Hemodialysis: History and Current Perspective

Nadeem A Siddiqui MD Dallas Nephrology Associates

Hemodialysis:History and Current Perspective

History of Dialysis Principles of Hemodialysis Practice of Hemodialysis Complications of Hemodialysis

Dialysis
Process by which the solute composition of a solution A is altered by exposing it to a second solution B through a semipermeable membrane

Necessary pre-requisites for Hemodialysis

1) Semi-permeable membrane 2) Anticoagulation 3) Knowing what to remove and how much of it

1773: Nurepuel isolates Urea by boiling urine in a pan

1828: Wohler synthesizes Urea and describes its molecular structure

Thomas Graham (1805-1869)

1850 Glasgow, Scotland: Thomas Graham s experiment to demonstrate diffusion across a semipermeable membrane (Pergamon paper)

Dialysis Membranes

1750:Advances in the dovelopment of smokeless gunpowder led to the synthesis of a strong Nitrocellulose called collodion. It was a combination of Nitric acid and cotton Addition of Camphor to this substance led to the synthesis of stable and strong plastics 1957:Helmut Staldiger polymerized Cellulose

1913:The First Hemodialysis Experiment

90 80 70 60 50 40 30 20 10 0

East West North

1st 2nd 3rd 4th Qtr Qtr Qtr Qtr

1937: William Thalhimer successfully lowers BUN by performing Hemodialysis in anephric dogs

1926:The First Human Experiment

George Haas used a collodion tube arrangement to successfully dialyze human subjects Allergic reactions to impurities in Hirudin led him to abandon his experiments

1937:Nils Alwall used the Alwall Kidney to perform the first ever hemodialysis treatment at the university of Lund, Sweden

 If I have seen farther it is because I have stood on the shoulders of Giants

Sir Isaac Newton

Hemodialysis:History and Current Perspective

History of Dialysis Principles of Hemodialysis

Mechanisms of Solute transfer

Diffusion Convection

Diffusive Clearance

A result of random molecular motion Influenced by concentration gradient of the solute and its Molecular weight as well as by the membrane permeability to the solute

Convective Clearance

Water molecules passing through a SPM carry with them the solutes in their original concentration. This is called the solvent drag phenomenon Water can be made to move across a SPM by the application of either a hydrostatic or an osmotic gradient

Hemodialysis:History and Current Perspective

History of Dialysis Principles of Hemodialysis Practice of Hemodialysis

The Hemodialysis circuit

Dialysis Membranes
Membrane
Regen. cellulose Modif. Cellulose Synthetic

Hydr.Perm. Examples
Low flux Low/High Flux High/Low flux

Biocomp.

cuprophane Poor Cell.acetate Interm. Cell di-acet. PAN,PS,PA, Good PC,PMMC

Dialysis Solution
Component Na K Ca Mg Acetate Chloride Bicarbonate Glucose Concentration mmol/L 140 2 1.25 (5 mg/dl) 0.5 (1.2 mg/dl) 3.0 108 35 5.6 (100 mg/dl)

Water Purification

Water Treatment System for Hemodialysis

Vascular Access

Indications for initiating Hemodialysis

In patients with calculated creatinine clearance <20 ml/min/1.73 m2

*Uremic symptoms Nausea/emesis Altered sleep pattern *Altered mental status Coma Stupor Tremor Asterixis Clonus Seizures
the onset of:

Indications for Hemodialysis

*Pericarditis or Tamponade (urgent indication) *Uremic platelet dysfunction (urgent indication) *Refractory volume overload *Refractory hyperkalemia *Refractory Metabolic acidosis with anuria

Indications for Hemodialysis

Steadily worsening renal function in a patient with measured 24 hour urinary creatinine clearance<15 ml/min when accompanied by worsening azotemia, poor nutritional status and refractory edema

Equations for estimation of renal function

Cockcroft and Gault equation MDRD Formula

The Cockcroft-Gault equation

Cr Cl =(140-age) x wt/72(serum Cr)

Decrease 15% for women Decrease 20% for paraplegia,40% for quadriplegia Increase 12% for AA males

Modification of diet in renal disease study JASN2000

The MDRD formula

GFR (ml/min/1.73m2)= 186 x Pcr -1.154 x age -0.203 x1.212 if black

X0.742 if female

The MDRD equation calculates GFR, hence values are lower than those of creatinine clearance by Cockcroft Gault equation.

Measurement of nutritional status

Physical Exam Skin fold thickness Mid arm muscle thickness Protein catabolic rate <1* Serum Albumin Serum Cholesterol Blood Lymphocyte count

Monitoring Dialysis Adequacy

Hemodialysis:History and CURRENT Perspective

History of Dialysis Principles of Hemodialysis Practice of Hemodialysis Complications of Hemodialysis

Complications of Hemodialysis
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

11.
12.

Dialysis Reactions Intradialytic Hypotension Neuromuscular complications Dialysis dysequilibrium Hemolysis Intradialytic hypoxemia Postdialysis syndrome Cardiac arrhythmia and sudden death Steal syndrome Dialysis associated hypoxemia Air embolism Metabolic derangements

Dialysis Reactions

Management of Intradialytic Hypotension

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

11.

Assess dry weight frequently Avoid BP meds before HD Avoid rapid UF Use sequential UF and HD Avoid feeding patients on HD Use Sodium modeling Use HCO3 based dialysate Keep Hct >33 Use non Cellulosic membranes Keep Dialysate temperature<37 degrees Celsius Assess cardiac function, r/o pericardial effusion/tamponade

Neuromuscular Complications: Muscle Cramps

Etiology: Hypo-osmolality, Carnitine deficiency, Hypomagnesemia, excessive inter-dialytic weight gain Rx: Dietary counseling, Sodium modeling, Saline or 50% dextrose bolus, ? Prophylactic Quinine sulfate or Oxazepam

Neuromuscular complications

Seizures Restless legs syndrome Headache

Dialysis Disequilibrium Syndrome (DDS)

Risk factors: Young age, severe and chronic azotemia, Initial dialysis treatment, High flux/ large surface area dialyzer Symptoms: Headache, nausea, emesis, blurred vision, hypertension, disorientation, muscle twitching

DDS

1.

2. 3.

Pathogenesis: Reverse urea effect ( rapid reduction of serum urea while CSF urea concentration remains high) Paradoxical CSF acidosis Intracerebral accumulation of idiogenic osmoles in uremia

DDS

1. 2.

3.

4.

Treatment Early detection of uremia, early intervention with dialysis First few treatments should aim to achieve modest reduction in serum urea concentration ( 30% or less) Sodium modeling, use of Bicarbonate dialysis, slow QB Prophylactic use of Mannitol is not recommended

Intradialytic Hemolysis

Uncommon From contamination of dialysate with Chloramine or Copper (deionization failure) From Methemoglobinemia from nitrate contamination

Intradialytic Hypoxemia

Arterial p O2 drops by 5 to 30 mm Hg during Hemodialysis due to central Hypoxemia. This is a result of a drop in CO2 that accompanies correction of acidosis on dialysis V/Q mismatch can occur due to pulmonary sequestration of activated leukocytes Acetate can induce respiratory muscle fatigue

Intradialytic Hypoxemia

Treatment : Supplemental oxygen during Hemodialysis in susceptible patients