Hemodialysis

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Components of dialysis :
 Blood
 Dialysate
 Dialyzing membrane
Principles:
Diffusion - movement from higher to lower concentration
Solute - dissolves in a solution
Solvent - medium that dissolves the solute
Convection - movement of solutes with the solvent
Ultrafiltration - convective transport; driven by osmotic or hydrostatic force through the
membrane; "solvent drag"
UF rate - total pressure gradient; h2o permeability of membrane
Osmosis - movement of h2o from higher to lower concentration thru a semi permeable
membrane
Reverse of Dialysis - pressure higher than osmotic pressure artificially applied on the side of
higher concentration to cause a reversal solvent flow
Dialyzer - artificial kidney
Toxic metabolites - removed by diffusion
Water - removed thru ultrafiltration (usually occurs as a result of negative pressure)
Diafiltration - simultaneous use of dialysis and UF to provide solute and water clearance
 
DIFFERENTIAL DIAGNOSIS
 
CREATININE - metabolite produced by SKELETAL MUSCLE metabolism released by plasma at
relatively constant rate; an indicator of kidney function
 NORMAL LEVEL: 0.6-1.3 mg/dl or 62-155 umol/l
BLOOD UREA NITROGEN - less useful to estimate level of kidney impairment; produced in the
liver; final product of protein metabolism
 NORMAL VALUE: 7-18 mg/dL or 2.5-6.4 mmol/l
URINARY SODIUM CONCENTRATION - very important cation in the body; regulator of
water retention and excretion; bonds with chloride and bicarbonate
 NORMAL VALUE: 40-220 mEq/l of urine
URINARY OSMOLALITY - measure of number of solute particles in a unit of solution; indicates
capacity of urine to concentrate urine
 NORMAL VALUE (Urine) : 50-1200 mOsm/kg of water
 (Serum) : 285-290 mOsm/kg of water
 Dipstick - may predict future disease or the present disease
 
URINE SEDIMENT CLINICAL SIGNIFICANCE
COMPONENT

Bacteria UTI / contamination

D I A LY S I S

Broad casts Formation occurs @ collecting tubules, serious kidney

disorder
 Epithelial cells ( N: 0-2 ) Tubular degeneration
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Fatty casts Nephrotic syndrome

Granular (N:0-2) or waxy casts Renal parenchymal disease

Hyaline casts (N: 0-2) ACIDIC OR HIGH SALT CONTENT

Red cell casts (N:0-3) Acute glomerulonephritis

White cell casts (N: 0-4) Pyelonephritis

Epithelial cells (common) Contamination

Renal cells (N:0-2) Tubular damage

Erythrocytes Renal disorders

Fat bodies Nephrotic syndrome

Leucocytes Renal disorders and pyelonephritis

 
CLINICAL FEATURES DURING RENAL FAILURE
 
Main clinical features of ARF:
 Fluid overload
 Unable to excrete salt and water
 Mild HPN, increased Jugular venous pressure
 Peripheral and pulmonary edema
 Increased body weight
 Hyponatremia
 Excesssive hypotonic saline isotonic or dextrose
 Causes cerebral edema (cells swell) [hyperrrr: cells shRink, hypoooww : cells sWell]
 Hyperkalemia
 Inability to excrete potassium
 Can lead to cardiac dysrythmias e.g, heart attack and bradycardia
 Hyperphosphatemia
 n/v, muscle weakness (mgt. phosphate binders)
 Hypocalcemia
 Decline in the concentration of serum calcium
 Can lead to muscle cramps (no muscle relaxation)
 Metabolic acidosis
 Accumulation of chloride and more acid, lungs attempt to maintain adequate pH by
eliminating Co2
 Compensation: hyperventilation
 Uremia
D I A LY S I S

 Inflammation of organs, immunity, anemia, coagulation effects on heart

 Uremic anemia; impaired kidneys unable to secrete erythropoietin essential for
formation of new red blood cells
 Coagulation affected by uremia
  Great risk for bleeding because of platelet dysfunction
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 Drug toxicity
PERITONEAL DIALYSIS
 Removal of toxic substances from the body using the peritoneum as the semi-permeable
membrane
 Solute exchanges is from the peritoneum to the solution called "dialysate".
IMPORTANCE OF PD
 Poisons don't build in the bloodstream
 Fewer dietary restrictions
 Feasibility of long distance travel
 No needle pricks
 Freedom in scheduling day to day activities
TYPES OF PD
 CAPD (Continuous Ambulatory PD)
 Most popular
 Continuous therapy and a steady physiologic state
 Simple
 CIPD (Continuous Intermittent PD)
 Hospital setting
 Done twice a week
 Dwell time: 30 minutes
 60 exchanges per session
 Use bottled or plasco PD solutions
 CCPD (continuous cyclic PD)
 Uses cycler machine
 Done at night time
MECHANISM OF PD
3 phases:
Inflow
Dwell
Drain
Complications of PD
 Peritonitis
 Catheter related complications
 Decreased peritoneal clearance
 Aggravation of hemorrhoids
 Hypotension
 Muscle cramps
 Low back pain
HEMODIALYSIS
Diffusion - toxin removal
Ultra filtration - water removal
Dialyzer: Hydrophobic - polysulfone (PSU) or polyether sulfone (PES)
D I A LY S I S

Hydrophilic - polyvinyl pyrolidones (PVP)

Anticoagulation:
Unfractioned or standard heparin
LMWH (low molecular weight heparin)
 Saline flushes
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Citrate
Dialysis Solution:
Dialysate
Removes wastes and extra fluid
Kinds: Acetate
Bicarbonate
Fluid Too LOW Too HIGH
Mg+ Weakness, asthenia, cramps Paralysis

HCo3 Acidosis Alkalosis

K+ Arrhythmia Arrhythmia

Ca+ Negative Calcium balance Hypercalcemia, tissue calcification

Na+ Intradialytic hypotension , cramps Increased thirst, weight gain, fluid overload,
hypertension
 
 
BENEFITS AND RISKS OF IHD
BENEFITS:
 Quick and intense solute and fluid removal
 No prolonged anticoagulation
 No prolonged blood material interaction
 Less heat loss
 Short duration
 Economical on line dialysate production
RISKS:
 On-Line dialysate production
 Intensive solute removal
 Edema/disequilibrium
 Intensive fluid removal: hypotensive
 Cardiac/shock/arrest
 
BENEFITS AND RISKS OF SLED
 
Sustained (Slow) Low Efficiency Dialysis
 
BENEFITS:
Fluid removal and solute clearance slower than IHD
Performed over 8-10 hours
Six times a week
Also referred as NOCTURNAL DIALYSIS
D I A LY S I S

Patient free to undergo treatments and tests during day time hours
Fluid management only on HD treatment
RISKS:
 On-line dialysate (fluid) production
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Pyrogen reaction
 
Solutes Transport Mechanism
ULTRAFILTRATION - movement of fluid through a semi-permeable membrane caused by pressure
gradient
DIFFUSION - movement of solutes from an area of higher concentration to an area of lower
concentration
 
LOW AND HIGH FLUX HEMODIALYSIS
 
Principles of adsorption - adherence of solutes and biological matter to the surface of a membrane
Dialysate flow - dialysis solution provides the diffusive movement
 Increase dialysate flow increases solute clearance but it depends also of
patient's vital signs and thermodynamically stability
 Qd for normal patient is 500 ml per minute
 Qd for SLED 300 ml-800ml per min.
Hemodiafiltration
 Combination of diffusive clearance (hemodialysis) and convective clearance
(hemofiltration)
 Use of dialysate on fluid side of filter and replacement solution on the blood side of the filter
Terminology
Quf UFR Ultra filtration

Qd DFR Dialysate flow rate

Qb BFR Blood flow rate

Qr RFR Replacement flow rate

TMP Transmembrane pressure

 
Methods of sterilization of dialyzers:
Ethylene oxide
Radiation
Steam
 
Vascular Access
 
Historical Background
1954-1st clinical report of hemodialysis
Dr. Shaldon and associates developed a catheter that could be replaced percutaneously
Was able to dialyze a patient for 12 sessions
1960-Dr. Scribner cannulated the vessel making hemodialysis feasible for a prolonged period of
time
D I A LY S I S

1966-Brescia-Cimino fistula simply known as the "Arterio Venous Fistula" was introduced
allowing long term hemodialysis access
1974-Bovine grafts introduced
 1975-Gore-Tex grafts introduced
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1976-PTFE (Polytefluoroethylene graft was introduced)

1983-Tunneled Cuffed catheter introduced
Vascular surgeon - does the operation of implanting a fistula
 
COMMON SITES CHRONIC DIALYSIS ACCESS
 Non dominant upper extremity
 Non dominant arm before the dominant arm
 Forearm before the arm
 Arm before the legs
 
TYPES of Vascular Access
 Scribner Shunt
 Shaldon Catheters
 Dual-lumen Catheter
 Permanent Catheter (permanent access)
*arteriovenous graft: no tourniquet
Access Types:
1. Internal Arterio Venous fistula (AVF)
2. Prosthetic bridge graft (AVG)
a. PTFE
b. Bovine
c. Autologous vein (saphenous)
d. Other
3. Central vein catheter
a. Temporary
b. Tunneled cuffed catheter (perm catheter)
4. Ports
5. Sites
a. Forearm > upper arm > thigh > thorax
COMMON SITES FOR ARTERIOVENOUS VASCULAR ACCESS
 Brachiocephalic (outside)
 Brachiobasilic (inside)
 Radiocephalic
 Snuffbox
 Ulnobasilic
Common AV Fistula Sites
 Radial-cephalic
 Brachial-cephalic
 Transposed Brachial-Basilic
 
CANNULATION APPROACH
 Determine sites
D I A LY S I S

 Cleanse areas
 Using determined cannulation gauge angle needle based on AVF/AVG and depth of vessel
 Keep skin taunt
 Stabilize vessel
  Penetrate skin (feel resistance 'give')
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 Proceed, still stabilizing vessel and feel achieved … slowly proceed - there should be NO
RESISTANCE
 Glide the needle for the full length of the needle
 Secure cannula with tape
 Ensure patient comfort at all times
COMPLICATIONS
 Pseudoaneurysms
 Infection
 Hematoma
 Stenosis
 "one-site-itis"
 Ischemic lesions
 Aneurysm
 Infiltration
CENTRAL VASCULAR DIALYSIS ACCESSESES
Complications:
 Infection (exit site infection, catheter infection and bacteremia)
 Flow problems (occlusions, thrombosis, central venous stenosis)
Common sites for temporary CVDC:
 Jugular veins
 Subclavian veins
 Femoral veins
RULE of 6's
A working AV fistula
 Blood flow >600 mL/min
 Diameter >0.6 cm
 Dicernible margins to allow for repetitive cannulation
 Depth of approx. 0.6 cm
 
STANDARD (UNIVERSAL) PRECAUTIONS
Initially recommended in 1985:
 Use of gown, gloves, goggles
 Adherence to routine and hand washing
 Appropriate disposal of needles and sharp objects
 Review of disinfection and sterilization
Replaced in 1996 due to local variation - STANDARD PRECAUTIONS
 Standard precaution should be used irrespective of patients infectious status
 All human blood and bodily fluids are assumed to be infectious for HIV, HBV and other blood-
borne pathogens
Technical Complications
Wednesday, May 21, 2014
11:28 AM
D I A LY S I S

 
COMMON COMPLICATIONS (TECHNICAL)
 
 Clotting
  Power failure
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 Blood leak
 Hemolysis
 Air embolism
 Exsanguination
 Dialyzer reactions
 
Clotting in Extracorporeal Circuit
 Formation of blood clots in the dialyzer and blood lines
 Inadequate anti coagulation
 Low BFR
 Air in bloodlines: poor priming techniques, loose connections
Signs:
 Increasing venous pressure
 Dark bloodlines or drip chambers
 Fibrin in drip chambers, visible clots or clumping, TMP alarm problems
Treatment:
 Anticoagulation
 Vascular access: needle catheter placement, CBC problems
 
Blood Leak
 membrane rupture allowing RBCs to cross over the membrane into the dialysate
Signs:
 Blood leak alarm
 Positive test for blood in the dialysate
Interventions:
 Check dialysate with blood leak strip
 If positive stop treatment, do not return blood
 If negative, may need to get different machine
 
Power failure
 Electricity is disruptive to the machine
 Storm/tornado/fire/construction
 Unable to mute alarms, air detector trips, clamping venous line
 
Hemolysis
 Breakdown or destruction of RBCs
 Releases potassium from damaged cells into the blood stream
 Decreasing the oxygen carrying capacity of the RBCs
 Potentially life threatening
Causes
Mechanical:
 Poor, incorrectly calibrated blood pump
 Excessive negative pressure
D I A LY S I S

 Deformity in lines
 Over occlusion of blood pump
Chemical and Thermal chemical:
 Improperly prepared dialysate
  Contaminated dialysate
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 Chemical agents : formaldehyde bleach , chlorine, copper, nitrates and nitrites

 Thermal: overheated dialysate (>42 degrees Celsius)
Signs of Hemolysis:
 Cherry red colored blood in venous line
 SOB
 Chest , abdominal and or back pain
 Cardiac arrest
 Stop dialysis and do not return blood to the patient
 Symptomatic management
 
Air Embolism
 Introduction of air into the extracorporeal system to stop circulation
Causes:
 Empty IV bag
 Air leak in the blood lines
 Air detector not armed
 Loose connections
 Separation of blood lines
 Pre-safety checks not done/improperly done
Signs and Symptoms:
Extracorporeal:
 Air pocket or foam pink in venous line
 Patient: coughing, SOB, chest pain or pressure, tachycardia, distended neck veins
 Cyanosis/gray color
 Slight paralysis on one side of the body (cerebral)
 Confusion, convulsions, coma
 Possible cardiac/respiratory arrest
Interventions:
 Clamp blood lines and stop blood pump
 Place patient in Trendelenburg position turning them on their LEFT side
 Oxygen for SOB and chest pain
 NSS to support BP
Causes:
 Under filling drip chambers
 Empty saline bag
 Loose connections
 Dialysis needle removed while blood pump is running
 Poor priming
Signs:
 Air bubbles/foam in bloodlines
 Air in blood alarm
Intervention/prevention
 Keep level of drip chambers up
D I A LY S I S

 Replace empty saline bags immediately

 Tighten connections when priming
 Tape needles securely
 Follow correct priming procedure
  
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EXSANGUNATION
 Extreme blood loss
 Bloodline separation
 Needles dislodging from access
 Rupture of access
 Crack in dialyzer casing/rupture of dialyzer
 Loose dialyzer caps/connections
Symptoms:
 Obvious bleeding source
 Hypotension
 Machine pressure change alarms
 Shock
 Seizures
 Cardiac arrest
Treatment of Exsanguination
 Identify the source of blood loss
 Stop dialysis
 Return blood if possible (not contaminated system)
 Normal saline to support BP
 Oxygen for SOB
 May need BT
 
DIALYZER REACTIONS
 First Use Syndrome
 Hypersensitivity to membrane
 
First Use Syndrome:
 Back pain
 Chest pain
 Hypotension
 Pruritus
 Vague discomfort
 Nausea
Hypersensitivity
 Anxiety
 Hives pruritus
 Dyspnea, wheezing
 Chest tightness
 Possible cardiac arrest
Intervention:
 Stop treatment if anaphylactic response to: respiratory distress, cardiac distress
 Symptomatic management
Prevention:
D I A LY S I S

 Use of synthetic membrane

 Reuse of dialyzers
 Proper priming of reuse and new dialyzers
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Psychological Aspects of HD
Wednesday, May 21, 2014
12:04 PM
STAGES OF ADJUSTMENT TO HEMODIALYSIS
 
1. Honeymoon Period
 Initial response to dialysis
 Lasts between few weeks to few months
 Physical and psychological improvements
 Hope and confidence start to appear
 Begin to accept treatment more positively
2. Period of Disenchantment
 Lasts for 2-6 months
 Attempt to return to normal life but start to face the limitations
 Family support and staff counseling is very important
 Reduced feelings of confidence and hope
3. Period of Long-term Adaptation
 Acceptance of limitations and possible complications in the future
 Behavior can swing from one stage to another
 
Psychological stressors of HD
1. Dialysis schedule and procedure
2. Diet and fluid restrictions
3. Loss of job
4. Problematic vascular access
5. Limitation to freedom of life
6. Reduced life expectancy
 
DEPRESSION
 Most important and common in patients with ESRD
Effects of Depression
1. Patients feel hopeless; abandon the will to survive
2. Fail with compliance
3. Exacerbation of medical illness
4. Loss of appetite resulting to nutritional deficiencies
5. Suicidal tendencies
Why Depression Occur?
1. Frustration in instinctual needs
2. Anxiety and fear associated with blood and injury
3. Financial aspects
4. Mourning process
5. Dependency
D I A LY S I S

6. Sensory deprivation in an HD unit

 
UNCOOPERATIVE BEHAVIOR
SEXUAL DYSFUNCTION
  Severe anemia, impaired testosterone and other hormone levels contribute to it.
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 Medications and depression

 60-70% of males develop impotence over time
 Females report to difficulty reaching orgasm
 Marked organic deterioration of nocturnal penile tumenescense
 Loss of masculinity
 
Treatment Options
 Education
 Sexual behavior therapy
 Exercise
 Medication
 Talking therapies
 Diversional activities
 
DO's
 Allow patient to express feelings or concern
 Listen with empathy - effortful, accurate
 Involve the family
 Explore possibilities of support
 Teach relaxation techniques
 Make sessions brief - brevity, clarity, accuracy
 Avoid making decisions for the patient
 
UNCONDITIONAL POSTIVE REGARD
Attending Skills
L- Lean forward
O- Open stance
V- Voice of compassion
E- Eye Contact
R- Relaxed
S- Sit in an angle
 
DON'Ts
 Do not do all the talking
 Avoid moralizing, being judgmental and showing disapproval
 Avoid telling the patient that things are not as bad as it is .
 Don't tell him to stop thinking about it or he should forget it.
 If patient is psychotic:
o Don't forget about the delusions
o Don't use angry or demanding tones
o Don't touch or stare without warning
o Don't bargain about the need for restraints and medication
D I A LY S I S

FACTORS for a good prognosis

1. Patient's capacity to regress to a state of dependence with our conflict
2. Strong religious belief
3. Presence of one or more family members
 4. Mean low BUN levels
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5. Indifference to fellow patients

D I A LY S I S