1. What are the types (primary and secondary) of dialysis? Describe each.

In clinical applicarion, there are three primary and two secondary types of dialysis. The three primary
types are hemodialysis, peritoneal dialysis, and hemofiltration. 
The first primary type of dialysis is Hemodialysis. Hemodialysis, also spelled haemodialysis, or simply
dialysis, is a process of purifying the blood of a person whose kidneys are not working normally. This type of
dialysis achieves the extracorporeal removal of waste products such as creatinine and urea and free water from
the blood when the kidneys are in a state of kidney failure. Hemodialysis is one of three renal replacement
therapies (the other two being kidney transplant and peritoneal dialysis). 
To get the blood to flow to the artificial kidney, the doctor will perform surgery to create an entrance
point (vascular access) into your blood vessels. The three types of entrance points are arteriovenous (AV) fistula
that connects an artery and a vein. It’s the preferred option. The AV graft is a looped tube and vascular access
catheter, this may be inserted into the large vein in the neck. Both the AV fistula and AV graft are designed for
long-term dialysis treatments. Catheters are designed for short-term or temporary use.
Hemodialysis treatments usually last three to five hours and are performed three times per week.
However, hemodialysis treatment can also be completed in shorter, more frequent sessions. Most hemodialysis
treatments are performed at a hospital, doctor’s office, or dialysis center. The length of treatment depends on the
body size, the amount of waste in the body, and the current state of the person's health. 
The second primary type of dialysis is 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. 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).
The third primary type is hemofiltration. Hemofiltration is a similar treatment to hemodialysis, but it
makes use of a different principle. The blood is pumped through a dialyzer or "hemofilter" as in dialysis, but no
dialysate is used. A pressure gradient is applied; as a result, water moves across the very permeable membrane
rapidly, "dragging" along with it many dissolved substances, including ones with large molecular weights, which are
not cleared as well by hemodialysis. Salts and water lost from the blood during this process are replaced with a
"substitution fluid" that is infused into the extracorporeal circuit during the treatment. 
The two secondary types are hemodiafiltration and intestinal dialysis. Hemodiafiltration is a combination
of hemodialysis and hemofiltration, thus used to purify the blood from toxins when the kidney is not working
normally. The combination is theoretically useful because it results in good removal of both large and small
molecular weight solutes and also used to treat acute kidney injury (AKI). 
In intestinal dialysis, the diet is supplemented with soluble fibers such as acacia fiber, which is digested by
bacteria in the colon. This bacterial growth increases the amount of nitrogen that is eliminated in fecal waste. An
alternative approach utilizes the ingestion of 1 to 1.5 liters of non-absorbable solutions of polyethylene glycol or
mannitol every fourth hour.

In biochemistry, there are five types of dialysis. Diffusion, Electrodialysis, Donnan Dialysis, Reverse
electrodialysis and Electro-electrodialysis.

Diffusion dialysis is a spontaneous separation process where the driving force which produces the
separation is the concentration gradient. It has an increase in entropy and decrease in Gibbs free energy which
means that it is thermodynamically favorable. Diffusion dialysis uses anion exchange membranes (AEM) or cation
exchange membranes (CEM) depending on the compounds to separate. AEM allows the passage of anions while it
obstructs the passage of cations due to the co-ion rejection and preservation of electrical neutrality. The opposite
happens with cation exchange membranes.

Electrodialysis is a process of separation which uses ion-exchange membranes and an electrical potential
as a driving force. It is mainly used to remove ions from aqueous solutions. There are three electrodialysis
processes which are commonly used - Donnan dialysis, reverse electrodialysis, and electro-electrodialysis. These
processes are going to be explained below.

Donnan dialysis is a separation process which is used to exchange ions between two aqueous solutions
which are separated by a CEM or an AEM membrane. In case of having a cation exchange membrane and two
solutions with different acidity, protons (H+) go through the membrane to the less acid side. It induces an
electrical power that will instigate a flux of the cations present in the less acid side to the more acid side. The
process will finish when the variation of concentration of H + is the same order of magnitude as the difference of
concentration of the separated cation.
Reverse electrodialysis is a technology based on membranes which gets electricity from a mixing of two
water streams with different salinities. It commonly uses anion exchange membranes (AEM) and cation exchange
membranes (CEM). AEM are used to allow the pass of anions and obstruct the pass of cations and CEM are used to
do the opposite. The cations and anions in the high salinity water moves to the low salinity water, cations pass
through the CEMs and anions through the AEMs. This phenomenon can be converted to electricity.

Electro-electrodialysis is an electro-membrane process utilizing three compartments, which combines

electrodialysis and electrolysis. It is commonly used to recover acid from a solution using AEM, CEM and
electrolysis. The three compartments are separated by two barriers, which are the ion exchange membranes. The
compartment in the middle has the water to be treated. The compartments located on the sides contain clean
water. The anions pass through the AEM, while the cations pass through the CEM. The electricity allows creating
H+ in the anions side to react with them and OH − in the cations side to react with them too.

2. Describe and explain the procedure of dialysis.

In clinical, there are 2 main types of dialysis: haemodialysis and peritoneal dialysis.
Hemodialysis involves diverting blood into an external machine, where it's filtered before being returned to the
body

Procedure for Hemodialysis

General Reassessment
 Acute and chronic dialysis prescription should be reviewed, evaluated and carried out accurately to obtain
the maximal efficiency for dialysis. 
  The patient physiologic status is assessed to ascertain the necessity of adjusting any dialysis orders. 
  All machine parameters are assessed to ensure that the prescribed procedure is correctly implemented. 
  The goal is to initiate and terminate the dialysis procedure safely and comfortably with no or minimal
complication.
Rinsing and Priming
 Rinsing of the dialyzer is important because it may reduce the incidence or severity of anaphylactic
dialyzer reaction by virtue of removal of leachable allergens. 
  Micro bubbles are removed when the venous end of the dialyzer is pointed upward. 
   The dialyzer should be used within 5-10 minutes to avoid leaching of residual ethylene oxide or other
leachable allergens into the rinsing fluid. 
  Dialyzer should be rinsed briefly immediately prior to dialysis if more than 10 minutes have elapsed.
Patient Monitoring Pre-dialysis
  Weight, pulse rate, B.P lying and standing temperature, fluid status, blood investigation and vascular
access patency and freedom from infection. 
  Obtaining Vascular access: 
o  Poor vascular access is a limiting factor to patient survival on hemodialysis. 
o  Great care must be taken to maintain adequate vascular access.
Percutaneous venous cannula (femoral, subclavian and jugular)
 Residual heparin or clot is first aspirated from both catheter lumen. 
   Check the patency of each lumen by irrigating with a saline filled syringe. 
   Heparin loading dose is administered in the venous limb and flushed with saline
    Initiate dialysis after 3 minutes. 
AVF and graft using permanent vascular access
Initiating Dialysis
  Set the blood flow rate at 50-100 ml/min, until the blood fills the blood circuit. 
  The priming fluid in the lines and dialyzer is disposed of to drain until the blood reaches the venous air
trap. 
 In unstable patient the priming fluid is usually given to the patient maintain the blood volume.  
 Increase the blood flow rate to the desired level after the circuit is filled with blood (150-250 in acute
cases)  
 Initiate the dialysis solution flow and adjust the TMP.
Alarms:  Blood circuit alarm and dialysis solution circuit alarms.

Patient monitoring during dialysis  

 Pulse rate, BP every 30 to 60 minutes in chronic dialysis, but at least every 15 minute in acute dialysis  
 Food and fluid intake, complication during dialysis and particular observation. 
Termination of dialysis 
Saline rinse:  
 The blood is returned by pumping sterile normal saline into the arterial side until the blood is displaced. 
 After the bubble trap the fluid should be very pale pink in color ( to assure that the patient has lost the
least of red cell) 
Saline air rinse:  
 The blood is forced by pumping a small amount of saline into the arterial line, then the line is opened to
allow air into the circuit to push the saline and blood.  
 The fluid entering the patient should be very pale pink in color.
Patient monitoring post dialysis:  
 Weight, pulse rate, BP lying and standing, Temperature, blood investigation and vascular access patency.  
 All patient parameters and any unusual occurrences should be documented on the patient file. 
Equipment care:  
 The dialysis machine is the responsibility of the staff and of the biomedical technicians. 
  Scheduled maintenance recommended by the manufacturer should be followed meticulously for the safe
and efficient function of the equipment.
 Peritoneal dialysis involves pumping dialysis fluid into the space inside your abdomen (tummy) to draw out
waste products from the blood passing through vessels lining the inside of the abdomen

Procedure for Peritoneal Dialysis

Action:
1. Warm fluid and explain procedures to patient.
 Part of compassionate patient-centered care is involving them in nursing actions.
2. Place surgical mask on patient and self, draw curtains, and ask any caregivers to leave until exchange is finished.
 Infection through the PD catheter is one of the greatest risks, so minimizing possible sources of infection
is vital.
3. Wipe bedside table with alcohol. 
 To prevent any contaminants from entering the sterile field.
4. Wash hands.
5. Place sterile towel under PD catheter, preventing contamination of other towels and center of drape.
 Prevents contaminants near connection site.
6. Place second sterile towel on bedside table (without contaminating sterile field).
 Provides sterile area to prepare supplies.
7. Place sterile bowl, sterile forceps, and two sterile cotton swabs, and gauze on sterile towel on bedside table.
8. Open container with 90% alcohol, stopcock, and suction tubing piece in it
 Allows you to retrieve necessary items without contamination
9. Use sterile forceps to remove stopcock and suction tubing from alcohol and place them in a sterile bowl. Place
forceps on edge of sterile field on table with tips inside sterile field.
 If placed directly on a sterile field, the towel would become wet and therefore contaminated.
 Maintaining the sterility of the tip for future use, though the handle is not sterile.
10. Cut open the following items and use sterile forceps to remove them from the package and place them in the
center of the sterile towel on the bedside table:
 - fluid
 - urinary bag
 - infusion set
 - syringe (if reusing syringe, use sterile forceps to obtain it from the sterile package and place on sterile towel on
bedside table) being careful to maintain sterility of items 
and sterile field
 Maintaining sterility of field and items and preparing for assembly.
 Tearing packages increase the likelihood of contamination.
11. Close catheter clamp, or use Kelly Clamp to clamp catheter.
 Prepares for disconnection and preserves sterility of gloves later in procedure.
12. Don sterile gloves
13. Using a syringe, remove from the LR bag the same amount of fluid as the amount of D50 tobe added. Discard
into a non-sterile kidney basin.
 Preparing to create a solution of the correct concentration.
14. Using a syringe, draw up an ordered amount of D50 and add to the bag of Lactated Ringer. Rotate to mix.   This
is the “dialysate”
 Creating the PD solution. Glucose provides the osmotic pressure for ultrafiltration.
15. Ensure roller clamp on infusion tubing is closed then spike dialysate bag.
16. Attach infusion to the appropriate port of stopcock.
 This is where dialysate will infuse through.
17. Attach suction tubing to “urinary bag” port of stopcock as far as possible and attach urinary bag to suction
tubing. Ensures drainage port on urinary bag is closed. Attach as far as possible to prevent leaks.
 This may become difficult after the suction tubing has been in the alcohol for some time and hardens.
Consider replacing suction tubing if needed.
18. Turn stopcock “Off” toward the Patient. To prevent fluid from draining prematurely.
19. With one hand, use a square of sterile gauze to hold the PD catheter. On the other hand, use one square sterile
gauze to remove cap from PD catheter and place in alcohol. Continue to hold catheter with the same hand – do
not let go until step 20 is complete.
 The catheter and cap are not sterile, so holding them with sterile gloves would contaminate the gloves.
20. With one hand, dip cotton swab into alcohol and cleanse the port in a circular motion. Allow to dry.
 Decrease risk of infection at port, allow to dry to prevent fusing to connector.
21. Attach “patient” port of stopcock to PD catheter, ensuring that it is pushed all the way in.
Note: hands are no longer sterile.
 The catheter is not sterile, so holding it with sterile gloves would contaminate the gloves. Must be pushed
all the way in to prevent leakage.
22. Place the urinary bag on the floor. Wrap dialysis fluid next to a hot water bottle.
 Facilitates drainage and keeps fluid warm while maintaining a closed system.
23. Turn the stopcock “off” towards the infusion set and open the catheter clamp.
 Allows dialysate to flow from abdomen into urinary bag.
24. Ensure dialysate is flowing into urinary 
bag without leaks.
 Allows accurate measuring of drainage and prevents contamination of sterile towels.
25. Remove gloves and cleanse hands. Gloves are no longer sterile.
 Monitor the bag often to ensure the urinary bag is emptied when it is full.
26. a. If reusing the syringe, use forceps to remove other items from the sterile towel on the bedside table and
place syringe in the center.
 b. Place a sterile bowl with 2 remaining gauze squares, and 1 sterile swab on the bedside table. Cover with sterile
gauze and place forceps in the bowl.
c. Then cover the syringe by folding the sterile towel, keeping the center sterile.
27. Reposition the patient from one side to the other and palpate abdomen as needed.
  This promotes and ensures complete draining.
28. When draining is finished, clean hands, put on clean gloves, hang fluid on IV pole, and turn stopcock off toward
patient.
 This will stop draining and allow flushing of stopcock.
29. Open Infusion Set clamp, allowing fluid to flush tubing until it enters the stopcock. Close Infusion Set clamp.
 Air will drain into urinary bag instead of peritoneal cavity.
30. Turn stopcock off to urinary bag and open roller clamp again to begin “Fill” phase, ensuring that filling happens
in ordered time. This allows new dialysate solution to enter 
peritoneal cavity in a closed system, decreasing risk of infection.
 Filling too quickly can cause complications and discomfort.
31. If using two bags, when first bag is empty: clean hands, put on clean gloves, close roller clamp, remove spike
from bag and spike second bag being extremely cautious not to contaminate or touch spike, then resume 
infusing. Remove gloves and clean hands.
 This action is one of the biggest risks as the system is then open to contamination.
32. Just before Fill phase is finished (all ordered fluid has been infused), remove sterile gauze from sterile bowl.
33. Use sterile forceps to remove catheter cap from alcohol and place in sterile bowl.
  Be careful not touch the end of the cap that attaches to the PD catheter as this will introduce
contaminants to peritoneum increasing risk for infection.
34. Close roller clamp on infusion set and clamp PD catheter.
 Prevents dialysate from flowing out when removing exchange set-up and re-capping PD catheter.
35. Clean hands and don sterile gloves. Prevents infection when handling the catheter and opening the system in
following steps.
36. Using remaining 2 pieces of sterile gauze.
 With one hand: hold PD catheter.
 With other hand: remove stopcock assembly from PD catheter.
Continue holding PD catheter with gauze in 
one hand until re-capping is completed. Using gauze preserves sterility of gloves and decreases risk of
contamination of the PD 
catheter.
37. Dip sterile cotton swab in alcohol and swab catheter port in a circular motion. Allow to dry.
 Cleans port of entry, preventing risk of infection.
38. Place catheter cap on port being extremely careful not to contaminate the end of the cap that attaches to the
port, or the port itself.
 Prevents infection from entering the peritoneum.
39. Disassemble system:
- Place suction tubing in 90% alcohol 
- Place stopcock in “open all ways” position 
into 90% alcohol. Do not leave suction tubing piece 
attached to stopcock
- Discard urinary bag after measuring output
- Discard infusion set and fluid bags.
 If suction tubing piece remains attached or the stopcock is not placed in an “open all ways” position,
alcohol is not able to access and disinfect all parts of the system.
40. Remove the surgical mask and allow caregivers to return.
PD system is now closed so risk for contamination is low.
41. Complete documentation including:
- amount of fluid
- color and quality of fluid
- times of in and out
- any concerns noted, such as discomfort
- what time the syringe is replaced
 Allows monitoring of efficacy of PD, fluid balance, and changes in patient's condition.
Procedure for Dialysis in Biochemistry
Equipment
Separating molecules in a solution by dialysis is a relatively straightforward process. Other than the
sample and dialysate buffer, all that is typically needed is:

 Dialysis membrane in an appropriate format (e.g., tubing, cassette, etc.) and molecular weight cut-
off (MWCO)
 A container to hold the dialysate buffer
 The ability to stir the solutions and control the temperature
General Protocol
A typical dialysis procedure for protein samples is as follows:

1. Prepare the membrane according to instructions

2. Load the sample into dialysis tubing, cassette or device
3. Place sample into an external chamber of dialysis buffer (with gentle stirring of the buffer)
4. Dialyze for 2 hours (at room temperature or 4 °C)
5. Change the dialysis buffer and dialyze for another 2 hours
6. Change the dialysis buffer and dialyze for 2 hours or overnight

3.  List down at least 5 factors affecting dialysis

Dialyzer related factors:

 Heat
 Affects the thermodynamics of molecules, increasing temperature speeds diffusion. Therefore, dialysis
will proceed faster at room temperature than at 4°C. In selecting the most appropriate temperature, it is
important to take into account the thermal stability of the molecule of interest.
 Concentration of a molecule 
  As the concentration of a molecule increases, so does the probability that one of those molecules will
contact the dialysis membrane and then diffuse across to the other side. 
Molecule's Molecular Weight
 As a molecule's molecular weight increases, the rate of movement in solution decreases along with the
chance of diffusion through the membrane - even if it the molecule is small enough to pass through the
pores.
Surface area of the membrane 
 Membranes normally used for laboratory dialysis applications are 0.5 to 1.2 mil (12 to 30µm) thick,
providing good diffusion rate as well as structural integrity. While membrane thickness is not a variable
that is easily modified, the surface area usually is. The flatter a sample can be spread over a membrane
surface, the faster will be its dialysis because all molecules in the sample will be closer to the membrane
and a higher proportion of them will be in direct contact with the membrane at any instant.
Stirring the Buffer 
 Increases the diffusion rate. As low molecular weight compounds exit through the pores on the outer side
of the membrane, they form a microenvironment termed a Nernst diffusion layer. In this layer, which is
approximately 200-300 molecules thick, the low molecular weight compounds are at a higher
concentration in relation to the rest of the dialysate. This high local concentration effectively slows the
rate of dialysis because molecules can randomly re-enter the dialysis membrane pores and return to the
sample. Stirring efficiently breaks up the macroenvironment outside the Nernst layer, helping to maintain
the concentration differential needed to drive the diffusion process.
Patient related factors
 Vascular access type 
 Recirculation percent
 Patient hematocrit

4. When does a patient have to undergo dialysis?

 Most people go on dialysis or get a kidney transplant when they have symptoms of kidney failure or when
the main measure of their kidney function (glomerular filtration rate, or GFR) is less than 10 milliliters per minute
(mL/min). Guidelines for doctors about when to start dialysis include kidney failure symptoms, problems
controlling blood pressure, problems controlling fluid, and problems with nutrition. The guidelines suggest these
problems happen when the GFR is between 5 to 10 mL/min.