patients with no residual renal
function.
 Patients who have truncal
obesity with or without prior
abdominal surgery.
 Presence of comorbid conditions.
Hemodialysis (HD)

Aprocess in which blood flows on

one side of a semipermeable
membrane with dialysate on the
other side.
Small molecules (electrolytes,
urea, creatinine but not proteins)
pass freely through this
membrane, diffuse down a
concentration gradient, and thus
are removed from the body.

Atthe same time, substances such

as HCO3 are added to the blood
from the dialysate.
Ultrafiltration

The process of removing volume

(as an ultrafiltrate of plasma) from
the patient by means of application
of negative pressure on the
dialysate side of the dialysis
membrane.
Typically, patients undergo both
dialysis and ultrafiltration
 Principle of Hemodialysis
(HD)

 Relies on the principle of solute

diffusion across a semipermeable
membrane.
 Movement of metabolic waste
products takes place down a
concentration gradient from the
circulation into the dialysate:
(artery  dialysis machine  vein)
 Consists of pumping
heparinized blood through the
dialyzer at a flow rate of 300 to
500 mL/min, while dialysate
flows in an opposite counter
current directions at 500 to 800
mL/min.
Components of a HD System

 Dialyzer
 Composition and delivery of
dialysate
 Blood delivery system
1. Dialyzer

consists of a plastic device with

the facility to perfuse blood and
dialysate compartments at a
very flow rates.
2. Dialysate

0 to 4 mmol/L - K+ concentration
of the dialysate (depending on the
predialysis plasma K+
concentration)

 1.25mmol/L (2.5 mEq/L) –

usual dialysate Ca++ concentration

 140mol/L – usual dialysate Na+

concentration
3. Blood Delivery System
is composed of:

 Extracorporealcircuit in the
dialysis machine.

 Dialysis access.
Components of the Dialysis
Machine
1. Blood pump

 moves blood from the access

site, through the dialyzer and
back to the patient.

 250 to 500 mL/min – blood flow

rate.
negative hydrostatic pressure on
the dialysate side can be
manipulated to achieve desirable
fluid removal: so called
ultrafiltration
2. Dialysis Soln. delivery
system
dilutes the dialysate concentrate
with water and monitors the:

temperature
conductivity
flow of dialysate

3. Safety monitors
Anticoagulation
1. Heparin

 Most widely used anticoagulant in

acute, as well as in chronic,
dialysis
 Inexpensive
 Its activity is predictable
Can be readily measured at the
bedside by means of the
activated clotting time.
2. Citrate

 Used for patients at highest risk

of bleeding
 Intolerant of the no-heparin
method.
 Binds calcium.
 Duration for Dialysis

CRF: 9 and 12 hrs/wk, usually

divided into three equal sessions

ARF: daily; dialysis may be better

control uremia, reduce
hypotensive episodes, more
rapidly resolved ARF and
significant lower mortality
Forms of HD Access
1. Dual-lumen catheter; placed in
a large central vein (such as the
internal jugular).

2. Arteriovenous fistula: a
surgically constructed connection
b/w an artery and a vein in the
arm.
3. Arteriovenous graft: a
surgically implanted Gore-Tex
tube that connects an artery and
a vein.
HD Angioaccess
Requires direct access to the
circulation, either via:

a. Native arteriovenous fistula

(preferred method of vascular
access), usually at the wrist
(Brescia-Cimino fistula)
b. Arteriovenous graft
(polytetrafluoroethylene.

c. Large-bore intravenous
catheter.
Other Dialysis Access
 Arm (brachial artery to basilia
vein)

 Leg (femoral artery to femoral

vein)

 Chest wall (axillary artery to

axillary vein)
 Subclavian vein- associated
with a higher rate of venous
stenosis

 Jugular vein - preferred to the

subclavian
FYI
2-3 weeks maximum usage of
temporary access

Thrombosis  most common

access-related complications due
to intimal hyperplasia, which
results in stenosis 2 to 3 cm
proximal to the venous stenosis.
 Complications of HD
 Hypotension.
 Muscle cramps.
 First use syndrome.
 Accelerated vascular disease.
 Rapid loss of residual renal
function.
 Access thrombosis.
 Access or catheter sepsis.
1. Hypotension (HPN)

 most common acute complication

(particularly among diabetics).

 leadsto decreased clearances as a

result of reduced blood flow.

 leadto renal hypoperfusion and to

recurrent episodes of ischemic
tubular necrosis.
Hypotension may result from:

 Overestimation of the patient’s

volume status.

 Overly
ambitious rate for fluid
removal.

 Impairment of the normal

homeostatic responses to
intravascular depletion.
 Infusionof dialysate at 37°C 
increase in body core temperature
 stimulation of thermoregulatory
reflexes, vasodilatation, and a
drop in blood pressure.

 Eatingor the administration of

enteric feeding during dialysis 
owing to vasodilatation of the
splanchnic circulation.
Mgt. of Hypotension
 Discontinuing ultrafiltration.

 Administration of 100 to 250 mL

of isotonic saline or 10 mL of 23%
saturated hypertonic saline.

 Administration of salt-poor
albumin.
Prevention of Hypotension
 Withholdingof antihypertensive
medications on the day prior to
and on the day of dialysis.

 Avoiding heavy meals during

dialysis.
Ultrafiltrationmodeling, such
that more fluid is ultrafiltered at
the beginning rather than the
end of the dialysis procedure.

 Hematocritmaintained at a
reasonable level.

 Useof inotropes (optimize

caqrdiac function).
 Decrease in the temperature of
the dialysate.

 Useof a high-dialysate calcium,

and low magnesium.

 Useof sodium modeling, by

helping to maintain the serum
oncotic pressure.
2. Muscle cramps

 Possiblydue to changes in muscle

perfusion because of excessively
aggressive volume removal,
particularly below the estimated
dry weight, and the use of low-
sodium containing dialysate.
Prevention of Muscle Cramps
 Reduction of volume removal
during dialysis.

 Useof higher concentration of

sodium in the dialysate.

 Useof quinine sulfate (260 mg

2h before treatment).
3. “First Use Syndrome”

Asymptom complex of
nonspecific chest and back pain
which appears to result from
complement activation and
cytokine release.
 Occur most frequently with the
bioincompatible cellulosic-
containing membranes.

 Intermediate hypersensitivity
reaction (anaphylactic) due to an
IgE – mediated reaction to
ethylene oxide used in the
sterilization of new dialyzer.
4. Cardiovascular disease

Major cause of death in patients

with ESRD receiving chronic
dialysis.

Inadequate treatment of
hypertension.
 Presence
of hyperlipidemia,
homocystinemia and anemia

 Calcification
of coronary arteries
(due to elevated calcium-
phosphorus product)

 Alterations
in cardiovascular
dynamics during the dialysis
treatment.
5. Dialysis Dysequilibrium
Syndrome

 is
a syndrome that typically
develops during or shortly after
hemodialysis, especially during
the first few dialysis sessions.

 is
the result of cerebral edema;
the exact pathogenesis remains in
dispute.
 causesnausea, vomiting, and
headaches, w/c may occasionally
progress to seizures and coma.

 is
usually self-limiting and only
requires measures for symptom
control.
Patients at risk of dialysis
disequilibrium syndrome:

Pediatric population and patients

with:
Intracranial pathology
Hepatic encephalopathy
Recent brain surgery
6. Hypoxemia

 Char.By a drop in the pO2 of up

to 15 mm Hg.

 is
associated with the use of
acetate dialysate.

 inthe absence of acetate, this

decrease is not usually of clinical
significance.
7. “Dialysis dementia”

 also
called dialysis
encephalopathy.

 is
a progressive, frequently fatal
neurologic disease.

 in
adults, the disease is seen
almost exclusively in patients
being treated with chronic
hemodialysis.
Etiology:

 Increase
in brain aluminum content
has been strongly implicated in
some cases of dialysis dementia

 Dialysisdementia most likely

represents a syndrome complex
that is the final common pathway
for a variety of etiologic agents.
 Categories of Dialysis
Dementia

1. An epidemic form that is related

to contamination of the dialysate,
often with aluminum.

2. Sporadic cases in which

aluminum intoxication is less
likely to be a contributory factor.
3. Dementia associated with
congenital or early childhood
renal disease.
 Prevention of Dialysis
Dementia
 No Tx for the sporadic form.

 Inthe early stages, the epidemic

form of dialysis dementia can be
reversed by removing the source of
aluminum.

 Deionization of the water used to

prepare dialysate.
 Sporadic cases of dialysis
dementia may be prevented by
substitution of calcium carbonate
(or acetate) for the control of
hyperphosphatemia.
Other trace elements may be
present in water that can result in
central nervous system toxicity
include:
 Cadmium, Mercury, Lead,
Manganese, Copper, Nickel,
Thallium, Boron, Tin
 Peritoneal Dialysis
A procedure in w/c dialysate is
infused into the abdominal cavity
through a catheter.

The peritoneal membrane allows

for diffusion of toxins an molecules
into the dialysate down their
concentration gradient.
The dialysate fluid is exchanged
several times a day, either
manually or through an automated
cycler.
Principle of PD:
 usesthe same principles of
diffusion, osmosis, and
ultrafiltration that apply to
hemodialysis

 theperitoneal membrane serves

as the dialyzing membrane
(“artificial kidney”)
a silastic catheter is surgically
implanted in the peritoneal
cavity below the umbilicus to
provide access.

 uses lactate in the dialyzing

solution
Complications of Peritoneal
Dialysis

 Peritonitis.
 Hyperglycemia.
 Hypertriglyceridemia.
 Obesity.
 Hypoproteinemia.
 Uremia secondary to loss of
residual renal function.
 Malnutrition.
Forms of Peritoneal Dialysis

1. Continuous cyclic peritoneal

dialysis (CCPD)

 Exchanges are performed in an

automated fashion, usually at
night.
The patient s connected to the
automated cycler, which then
performs 4 to 5 exchange cycles
while the patient sleeps.

Peritoneal dialysis cyclers

automatically cycle dialysate in
and out of the abdominal cavity.
In the morning the patient,
with the last exchange
remaining in the abdomen, is
disconnected from the cycler
and goes about his regular daily
activities.
2. Continuous ambulatory
peritoneal dialysis (CAPD)

dialysis solution is manually

infused into the peritoneal cavity
during the day and exchanged 3
to 4 times daily
nighttime dwell is frequently
instilled at bedtime and remains
in the peritoneal cavity through
the night

the drainage of spent dialysate

(effluence) is performed manually
with the assistance of gravity to
move fluid out of the abdomen.
3. Nocturnal intermittent
peritoneal dialysis (NIPD)

patient is give approximately

10 h of cycling each night.

the abdomen is left dry during

the day.
Kt / V
A clearance term that reflects the
removal of urea during dialysis.

It allows monitoring of therapy

and identification of problems in
the delivery of dialysis.

Generally Kt/V should be > 1.3.