Iloilo Doctors’ College, College of Nursing

Medical and Surgical Nursing - Lecture

RENAL SYSTEM

SUPPORT OF RENAL FUNCTION

 Regulation and maintenance of the extracellular fluid and
 Acute renal failure is a syndrome with numerous causes, electrolyte constituents are principal via the process of
including glomerulonephritis, prerenal azotaemia, urinary filtration and reabsorption. The kidneys receive
tract obstruction and vasculitis. Acute tubular necrosis approximately 25% of the cardiac output each minute and
(ATN) is a collective term commonly used to describe excrete approximately 180 L/day of glomerular filtrate.
acutely deteriorating renal function, reflecting pathological Fortunately, tubular reabsorption accounts for
changes from various renal insults of a nephrotoxic or approximately 178.5 L/day of the original filtrate, allowing
ischaemic origin. for a modest daily fluid intake of 1.5 L to achieve fluid
 Acute renal failure is defined by a rapid deterioration in balance.
renal function (hours to days), which is easily detected by
commonly measured markers of kidney performance, ANATOMY OF KIDNEY, NEPRHON AND, URINARY
including blood urea nitrogen, serum creatinine, and a DRAINAGE SYSTEM
failed ability to adequately regulate electrolytes, sodium
 The ureters, bladder and urethra collect, drain and
and water balance. While generally reversible, ARF can
temporarily store the urine produced from each kidney.
be life-threatening in the critically ill patient if acid–base
 The kidneys are located in the retroperitoneal space on
balance, electrolyte levels (particularly potassium) or fluid
the posterior wall of the abdominal cavity, encased in a
overloads are not effectively diagnosed and managed.
protective combination of the ribs, muscle, fat, tendon,
 The preferred serum marker of renal function is the
and the renal capsule. Each adult kidney weighs
serum creatinine level. The exact level of serum
approximately 140 g.
creatinine that is considered excessive is disputed;
however, a doubling of the baseline serum creatinine or
levels in excess of 200 μmol/L is commonly agreed on as
being indicative of ARF.
 Urine output is also a key factor in determining the
severity of ARF. It is well established that oliguric renal
failure, that is, a urine output of less than 0.5 mL/kg/h in
adults and 1 mL/kg/h in infants, is associated with poorer
patient outcomes than the non-oliguric form.
 Acute renal failure is reported to occur in 20–25% of
intensive care patient admissions, much higher than the
broader hospital rate of 5%.
 In critical care, ARF often forms part of multiple organ
dysfunction syndromes, whose cause has often been
associated with sepsis, trauma, pneumonia, or
cardiovascular dysfunctions.

RELATED ANATOMY and PHYSIOLOGY

 The renal system has a number of functions, including

regulation and maintenance of fluid and electrolyte
balance, clearance of metabolic and other waste
products, an indirect role in the maintenance of blood
pressure, acid-base balance, and endocrine function.
 In critical care, an appreciation of the renal system’s fluid
management, blood pressure, electrolyte, and acid-base
functions is essential.

1 ARMILDEZ, IMAH BLESS BSN IV- A

Iloilo Doctors’ College, College of Nursing
Medical and Surgical Nursing - Lecture
RENAL SYSTEM

 The functional unit of the kidney is the nephron, which
consists of a filtrate-collecting device (the Bowman’s
capsule), a convoluted tubule that varies in length and
diameter, finally attaching to a common filtrate-collecting
tubule and duct.
 Within the Bowman’s capsule rests the glomerulus, a tuft
of interlaced capillaries that arise from the afferent
arteriole. The efferent arteriole then drains from the
glomerulus via a closely entwined network called the
peritubular capillaries, until these collect in the venous
network of the kidney.
 The glomeruli and nephrons lie in the cortical area of the
kidney, while the collecting ducts gather together into the
renal pyramids, which lie in the medulla of the kidney.
The pyramids drain into the calyces of the kidney, which
then drain into the renal pelvis where urine is gathered to
drain into the ureter.
 The major blood vessels of the kidney, the renal artery,
and veins also enter the renal capsule through the pelvis
of the kidney
 As the filtrate transgresses the glomerulus it is collected
into the Bowman’s capsule and delivered into the
proximal convoluted tubule, loop of Henle, and then the
distal convoluted tubule, where a number of processes
result in the reabsorption of about 99% of the glomerular
filtrate.
 The remaining fluid within the tubule drains into the
collecting tubule to form urine. This fluid has
substantially different properties from the original
glomerular filtrate, as fluid and many electrolytes and
glucose are reabsorbed by the peritubular capillaries.
 Along with blood pressure, the sodium content of the
extracellular fluid is critical in maintaining fluid balance,
as it constitutes the major electrolyte and osmotic agent
of the glomerular filtrate.
 It is imperative that sodium intake and loss is equally
balanced, as excessive losses will result in associated
fluid loss and excessive intake will result in fluid retention.

If sodium balance is not maintained, other compensations

such as a rise in blood pressure may result to restore
fluid balance.
 As blood pressure rises, the excretion of sodium also
increases by way of the production of additional
glomerular filtrate.

URINE PRODUCTION, REGULATION OF GFR, AND

FILTRATE REABSORPTION IN THE NEPHRON

 Urine production consists of three-stage process, which

occurs in the nephron: glomerular filtration, tubular
reabsorption, and tubular secretion.
 The glomerular filtration rate (GFR) is about 125 mL/min
under normal conditions. Changes in the diameter of the
afferent and efferent arteriole help regulate glomerular
blood flow, but this is unable to compensate for large
variations of mean blood pressure; hence, filtration rates
may rise or fall markedly over the course of a day.

2 ARMILDEZ, IMAH BLESS BSN IV- A

Iloilo Doctors’ College, College of Nursing
Medical and Surgical Nursing - Lecture
RENAL SYSTEM

HORMONAL AND NEURAL REGULATION OF RENAL
FUNCTION  This response is essential in assisting with retaining fluid

SYMPATHETIC NERVOUS SYSTEM
 Stimulation of the sympathetic nervous system (SNS) by
loss of blood volume occurs by reflex via the low-
pressure volume sensors in the pulmonary and venous
circulations.
 The SNS widely innervates the kidney and is able to
reduce the filtration rate by constricting the afferent
arteriole of the glomerulus, thus inhibiting blood flow and
pressure necessary to create the glomerular filtration
rate.
 Increases the reabsorption of salt and water in the tubule
and stimulates the release of renin.
ANTIDIURETIC HORMONE
 The antidiuretic hormone (ADH) is excreted from the
pituitary gland under the regulation of hypothalamic
osmoreceptors (thirst center) and reduces kidney
diuresis (the excretion of water).
 By enhancing the kidney’s ability to concentrate urine,
ensures that the excretory functions of waste products
and electrolytes continue while limiting fluid loss.
 ADH is essential to surviving limited periods of fluid
deprivation and fine-tuning urine volume production on a
continuous basis.
in the event of falling blood pressure, or boosting fluid
excretion as blood pressure rises.
 It also responds effectively to a rise in sodium intake by
reducing angiotensin II formation and allowing a larger
natriuresis, resulting in the maintenance of sodium
balance, a key to tissue fluid distribution and balance.
 Aldosterone is a mineralocorticoid excreted from the
adrenal cortex in response to angiotensin II. Aldosterone
increases the reabsorption of sodium, and hence water,
in the cortical collecting tubules and increases the rate of
potassium excretion. This has a dual effect of regulating
sodium balance and extracellular fluid volume.
 As fluid volume accumulates, the rise in glomerular
filtration rate self-limits the volume effect by increasing
both diuresis and natriuresis.

RENIN–ANGIOTENSIN–ALDOSTERONE SYSTEM
(RAAS)
 Renin is the chemical trigger to initiate a cascade system
that results in two powerful hormones acting on the
kidney to significantly influence sodium and water
excretion.
 Renin is produced and released from the juxtaglomerular ATRIAL NATRIURETIC PEPTIDE
apparatus, a collection of cells in the macula densa of the  Atrial natriuretic peptide (ANP) is a hormone released
distal tubule, and the adjacent afferent arteriole next to from the atria of the heart in response to atrial stretching
the glomerulus, which monitors blood sodium during periods of increased circulating fluid volume.
concentration.  ANP is therefore often described as having an
 When released, renin stimulates the activation of antagonizing effect on the RAAS (which acts primarily to
angiotensin I from angiotensinogen. Under the influence preserve sodium and water).
of coenzyme A, angiotensin I convert to angiotensin II, a
potent vasoconstrictor and stimulus to reabsorb sodium
and water. The vasoconstrictor effect raises blood
pressure and flows to the glomerulus, inhibiting further
renin release (a negative feedback mechanism) as
perfusion pressure normalizes. This allows the return of
natriuresis (sodium excretion) and diuresis.

3 ARMILDEZ, IMAH BLESS BSN IV- A

Iloilo Doctors’ College, College of Nursing
Medical and Surgical Nursing - Lecture
RENAL SYSTEM
 These natriuretic, and hence diuretic, effects are mild and
self-limiting and occur in response to mild rises in GFR
and reductions in sodium reabsorption. As the blood
pressure falls, the drop in GFR compensates for the
effect of ANP, ensuring that excessive loss of sodium and
water does not occur.
REGULATION OF ACID-BASE AND ELECTROLYTE
BALANCE
 The kidney assists in the management of body pH by
regulating the excretion of H+ and HCO3 − ions.
 During acidosis the kidney raises H+ secretion by active
transport to combine with ammonia (NH3 +) in the renal
tubule to form ammonium (NH4 +), which is unable to be
reabsorbed. Coincidentally, raised H+ excretion
increases the reabsorption of sodium, which increases
the alkalotic ion, bicarbonate (HCO3 −).
 During alkalosis the reabsorption of hydrogen ions is
increased. These changes in the secretion of hydrogen
ion concentration in the renal filtrate alter the pH of the
urine down to a maximum level of 4. The buffering of H+
with ammonia reduces the acidifying effect of the
hydrogen ions, particularly as some ammonium combines
with chloride to form ammonium chloride.
ROLE AS AN ENDOCRINE ORGAN
 Erythropoietin is important in stimulating the generation of
new red blood cells and is released from the kidney in
response to a sustained drop in arterial blood oxygen
levels. Calcitriol helps regulate the absorption of calcium
from the gut, which in turn promotes bone resorption of
calcium and the reabsorption of calcium in the kidney.
The kidney also acts to convert vitamin D to its active
form, which is necessary for the maintenance of body
calcium levels.
PATHOPHYSIOLOGY AND CLASSIFICATION OF
RENAL FAILURE
PRERENAL CAUSES
 Prerenal factors affecting the blood supply to the kidneys,
such as hypovolaemia, cardiac failure, or hypotension/
shock, can cause ARF.
 As blood flow to the kidneys is reduced, less
glomerulofiltration occurs, urine production diminishes
4 ARMILDEZ, IMAH BLESS BSN IV- A
and wastes accumulate. This state can be reversed by
restoration of blood volume or blood pressure.
 In the short term (1–2 hours), nephrons remain
structurally normal and respond by limiting fluid lost by
urine production while concentrating the excretion of
waste products. The physiological process combines the
neuroendocrine control of the hypothalamus and the
sympathomimetic response, which then regulates both
antidiuretic hormone secretion and the stimulation of the
renin-angiotensin-aldosterone system.
 This process is highly influenced by any preexisting
illness or concurrent factors such as diabetes and
systemic infection.
INTRARENAL (INTRINSIC) CAUSES
 Intrinsic damage to the nephron structure and function
can be due to infective or inflammatory illness, toxic
drugs, toxic wastes from systemic inflammation in sepsis,
vascular obstructive thrombus, or emboli.
GLOMERULONEPHRITIS
 This condition is caused by either an infective or a non-
infective inflammatory process damaging the glomerular
membrane or a systemic autoimmune illness attacking
the membrane. Either cause results in a loss of
glomerular membrane integrity, allowing larger blood
components such as plasma proteins and white blood
cells to cross the glomerular basement membrane. This
causes a loss of blood protein, tubular congestion, and
failure of normal nephron activity. Resolution is based on
treating the cause, such as an infection or autoimmune
inflammatory illness
NEPHROTOXICITY
 Nephrotoxicity occurs as a result of damage to nephron
cells from a wide range of agents, including many drugs
used in critical care (e.g. antibiotics, anti-inflammatory
agents, cancer drugs, radio-opaque dyes).
 Toxic products of muscle breakdown in severe illness
and trauma, commonly called Rhabdomyolysis blood
product administration reactions and blood cell damage
associated with major surgery are also causative agents.
 As these agents may often be given concurrently, a
cumulative effect, along with intermittent falls in renal
perfusion, may result in the development of intrinsic ARF.
Iloilo Doctors’ College, College of Nursing
Medical and Surgical Nursing - Lecture
RENAL SYSTEM

VASCULAR INSUFFICIENCY
 One-third of patients who develop ARF in the ICU have
chronic renal dysfunction.
 This chronic dysfunction may be undiagnosed prior to
the critical illness and may be related to diabetes, the
aging process, and/or long-term hypertension.
 These factors create a reduction in both large and
microvasculature blood flow into and within the kidney,
therefore reducing glomerular filtration activity and
affecting the reabsorption and diffusive process of the
nephron. This reduction in blood flow is exacerbated by
degenerative vessel obstruction with atheromatous
plaque, particularly pronounced in diabetic patients due
to ineffective glucose metabolism.

POSTRENAL CAUSES
 Urinary tract obstruction is the primary postrenal cause of
ARF, and is uncommon in the critical care setting as it is
rarely associated with acute onset renal failure.
 Postrenal obstruction is more common in the community
and is associated with urological disorders such as
prostate gland enlargement in males, urinary tract
tumours and renal calculi formation impairing urine
outflow. It is essential that blockage of any urinary
drainage device be excluded in the critically ill patient
when undertaking an assessment of apparent oliguria.
ACUTE RENAL FAILURE: CLINICAL AND
DIAGNOSTIC CRITERIA FOR CLASSIFICATION AND
MANAGEMENT
CLINICAL ASSESSMENT
 The clinical history is important in differentiating
preexisting renal disease and cataloging the numerous
factors already discussed that can contribute to renal
dysfunction. As the majority of renal failure patients in the
ICU will succumb to the combination of prerenal renal
failure and ATN, the key assessments used in monitoring
renal function are urine output, serum creatinine, and

ACUTE TUBULAR NECROSIS AND ACUTE KIDNEY urea levels, combined with more general hemodynamic
INJURY measures including HR, CVP, BP, PCWP.

 Acute tubular necrosis describes damage to the tubular

DIAGNOSIS
portion of the nephron and may range from subtle
 The management of ARF begins with making the
metabolic changes to the total dissolution of cell
diagnosis, based on the patient’s presenting signs and
structure, with tubular cells ‘defoliating’ or detaching from
symptoms linked to the patient's history. A long-term
the tubule basement membrane.
history of renal disease involving urinary tract infections,
 In critical illness, the most common combination causing
diabetes, cardiac failure, and systemic inflammatory
ARF is the administration of nephrotoxic agents in
illnesses are all highly relevant. The immediate history of
association with prolonged hypoperfusion or ischemia
presentation to a hospital involving surgery or any life-
(oxygen deprivation).
threatening illness with associated shock is also highly
 This type of tubular necrosis can be further mediated by
relevant in association with reduced urine output
infection, blood transfusion reactions, drugs, ingested
volumes over time.
toxins, and poisons, or be a complication of heart failure
or major cardiovascular surgery.
CONSENSUS DEFINITION: THE RIFLE CRITERIA
 ATN is the causative mechanism for up to 30% of acute
kidney failure in the intensive care setting, with the  This is a useful classification system to grade loss of
precise causative illness not easily identifiable in critically kidney function, reflecting stages of injury to the kidney
ill patients with multiple co-morbidities. before failure occurs.
5 ARMILDEZ, IMAH BLESS BSN IV- A
Iloilo Doctors’ College, College of Nursing
Medical and Surgical Nursing - Lecture
RENAL SYSTEM

essential due to the combined increase in protein

catabolism and caloric requirements of associated with
critical illness.
RENAL REPLACEMENT THERAPY

 If conservative measures fail, then the ongoing

management of the patient with ARF requires RRT. This
enables control of blood biochemistry, prevents toxin
accumulation, and allows the removal of fluids so that
adequate nutrition can be achieved.

CLINICAL MANAGEMENT RENAL DIALYSIS

 In critically ill patients, kidney function failure may be
associated with an initial renal response to a fall in  Despite its complex physiology,

perfusion associated with systemic shock. As the majority human kidney function is able to be

of patients recover their renal function from ICU ARF, largely replaced with a management

initial clinical management is aimed at reducing further program that includes an

renal damage. artificial process of RRT that

 If kidney function becomes so compromised that blood can sustain individuals for many

pH, fluid, and electrolyte balance cannot be sustained, years in the community setting. In critically ill patients with

then a replacement therapy will need to be introduced. ARF, this program focuses predominantly on RRT, rather

This is continued until kidney function is marked by the than on the endocrine functions of the kidney.

return of urine production or patients are moved to a

more chronic form of replacement therapy, such as HISTORY

intermittent hemodialysis.  Dialysis is a term describing RRT and refers to the

purification of blood through a membrane by diffusion of

REDUCING FURTHER INSULTS TO THE KIDNEYS waste substances.

 After diagnosis, the next management principle is to

remove or modify any cause that may exacerbate the
pathological process associated with ARF. Further
interventions and investigations are performed in relation
to the findings from the history and presentation.
These may include:
- further intravenous fluid resuscitation (despite an
oligo-anuric state) and restoration of blood pressure
- physical or diagnostic assessment for renal outflow
- obstruction and alleviation if present
- ceasing or modifying the dose of any nephrotoxic
- drugs or agents and treating the infection with
alternative, - less toxic antibiotics.

NUTRITION
 When ARF is persistent, providing nutritional support is
another important management strategy. A review of
nutrition in ARF suggested that an intake of 30–35
kcal/kg/day and a protein intake of 1–2 g/kg/day is
6 ARMILDEZ, IMAH BLESS BSN IV- A
Iloilo Doctors’ College, College of Nursing
Medical and Surgical Nursing - Lecture
RENAL SYSTEM

 The Kolff rotating drum kidney, one of the earliest DEVELOPMENT OF RENAL REPLACEMENT
attempts at RRT used cellulose tubing rolled around a THERAPY IN CRITICAL CARE
wooden skeleton built as a large, drum-styled cage.
 Historically, ARF was treated in the ICU with the use of
Cellulose acetate (material similar to ‘sticky tape’) tubing
peritoneal dialysis (PD), which did not require specialist
was strong, did not burst under pressure, and could be
nurses or physicians.
sterilized. The drum with the blood-filled cellulose tubing
 This simple technique removes wastes by infusing a
wound around it was immersed in a bath of weak salt
dialysis fluid into the abdomen, allowing diffusion and
solution, and as blood passed through, the rotating
osmosis to occur between the peritoneum and fluid
cellulose tubing allowed the waste exchange to occur by
before draining ou again in repeated cycles.
diffusion
 This was performed by the ICU nurse and prescribed by
ICU physicians, but was inadequate in its clearance of
waste and fluid volume, and was associated with
infection, limiting respiratory function and exacerbating
glucose intolerance.
 In 1977 Peter Kramer, a German ICU physician,
frustrated with the limitations of PD and the delays in
gaining a dialysis nurse and machine to attend the ICU,
developed a new dialytic technique by inserting a
catheter into the femoral artery and allowing blood to
flow to a membrane and back to the femoral vein.
 As the blood passed through the membrane, plasma
water was filtered out.
 The technique was called continuous arteriovenous
haemofiltration (CAVH). It was later renamed slow
continuous ultrafiltration (SCUF), as it enabled the
removal of plasma water in addition to dissolved wastes
  This large extracorporeal blood volume became a (convective clearance of solutes) at a flow rate of 200–
focus for further development of the therapy. The goal 600 mL/h by passive drainage from the membrane as
was to develop a membrane for solute exchange with a blood flowed through it.
greater surface are than the cellulose membrane used by
Kolff but needing less blood volume. REFINEMENT OF RENAL REPLACEMENT
 This led to the development of the hollow-fiber filter THERAPY
membrane structure in the 1960s, the same design
 The use of roller blood pumps to generate pressure and a
concept that is used today. Since then significant
reliable flow of blood, thus eliminating the need for
developments have occurred, with new fibers using the
arterial puncture and access, was introduced by two
polymer polysulfone or other artificial synthetic chemical
German groups.
structures that better imitate the nephron glomerulus and
 This approach, termed continuous venovenous
the ability to transfer wastes and plasma water for an
hemofiltration (CVVH), could reliably pump blood at a
effective ‘artificial kidney’.
constant rate and achieve ultrafiltration volumes of 1000
 • This combination of the extracorporeal circuit (EC),
mL/h. This therapy was able to remove large volumes of
blood pump and filter membrane (or artificial kidney or
plasma water and if run continuously with similar
dialyser), and the associated nursing management is now
amounts replaced by a balanced plasma water substitute,
commonly known as hemodialysis. The major treatment
effective clearance of wastes similar to a
components are essentially the same as those first
developed in the 1960s, with the key component being
the device membrane.
7 ARMILDEZ, IMAH BLESS BSN IV- A
Iloilo Doctors’ College, College of Nursing
Medical and Surgical Nursing - Lecture
RENAL SYSTEM
high-intensity dialysis treatment could be achieved
without cardiovascular instability.
 With further modifications to the circuit and filter set-up, a
diffusive component was added to the therapy by running
a dialysate volume through the hemofilter, flowing
between the membrane fibers and countercurrent to
blood flow. This was termed continuous venovenous
hemodiafiltration (CVVHDf). To deliver continuous forms
of venovenous RRT required the introduction of blood
pumps from modified dialysis machines into the ICU, and
created a major education and training need for critical
care nursing
APPROACHES TO RENAL REPLACEMENT
THERAPY
 Both IHD and CRRT require a machine to pump blood
and fluids; pressure and flow devices to monitor
treatment; a tubing and filter membrane set that together
create an extracorporeal circuit (EC) (outside the body
blood pathway); and a catheter connecting the patient’s
circulation to the circuit.
 This catheter enables blood to be drawn from and
returned to the patient (known as ‘access’). Access can
be achieved by three different techniques:
 Temporary catheters inserted via a skin puncture into an
artery (A) for drawing blood and a vein (V) to return the
blood (AV access).
 A surgical joining of an artery and vein (usually in the
forearm), making a large vessel that is punctured with
needles to both draws and return the blood (AV fistula)
 A catheter with two lumens to draw and return blood via a
large central vein (venovenous access catheter).
HEMODIALYSIS, HEMOFILTRATION, AND
HEMODIAFILTRATION
 Haemodialysis, hemofiltration, and hemodiafiltration are
three common techniques used to achieve artificial
kidney support in ARF.
8 ARMILDEZ, IMAH BLESS BSN IV- A
 The extracorporeal component is a common factor in all
these different circuit designs. The difference between
treatments is how the solutes (urea, creatinine, and other
waste products) and solvent (blood plasma water) are
removed from the blood as it passes through the filter
membrane (artificial kidney), and the intermittent versus
continuous prescription of the therapy.
 This is determined by the way in which the dialysis fluids
are mixed with or exposed to the blood, the rate and
direction of blood and fluid flow, and how fluid loss or a
negative fluid balance is achieved.
 The three physical mechanisms of fluid and solute
management are convection, diffusion, and ultrafiltration.
CONVECTION
 Convection is the process whereby dissolved solutes are
removed with blood plasma water as it is filtered through
the dialysis membrane. The word is derived from the
Latin convehere, meaning ‘to remove or to carry along
with.
 This process is very similar to that occurring in the native
kidney glomerulus, as plasma water is filtered across the
nephron tubule via the Bowman’s capsule.
 In RRT, the plasma water with the dissolved wastes is
discarded; the plasma water deficit is then replaced with
manufactured artificial plasma water in equal or slightly
lower amounts to achieve a desired fluid balance. This
blood-washing (purification) process is commonly known
as hemofiltration. When applied on a continuous basis in
the ICU, hemofiltration can adequately replace essential
renal functions and is particularly effective in managing
fluid balance.
Iloilo Doctors’ College, College of Nursing
Medical and Surgical Nursing - Lecture
RENAL SYSTEM

DIFFUSION

 Diffusion refers to the physical movement of solutes

across a semipermeable membrane from an area of high
concentration to that of a relatively low concentration;
that is, solutes move across a concentration gradient. A
higher concentration gradient results in a greater rate of
diffusive clearance.
 • As blood passes through the dialysis membrane,
dialysate fluid, reflecting normal blood chemistry, is
exposed to the blood on the opposing side of the
membrane fiber. Diffusive clearance is continuous as
solute exchange occurs by diffusion with the dialysate
fluid and the blood is continually moving in and out of the
membrane. As ‘dirty’ or waste-laden blood enters the
membrane and ‘clean’, fresh dialysate is in continuous
supply, this process performs an effective waste-removal
process. The two mediums are usually established in
countercurrent or opposing flow to each other, making
diffusion another process, mimicking the normal nephron
function of the kidneys.
 • The technique of solute removal using diffusion alone is
termed dialysis; when used with blood, the process is
termed hemodialysis (HD). When applied on an
intermittent basis, as is normal for patients receiving
RRT for chronic renal failure, it is called intermittent
hemodialysis

ULTRAFILTRATION

9 ARMILDEZ, IMAH BLESS BSN IV- A