PRINCIPLE

Dialysis works on the principles of the diffusion of solutes and ultrafiltration of

fluid across a semi-permeable membrane. Diffusion is a property of substances in
water; substances in water tend to move from an area of high concentration to an
area of low concentration. Blood flows by one side of a semi-permeable
membrane, and a dialysate, or special dialysis fluid, flows by the opposite side. A
semipermeable membrane is a thin layer of material that contains holes of
various sizes, or pores. Smaller solutes and fluid pass through the membrane, but
the membrane blocks the passage of larger substances (for example, red blood
cells, large proteins). This replicates the filtering process that takes place in the
kidneys, when the blood enters the kidneys and the larger substances are
separated from the smaller ones in the glomerulus.
The kidneys have important roles in maintaining health. When healthy, the
kidneys maintain the body's internal equilibrium of water and minerals (sodium,
in medicine, dialysis is a process for removing waste and excess water from
the blood, and is used primarily potassium, chloride, calcium, phosphorus,
magnesium, sulfate). The acidic metabolism end-products that the body cannot
get rid of via respiration are also excreted through the kidneys. The kidneys also
function as a part of the endocrine system, producing erythropoietin and
calcitriol. Erythropoietin is involved in the production of red blood cells and
calcitriol plays a role in bone formation. Dialysis is an imperfect treatment to
replace kidney function because it does not correct the compromised endocrine
functions of the kidney. Dialysis treatments replace some of these functions
through diffusion (waste removal) and ultrafiltration (fluid removal). Blood is
diverted from an artery, usually on in wrist into the dialyzer, where it flows either
by its own impetus or with aid of mechanical pump along one surface of
membrane. Finally blood passes through the trap that removes clots and bubbles
and return to the vein in the patients forearms. In patients with chronic kidney
failure who require frequent dialysis, repeated surgical access to the blood vessels
in treatment is obviated by provision of an external plastic shunt between them.
In medicine, is a process for removing waste and excess water from the blood,
and is used primarily as an artificial replacement for lost kidney function in people
with renal failure.
THE TWO MAIN TYPES OF
DIALYSIS-
HEMODIALYSIS
PERITONEAL DIALYSIS

Hemodialysis removes wastes and water by circulating blood outside the body
through an external filter, called a dialyzer, that contains a semipermeable
membrane. The blood flows in one direction and the dialysateflows in the
opposite. The counter-current flow of the blood and dialysate maximizes the
concentration gradient of solutes between the blood and dialysate, which helps
to remove more urea and creatinine from the blood. The concentrations of
solutes (for examplepotassium, phosphorus, and urea) are undesirably high in the
blood, but low or absent in the dialysis solution, and constant replacement of the
dialysate ensures that the concentration of undesired solutes is kept low on this
side of the membrane. The dialysis solution has levels of minerals
like potassium and calciumthat are similar to their natural concentration in
healthy blood. For another solute, bicarbonate, dialysis solution level is set at a
slightly higher level than in normal blood, to encourage diffusion
of bicarbonate into the blood, to act as a pH buffer to neutralize the metabolic
acidosis that is often present in these patients. The levels of the components of
dialysate are typically prescribed by a nephrologistaccording to the needs of the
individual patient.
In peritoneal dialysis, wastes and water are removed from the blood inside the
body using the peritoneal membrane of the peritoneumas a natural
semipermeable membrane. Wastes and excess water move from the blood,
across the peritoneal membrane, and into a special dialysis solution, called
dialysate, in the abdominal cavity which has a composition similar to the fluid
portion of blood.

HEMODIALYSIS

In hemodialysis, the patient's blood is pumped through the blood compartment of
a dialyzer, exposing it to a partially permeable membrane. The dialyzer is
composed of thousands of tiny synthetic hollow fibers. The fiber wall acts as the
semipermeable membrane. Blood flows through the fibers, dialysis solution flows
around the outside of the fibers, and water and wastes move between these two
solutions. The cleansed blood is then returned via the circuit back to the body.
Ultrafiltration occurs by increasing the hydrostatic pressure across the dialyzer
membrane. This usually is done by applying a negative pressure to the dialysate
compartment of the dialyzer. This pressure gradient causes water and dissolved
solutes to move from blood to dialysate, and allows the removal of several litres
of excess fluid during a typical 4-hour treatment. In the US, hemodialysis
treatments are typically given in a dialysis center three times per week (due in the
US to Medicare reimbursement rules); however, as of 2007 over 2,500 people in
the US are dialyzing at home more frequently for various treatment lengths.
Studies have demonstrated the clinical benefits of dialyzing 5 to 7 times a week,
for 6 to 8 hours. This type of hemodialysis is usually called "nocturnal daily
hemodialysis", which a study has shown a significant improvement in both small
and large molecular weight clearance and decrease the requirement of taking
phosphate binders. These frequent long treatments are often done at home while
sleeping, but home dialysis is a flexible modality and schedules can be changed
day to day, week to week. In general, studies have shown that both increased
treatment length and frequency are clinically beneficial.







PERITONEAL DIALYSIS


In peritoneal dialysis, a sterile solution containing glucose (called dialysate) is run
through a tube into the peritoneal cavity, the abdominal body cavity around
the intestine, where the peritoneal membrane acts as a partially permeable
membrane. The peritoneal membrane or peritoneum is a layer of tissue
containing blood vessels that lines and surrounds the peritoneal, or abdominal,
cavity and the internal abdominal organs (stomach, spleen, liver, and intestines).
Diffusion and osmosis drive waste products and excess fluid through the
peritoneum into the dialysate until the dialysate approaches equilibrium with the
body's fluids. Then the dialysate is drained, discarded, and replaced with fresh
dialysate.
This exchange is repeated 4-5 times per day; automatic systems can run more
frequent exchange cycles overnight. Peritoneal dialysis is less efficient than
hemodialysis, but because it is carried out for a longer period of time the net
effect in terms of removal of waste products and of salt and water are similar to
hemodialysis. Peritoneal dialysis is carried out at home by the patient, often
without help. This frees patients from the routine of having to go to a dialysis
clinic on a fixed schedule multiple times per week. Peritoneal dialysis can be
performed with little to no specialized equipment (other than bags of fresh
dialysate).






STARTING INDICATIONS
The decision to initiate dialysis or hemofiltration in patients with renal
failure depends on several factors. These can be divided into acute or chronic
indications.
Acute indications for dialysis:
Indications for dialysis in the patient with acute kidney injury are summarized
with the vowel acronym of "AEIOU".
Acidemia from metabolic acidosis in situations in which correction with sodium
bicarbonate is impractical or may result in fluid overload.
Electrolyte abnormality, such as severe hyperkalemia, especially when combined
with AKI.
Intoxication, that is, acute poisoning with a dialyzable substance. These
substances can be represented by the mnemonic SLIME: salicylic
acid, lithium, isopropanol, Magnesium-containing laxatives, and ethylene glycol.
Overload of fluid not expected to respond to treatment with diuretics.
Uremia complications, such as pericarditis, encephalopathy, or gastrointestinal
bleeding.
Chronic indications for dialysis:
Symptomatic renal failure
Low glomerular filtration rate (GFR) (RRT often recommended to commence at a
GFR of less than 10-15 mls/min/1.73m
2
). In diabetics, dialysis is started earlier.
Difficulty in medically controlling fluid overload, serum potassium, and/or serum
phosphorus when the GFR is very low
COST AND EXPENDITURE



PERITONEAL DIALYSIS-

This involves the cost of the PD bags of fluid. The fluid is available in different
concentrations. The rate of the fluid does not depend on the concentration. The
rate depends only on the volume. Most people on CAPD use the 2 liter bags while
those on CCPD use 5 liter bags.

CAPD
There are different companies offering PD treatment in India like Baxter, Gambro
etc.
Cost of one 2 liter bag: Rs. 170

Total cost of bags assuming 4 exchanges per day, 7 days a week: Rs. 21,000

CCPD
Cost of one 5 liter bag: Rs. 416
Total cost of bags assuming 2 bags used per night, 7 nights a week: Rs. 25,000
Cost of renting home Choice machine: Rs. 10,000 per month.

HEMODIALYSIS-
Cost of dialysis with new kit: Rs. 2,000 to 3,000
Cost of dialysis with reuse: Rs. 1,250 to Rs. 2,300
Assuming one does thrice a week session and uses a new kit every 2 weeks:

Total minimum cost: Rs. 17,000



INTRODUCTION
Dialysis in chemistry, separation of suspended colloidal particles from dissolved
ions or molecules of small dimension by means of their unequal rates of diffusion
through pores of semi-permeable membrane. Dialysis also called hemodialysis,
renal dialysis or kidney dialysis in medicine, the process of removing blood from
patients whose kidney functioning is faulty, purifying that blood by dialysis and
returning it to the patients bloodstream. The artificial kidney or hemodialysis is a
machine that provides a means for removing certain undesirable substances from
blood or adding needed components to it. Another function of natural kidney,
secretion of hormones that influences blood pressure cannot be duplicated.
Modern dialyzers rely on physiochemical principles Dialysis and ultra filtration.
In dialysis two liquids separated by a porous membrane exchange those
components that exist as particles small enough to diffuse through pores. When
blood is brought into contact with one side of such membrane dissolve
substances pass through into a sterile solution placed on other side of membrane
.To prevent or limit the loss of diffusible substances required by the body, such as
sugars, amino acids and necessary amount of salts. Those compounds are added
to the sterile solution; thus their diffusion from blood is offset by equal
movement in opposite direction. The lack of diffusible material in blood can be
corrected by incorporating them in the solution from which they enter the
circulation.
Although, water passes easily through the membrane, it is not removed by
dialysis because its concentration in blood is lower than in solution. Indeed, water
tends to pass from solution into blood. The dilution of blood that would result
from this process is presented by ultra filtration by which some of the water ,
along with some dissolved material is forced through the membrane by maintain
the blood at higher pressure than solution.

HISTORY

The process of Dialysis was first employed in 1861 by British chemist Thomas
Graham.
Dialysis which was first used to treat human patients in 1945 replaces or
supplements the action of kidney in a person suffering from acute or chronic renal
failure or from poisoning by diffusible substances, such as Aspirin, Bromides or
Barbiturates.
Dr. Willem Kolff, a Dutch physician, constructed the first working dialyzer in 1943
during the Nazi occupation of the Netherlands. Due to the scarcity of available
resources, Kolff had to improvise and build the initial machine using sausage
casings, beverage cans, a washing machine, and various other items that were
available at the time. Over the following two years,[1943-1945] Kolff used his
machine to treat 16 patients suffering from acute kidney failure, but the results
were unsuccessful. Then, in 1945, a 67-year-old comatose woman regained
consciousness following 11 hours of hemodialysis with the dialyzer, and lived for
another seven years before dying from an unrelated condition. She was the first-
ever patient successfully treated with dialysis.
The membrane first used in dialysis were obtained from animals or prepared
from collodion, cellophane has been found to be more suitable and tubes or sheet
of it are used in many dialyzers. In late 1960s hollow filaments of cellulosic or
synthetic materials were introduced for dialysis; bundles of such filaments
provide a large membrane surface in a small volume, a combination
advantageous in devising compact dialyzers.
DIET FOLLOWED DURING
DIALYSIS

The hemodialysis diet is tailored to patients who are in stage 5 of chronic kidney
disease (CKD), also known as end stage renal disease (ESRD). These patients have
very little or no kidney function and must undergo dialysis to clean their blood of
waste and excess fluids.
Hemodialysis is one type of dialysis. The procedure is done several times a week,
usually for 3 to 4 hours at a time. The hemodialysis diet is designed to reduce the
amount of fluid and waste that builds up between hemodialysis treatments so
that you can feel your best.

In addition to enjoying a variety of nutritious foods, the hemodialysis diet will
introduce a higher amount of protein into your eating plan. The exact amount will
be determined by your dietitian. You will be encouraged to get protein from high
quality sources such as lean, meat, poultry, fish and egg whites. These high
protein foods provide all the essential amino acids your body needs
The hemodialysis diet will restrict foods that contain high amounts
of sodium, phosphorus and potassium. Your dietitian will provide you with a diet
guide and food lists that indicate which foods are allowed and which ones you
should avoid or limit. You will also limit your fluid intake.

Potassium builds up in the blood between dialysis treatments. The amount of
potassium that accumulates is determined by the amounts and types of foods
eaten, as well as how much kidney function remains. Too much potassium is very
dangerous. It can cause muscle weakness and make your heart stop beating.
Potassium is easily removed by dialysis. Certain fruits, vegetables, dairy products
and other foods that are very high in potassium will need to be restricted on your
hemodialysis diet.

Phosphorus is difficult for hemodialysis to filter from the blood. This mineral can
build to high levels in the bloodstream and cause complications to your health,
such as weak bones,heart problems, joint pain, or skin ulcers. By limiting foods
that contain phosphorus, you lessen the risk of developing other health problems.
Sodium causes your body to hold onto more fluid and raises your blood pressure.
You may feel uncomfortable and short of breath if you consume too much sodium
and fluid. When excess fluid is removed during dialysis, you can get muscle
cramps and feel dizzy and weak during or after treatment. Eating less sodium and
drinking less fluid can help you feel comfortable before and after your dialysis
sessions.

Fluid intake is not limited to what you can drink; fluid is also hidden in some
foods you eat. Being aware of the fluid in foods such as gelatin, ice, sherbet,
watermelon, sauces, gravies and other high liquid foods is important.