Dialysis

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 Types of Dialysis
• Dialysis may be required for the treatment of
either acute or chronic kidney disease, mostly
in renal failure.
• Two major types:
1. Haemo-dialysis
2. Peritoneal Dialysis

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 Haemodialysis – Artificial Kidney
• The basic principle of the artificial kidney is to
pass blood through minute blood channels
bounded by a thin membrane.
• On the other side of the membrane is a dialyzing
fluid into which unwanted substances in the
blood pass by diffusion.
• In the artificial kidney, blood flows continually
between two thin membranes of cellophane;
outside the membrane is a dialyzing fluid.
• The cellophane is porous enough to allow the
constituents of the plasma, except the plasma
proteins, to diffuse in both directions—from
plasma into the dialyzing fluid or from the
dialyzing fluid back into the plasma. 3
Artificial Kidney Unit

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 Basic Principle
• If the concentration of a substance is greater
in the plasma than in the dialyzing fluid, there
will be a net transfer of the substance from
the plasma into the dialyzing fluid.

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 Factors Affecting Dialysis
• The rate of movement of solute across the
dialyzing membrane depends on
(1) the concentration gradient of the solute
between the two solutions,
(2) the permeability of the membrane to the
solute,
(3) the surface area of the membrane, and
(4) the length of time that the blood and fluid
remain in contact with the membrane.
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• In normal operation of the artificial kidney, blood
flows continually or intermittently back into the
vein.
• The total amount of blood in the artificial kidney
at any one time is usually less than 500 milliliters,
the rate of flow may be several hundred milliliters
per minute, and the total diffusion surface area is
between 0.6 and 2.5 square meters.
• To prevent coagulation of the blood in the
artificial kidney, a small amount of heparin is
infused into the blood as it enters the artificial
kidney.
• In addition to diffusion of solutes, mass transfer
of solutes and water can be produced by applying
a hydrostatic pressure to force the fluid and
solutes across the membranes of the dialyzer;
such filtration is called bulk flow. 7
 Dialysing Fluid
• The concentrations of ions and other substances
in dialyzing fluid are not the same as the
concentrations in normal plasma or in uremic
plasma.
• Instead, they are adjusted to levels that are
needed to cause appropriate movement of water
and solutes through the membrane during
dialysis.
• There is no phosphate, urea, urate, sulfate, or
creatinine in the dialyzing fluid; however, these
are present in high concentrations in the uremic
blood.
• Therefore, when a uremic patient is dialyzed,
these substances are lost in large quantities into
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the dialyzing fluid.
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• Artificial kidneys can clear urea from the plasma
at a rate of 100 to 225 ml/min, which shows that
at least for the excretion of urea, the artificial
kidney can function about twice as rapidly as two
normal kidneys together, whose urea clearance is
only 70 ml/min.
• Yet the artificial kidney is used for only 4 to 6
hours per day, three times a week.
• Therefore, the overall plasma clearance is still
considerably limited when the artificial kidney
replaces the normal kidneys.
• The artificial kidney cannot replace some of the
other functions of the kidneys, such as secretion
of erythropoietin, which is necessary for red
blood cell production. 10
 Peritoneal Dialysis
• In peritoneal dialysis, 1.5–3 L of a dextrose-
containing solution is infused into the peritoneal
cavity and allowed to dwell for a set period of
time, usually 2–4 h.
• As with hemodialysis, toxic materials are removed
through a combination of convective clearance
generated through ultrafiltration and diffusive
clearance down a concentration gradient.
• The clearance of solutes and water during a
peritoneal dialysis exchange depends on the
balance between the movement of solute and
water into the peritoneal cavity versus absorption
from the peritoneal cavity. 11
• The rate of diffusion diminishes with time and
eventually stops when equilibration between
plasma and dialysate is reached.
• Absorption of solutes and water from the
peritoneal cavity occurs across the peritoneal
membrane into the peritoneal capillary
circulation and via peritoneal lymphatics into
the lymphatic circulation.
• The rate of peritoneal solute transport varies
from patient to patient and may be altered by
the presence of infection (peritonitis), drugs,
and physical factors such as position and
exercise. 12
Peritoneal Dialysis

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 Types of Peritoneal Dialysis
• Peritoneal dialysis may be carried out as
1. Continuous ambulatory peritoneal dialysis
(CAPD),
2. Continuous cyclic peritoneal dialysis (CCPD),
or
3. A combination of both.

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 CAPD
• In CAPD, dialysis solution is manually infused
into the peritoneal cavity during the day and
exchanged three to five times daily.
• A night time dwell is frequently instilled at
bedtime and remains in the peritoneal cavity
through the night.
• The drainage of spent dialysate is performed
manually with the assistance of gravity to
move fluid out of the abdomen.
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 CCPD
• In CCPD, exchanges are performed in an
automated fashion, usually at night; the
patient is connected to an automated cycler
that performs a series of exchange cycles
while the patient sleeps.
• The number of exchange cycles required to
optimize peritoneal solute clearance varies by
the peritoneal membrane characteristics; as
with hemodialysis, experts suggest careful
tracking of solute clearances to ensure dialysis
"adequacy." 16
CCPD Cycler

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 Peritoneal Dialysis Solution
• Peritoneal dialysis solutions are available in
volumes typically ranging from 1.5 to 3.0 L.
• Lactate is the preferred buffer in peritoneal
dialysis solutions.
• The most common additives to peritoneal
dialysis solutions are heparin to prevent
obstruction of the dialysis catheter lumen
with fibrin and antibiotics during an episode
of acute peritonitis.
• Insulin may also be added in patients with
diabetes mellitus.
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• Thank You.

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