Renal Replacement Therapy

Objectives of presentation
• Mechanisms of dialysis

• Indications of dialysis

• Hemodialysis apparatus ( vascular access —> extracorporeal circuit —> Dialysate

circuit —> Dialyzer)

• Anticoagulation for dialysis

• Modalities of hemodialysis

• Initiation of dialysis in kidney failure and AKI patients

• Peritoneal dialysis

• Complications of hemodialysis and peritoneal dialysis

 Renal replacement therapy (RRT)
• RRT : A treatment modality which replaces partial or complete function
of native kidney

• Broadly two types of RRT :

1. Dialysis

2. Renal transplant

• In 2020, KDIGO suggested “kidney replacement therapy” as preferred

term over “renal replacement therapy”.
 Historical development
• In 1861, Thomas Graham invented the fundamental process of separating
solutes using semipermeable membrane in vitro and coined the term
“dialysis”.

• In 1943, Willem J. Kolff used rotating drum artificial kidney for the first
time to treat renal failure patients.

• First hemodialysis in India was performed at CMC, vellore in 1961 under

supervision of Dr. Satoru Nakamoto.
 Dialysis
• It is a process whereby the solute composition of solution - A, is altered
by exposing it to solution - B, through a semipermeable membrane.

• Solutes can pass through the semipermeable membrane via two

mechanisms

1. Diffusion

2. Convection
- Movement of solutes

- Through a semipermeable membrane

- Caused by concentration gradient.

- Movement of solution

- Through a semipermeable membrane

- Caused by pressure gradient

(hydrostatic).
 Convection

• Convection is the movement of solute molecules through membrane

pores, dragged by fluid moving during ultrafiltration.

• Compared to diffusion, convection permits removal of higher molecular

weight solutes at a higher rate.
 Indications of dialysis

• Acute kidney injury (AKI) with life threatening changes in fluid, electrolyte
and acid-base balance

• Kidney failure

• Fluid, electrolyte and acid-base imbalance refractory to medical therapy

• Toxins/Poisoning

• Severe sepsis



 Classification of Dialysis
Based on –



1. Location of therapy: 

Home, Hospital

2. Manner of access: 

Hemodialysis (arterio-venous, veno-venous), Peritoneal dialysis

3. Duration of therapy: 

Intermittent, Continuous

4. Dominant mechanism of solute clearance: 


Diffusion, Ultrafiltration or Both
 Hemodialysis apparatus





1. Blood circuit
2. Dialysis solution
(Dialysate) circuit 3. Dialyzer
a. Inflow blood line/Arterial line

b. Roller pump
a. Proportionating system

c. Outflow blood line/Venous line b. Monitors and alarms

c. Ultrafiltration control
 Hemodialysis apparatus





 Vascular access for hemodialysis

• Vascular access for dialysis are of three types. They are

• Arteriovenous fistula

• Arteriovenous graft

• Dialysis Catheters
 Arteriovenous fistula
• Preferred for patients anticipated to have long term dialysis.

• Most common location - forearm (non-dominant)

• Advantages:

• Best patency rates

• Lowest rate of thrombosis and infections

• Lower mortality and morbidity

• Low cost

• Most AV fistulas take 4-8 weeks to achieve physiological maturation.

Arteriovenous fistula
 Arteriovenous grafts
• Preferred for patients with vascular anatomy not favorable for AV fistula.

• Most common location - forearm and upper arm

• Most common material used - expanded polytetrafluoroethylene (ePTFE)

• Advantages:

• Technically easy to insert, cannulate and repair

• Can be used at multiple sites

• Shorter maturation time (2-3 weeks)

• Disadvantages: higher rate of stenosis and thrombosis

Arteriovenous grafts
 Dialysis catheters
• Preferred for patients with short term dialysis requirement and in emergent
conditions.

• Two types -1) tunneled 2) non-tunneled

• Most common location for Dialysis catheter - Right IJV > Femoral vein > Left IJV

• Advantages :

• Ease of insertion

• Can be used at multiple sites

• Can be used in emergent conditions

• Disadvantages : High morbidity due to thrombosis and infections

Non tunneled dialysis catheters
Tunneled dialysis catheter
 KDOQI clinical practice guidelines for vascular access: 2019

• Referral for dialysis access assessment and creation should be done in

non dialysis CKD patients with progressive decline in kidney function
when eGFR is 15-20ml/min/1.73m2

• Long term : AV fistula or graft (based on clinical judgement)

• Short or long term : Tunneled dialysis catheters

• Limited time (< 2 weeks) : Non tunneled dialysis catheters

Extracorporeal circuit
Dialysate circuit
Dialysate composition
 Dialyzer
• Dialyzer is often called “artificial kidney”

• It is the site where blood and dialysate interact with each other across a
semipermeable membrane.

• Two types of dialyzer: 1. Hollow fibre (most commonly used) 2.Parallel plate

• Membrane in dialyzer are made up of either

• Cellulose material: cellulose acetate, cellulose discettate

• Synthetic material: polyamide, polysulfone, polymethylmethacrylate

• Synthetic membranes are more biocompatible and are often preferred

Hollow fibre dialyzer vs Parallel plate dialyzer
Types of Dialyzers
Anticoagulation
 Modalities of hemodialysis
• Intermittent modalities
• Intermittent hemodialysis (IHD)

• Prolonged intermittent renal replacement therapy (PIRRT)

• Sustained low efficiency daily dialysis (SLEDD)

• Extended daily dialysis (EDD)

• Slow continuous dialysis (SCD)

• Sustained low efficiency daily diafiltration (SLEDD-f)

• Sustained hemodiafiltration (S-HDF)

• Accelerated venovenous hemofiltration (AVVH)

 Modalities of hemodialysis
• Continuous modalities
• Continuous renal replacement therapy (CRRT)

• Slow continuous ultrafiltration (SCUF)

• Continuous arteriovenous hemofiltration (CAVH)

• Continuous arteriovenous hemodialysis (CAVHD)

• Continuous arteriovenous hemodiafiltration (CAVHDF)

• Continuous venovenous hemofiltration (CVVH)

• Continuous venovenous hemodialysis (CVVHD)

• Continuous venovenous hemodiafiltration (CVVHDF)

Intermittent hemodialysis (IHD)
• Most common form of dialysis utilised for kidney failure patients

• Suitable modality for rapid correction of hyperkalemia and drug intoxications

• Mechanism of solute clearance: diffusion

• Duration of IHD is usually 3-6 hours

• Blood flow rates of 300-500 ml/min is required

• It can be performed with less or no anti coagulation

• Hypotension is observed in 30% of patients undergoing IHD

• IHD can cause rapid intracellular fluid and solute shift

 Prolonged intermittent renal replacement therapy (PIRRT)
• Suitable modality for patients with acute kidney injury (AKI)

• Mechanism of solute clearance

• Diffusion: SLEDD, EDD, SCD

• Convection: AVVH

• Diffusion & Convection: SLEDD-f, S-HDF

• Duration of PIRRT is usually 8-16 hours

• Blood flow rates of 100-300 ml/min is required

• Anti coagulation requirement is variable

• PIRRT can be administered with conventional hemodialysis machines

• Improved hemodynamic stability is observed when compared to IHD

 Continuous renal replacement therapy (CRRT)
• Most common form of dialysis utilised for critically ill patients suffering from AKI

• Improved hemodynamic stability and more continuous solute clearance is observed when
compared to IHD

• Mechanism of solute clearance: diffusion, convection or combination of both

• Duration of CRRT is usually 24 hours

• Blood flow rates of 100-300 ml/min is required

• Disadvantages include:

• Greater requirement of anti coagulation

• Reduced patient mobility

• Labour intensive procedure

• Replacement fluid is infused into blood to replace excess fluid and electrolyte loss
Comparison between IHD, PIRRT & CRRT
Terminology of Hemodialysis prescription in kidney failure
Initiation of dialysis in kidney failure patients
Initiation of dialysis in kidney failure patients
KDOQI guidelines on hemodialysis adequacy: 2015 update
Initiation of dialysis in AKI patients - KDIGO 2012
Modality of dialysis in AKI patients - KDIGO 2012
Dose of dialysis in AKI patients - KDIGO 2012
Discontinuation of dialysis in AKI patients - KDIGO 2012
Peritoneal dialysis
• Peritoneal dialysis involve infusion of dialysate into peritoneal space such that water,
toxins and other solutes can be dialyzed out of body using peritoneum as
semipermeable membrane.

• Predominant mechanism of solute clearance: Diffusion

• Advantages:

• Technically simple

• No requirement of vascular access or anti coagulation

• Hemodynamics are stable

• Lower cost
Peritoneal dialysis
• Disadvantages:

• No control over rate of fluid removal

• Risk of peritonitis

• Impaired diaphragmatic movement

• Contraindications:

• Recent abdominal surgery

• Abdominal drains

• Diaphragmatic incompetence

• Ileus
Three pore model of peritoneal transport
Standard peritoneal dialysis fluid composition
Peritoneal dialysis in kidney failure patients

• Various forms of peritoneal dialysis used in kidney failure patients include:

• Continuous ambulatory peritoneal dialysis (CAPD)

• Automated peritoneal dialysis (APD)

• Outcomes of peritoneal dialysis in kidney failure patients compared with in centre

hemodialysis

• No difference in overall survival

• Greater patient satisfaction and quality of life

Peritoneal dialysis in AKI patients

• Various modalities of peritoneal dialysis in AKI patients include

• Acute intermittent peritoneal dialysis (IPD)

• Continuous equilibrated peritoneal dialysis (CEPD)

• Tidal peritoneal dialysis

• Continuous flow peritoneal dialysis

• High volume peritoneal dialysis (HVPD)

Peritoneal dialysis in AKI: ISPD guidelines 2020
 Complications of Hemodialysis
• Acute complications of hemodialysis

• Severe fluctuations in blood pressure

• Hypoxemia

• Air embolism

• Anaphylaxis

• Hypokalemia & Hyperkalemia

• Arrhythmia

• Cardiac arrest
Complications of Hemodialysis

• Infectious complications

• Blood stream infections

• Hospital acquired pneumonia

• Viral infections like HIV/HBV/HCV

 Complications of hemodialysis
• Neurological complications
• Muscle cramps

• Headache

• Dialysis disequilibrium syndrome – 


( ?cerebral edema in new patient with high BUN started on HD )

• Seizure

• Hematological complications of hemodialysis

• Anemia

• Leukopenia

• Thrombocytopenia

• Hemorrhage
 Complications of peritoneal dialysis
• Infectious complications

• Peritonitis

• Non infectious complications

• Catheter malfunction

• Drain pain

• Hydrothorax

• Hernia

• Encapsulating peritoneal sclerosis

Thank you!