Module 4

Hemodialysis Devices

M3 Dialysis Center, Inc

Hemodialysis Nurse Training Course
2014
 Hemodialysis Nurse Training Course
M3 Dialysis Center, Inc.
MODULE 4: Hemodialysis Devices

Objectives
After completing this module, the learner will be able to:
1. Identify the purpose and characteristics of dialyzers.
2. Describe the purpose and chemical composition of dialysate.
3. Describe dialysate preparation and the three monitoring functions of the dialysate
delivery subsystem.
4. Describe the extracorporeal blood circuit functions and monitoring systems.

Definition of Terms
Adsorption
Biocompatibility
Cellulose membrane
Clearance
Convection
Dialysate
Dialysate Delivery System
Dialyzer
Diffusion
Extracorporeal Circuit
Hemodialysis Delivery System
Mass Transfer Coefficient
Membrane Surface Area
Modified-cellulose membrane
Molecular Weight Cut Off
Semi-permeable membrane
Synthetic membrane
Ultrafiltration
Ultrafiltration Coefficient

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A dialyzer lets the patient’s blood
interact with dialysate through a semi-
permeable membrane. A dialysate is a
blend of treated water and chemicals; it
removes wastes and fluid, and balances
electrolytes. A delivery system supplies
fresh dialysate and removes used dialysate.
The dialyzer, dialysate, and delivery system
replace some tasks that failed kidneys can
no longer do.
Modern high-tech delivery systems
include a blood pump, an ultrafiltration
pump, a dialysate conductivity monitor,
alarms, and pressure gauges. Better
membranes, safety monitors, and the use of
computers have made dialysis safer. These
advances allow today’s staff to turn more of
their time to patients. Trained staff who
knows dialysis principles, equipment, and
procedures is the most vital monitors of
patient safety.
Dialyzers
Functions and Components
- have a blood and a dialysate
compartment
- Semi-permeable membrane
keeps the two compartments
apart; membrane is housed in a
plastic case, which holds the
dialyzer together and forms
pathways for blood and dialysate
to flow in and out
Dialyzer Characteristics
 Biocompatibility
- means not harmful to biological
function
- immune cells in the blood reacts
to materials used to make
dialysis membranes
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- vital to use a membrane the
patient can tolerate
- can be tested by checking the
patient’s blood for certain
proteins and chemicals
- adsorption (attract and hold) of
proteins into the fiber wall is key
to its biocompatibility; proteins
coat the surface so blood does
not touch the “foreign”
membrane; the protein coating
explains why reprocessed
(cleaned and reused) dialyzers
can be more biocompatible than
new ones.
Note: Reprocessing dialyzers with bleach
can strip the protein coating off the
membrane.
Figure 1: Dialyzer design
- Synthetic membranes are more
biocompatible than cellulose
membranes; are also
hydrophobic (water repelling)
 makes them better able
to adsorb blood proteins

 Surface Area
- a key to how well a dialyzer can
remove solutes
- dialyzers with more surface area
 expose more blood to
dialysate  more solutes can be
removed from the blood
- Total dialyzer surface area can
range from 0.5 – 2.4 square
meters.
 Mass Transfer Coefficient (KoA)
- is the ability of a solute to pass
through the pores of a dialyzer
- (in theory) is the highest possible
clearance of a given dialyzer at
infinite blood and dialysate flow
- The higher the KoA, the more
permeable the dialyzer.
 Molecular Weight Cutoff
- determines the largest molecule
that can pass through the
membrane
- measured in daltons (Da)
- the average weight of a
molecule, expressed as the sum
of the atomic weights of all the
atoms in the molecule
- Larger molecules = higher
Dialyzer
Surface Area
Type
2
F8 1.8 m
Revaclear 1.4 m2
HF80S 1.8 m2
F160NR 1.5 m2
F180NR 1.8 m2
Table 1: VariationsTable 1: Variations of Dialyzers
of Dialyzers
Hemodialysis Nurse Training Course
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MODULE 4: Hemodialysis Devices
molecular weights; smaller
molecules = lower ones
- Dialyzers have molecular weight
cutoffs ranging from 3,000 to
more than 15,000 Da
 Ultrafiltration Coefficients (KUf)
- the amount of fluid that will
pass through the membrane in
one hour, at a given pressure
Ultrafiltration (UF) - a way to
remove excess water from a
patient during hemodialysis by
applying hydraulic pressure
(pressure applied to the blood or
dialysate compartment forces
water across the membrane)
- dialysis machines can vary the
hydraulic pressure to control the
ultrafiltration rate (UFR) and
amount of water removed
- High pressure in the blood
compartment more fluid out
of the blood and into the
dialysate
- Transmembrane pressure
(TMP)- pressure difference
across the membrane
** blood compartment
pressure minus dialysate
compartment pressure
KoA Kuf
(mL/h/mmHg)
- provided by the
726 7.5 dialyzer’s manufacturer
- helps the staff member
732 50 predict how much fluid
805 55 will be removed from
the patient during a
1064 50 treatment
1239 62
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MODULE 4: Hemodialysis Devices

Sample Problem:
A dialyzer with a KUf of 10 will Molecule Molecular Weight (Da)
remove 10 ml of fluid per hour for each
Albumin 66,000
mmHg of pressure.
B2 Microglobulin 11,600
Let’s say a dialyzer has a KUf of 10,
and a TMP of 100 mmHg, the patient Creatinine 113
would lose 1,000 ml of fluid per hour of
dialysis (10 x 100 = 1,000). Phosphorus (PO4²) 94.9
Z inc (Zn²+) 65.3
 Clearance (K)
- amount of blood that can be Nitric Oxide (NO3) 62
cleared of a solute in a given Urea 60
period of time
- how well dialyzers remove Calcium (Ca++) 40
solutes from the blood varies
Water (H2O) 18
from one another
- clearance rates for different Table 2: Molecular Weight of Solutes
molecules are given by the  Concentration
manufacturer for certain blood gradient
and dialysate flow rates  Size, weight and
- three main ways to remove charge of the solutes
solutes that affect a dialyzer’s
clearance: diffusion,  Convection
convection, and adsorption o as fluid crosses a semi
permeable membrane,
some solutes are pulled
 Diffusion along with it
o best way to remove small o solvent drag
(low molecular weight) o best way to remove
solutes larger solutes
o depends on: o Convective clearance
 Blood and dialysate depends on:
flow rates  Molecular weight
 Membrane surface cutoff o the
area and thickness membrane
 Number of pores  Membrane surface
 Solution temperature area
 Membrane resistance  Ultrafiltration rate
(UFR)

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MODULE 4: Hemodialysis Devices

F8* HF80S F180NR Revaclear*

Urea 186/240 248 274 196/271

Creatinine 172/216 225 251 189/250

Phosphate 138/165 220 238 185/239

B12 76/83 155 168 144/170
B2M Not specified 0.65 Not specified 0.7

*Qb = 200/300, Qd = 500mL/min, UF= 0/60

Clearance = mL/min
Table 3: Clearance values of Various Dialyzers

** A sieving coefficient is for better

used to say how much solute is compatibility
expected to be removed by  adsorbed material
convection. can build up on the
membrane 
Sample Problem: ↓diffusion and
A sieving coefficient of 0.5 for a convection
solute means that 50% of the solute will  highly adsorptive
pass through the membrane to the membranes  less
dialysate side. The other 50% will be effective when they
adsorbed or rejected by the membrane. are reprocessed
many times; cannot
 Adsorption be evaluated by
o occurs when material testing dialyzers for
sticks to the dialyzer total cell volume (also
membrane called fiber bundle
o dialyzers adsorb volume)
materials, usually small
proteins, to some extent;
hydrophobic synthetic
membranes adsorb more
than cellulose
membranes
o Pros & Cons (in dialysis):
 adsorbed protein
keeps the membrane
away from the blood,

Figure2: Adsorption
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MODULE 4: Hemodialysis Devices

 Total cell volume - an indirect Membranes

measure of changes in solute
transport for hollow fiber dialyzers
The semi permeable membrane
that are reused.
acts in some ways like the vessel wall of a
human nephron, because it is selective.
o A dialyzer’s adsorptive
- with microscopic pores, the
ability depends on:
membrane allows only certain
 Membrane material
solutes and water to pass
 Surface area
through
 How much material
- large substances such as protein
has already adsorbed
and blood cells won’t fit through
to the membrane
the small pores.

Dialyzer Design There are membrane factors that

affect removal of solutes and fluids during
Hollow fiber dialyzer - a clear plastic dialysis. These include the membrane
cylinder that holds thousands of fiber tubes material and characteristics of each
almost as thin as strands of hair dialyzer.
- fibers are held in place at each
end by polyurethane, Membrane Materials
clay-like “potting” - can affect diffusion
material that holds and UF as well as
fibers open so blood efficiency of dialysis
can flow inside them and the patient’s
- Hollow fiber dialyzers comfort during
allow for well- treatment
controlled, predictable
UF.  Cellulose
- fibers are rigid  no membranes
membrane compliance o made from
(change in shape or cotton-based
volume due to material that is
pressure); instead, hold spun into
almost the same hollow fibers
amount of fluid at high o have thin fiber
pressures as they do at walls (8-15
low pressures. microns)
- Resistance to blood flow Figure3: Dialyzer Design o size of
is low in hollow fiber dialyzers. molecules
cleared is
limited to about
3,000 Da

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MODULE 4: Hemodialysis Devices

o slower removal of middle molecules,

molecules in the larger depends mainly on UF
molecular weight range, rates
such as beta-2- o do a good job of
microglobulin (ß2m = removing solutes up to
11,800) 15,000 Da
o surface areas range from o clears ß2m to some
0.5-2.1 meters extent
o have larger in vitro o membrane
(tested in a laboratory) biocompatibility ranges
urea and creatinine from good to very good
clearances compared to o are close to pure
synthetic dialyzers synthetics
o are the least
biocompatible; causes  Synthetic membranes
the most complement o are made from polymers
activation that are formed into
o least able to remove hollow fibers
solute by adsorption o The materials used in
synthetic membranes
 Modified cellulose are:
membranes  Polycarbonate
o hydroxyl group (OH-) are  Polyacrylonitrile
removed and replaced (PAN)
with acetate (cellulose  Polysulfone (PSF)
acetate), amino acids, or  Polymethylmethacryl
synthetic molecules ate (PMMA)
o have much
thicker fiber Cellulose Synthetic
walls = 22-40
microns Material Cotton-based Polymers
o use
Width Thin Thickest
convection,
(8-15 microns) (30-55 microns)
diffusion and
adsorption to Size Up to 3,000 Da Up to 15,000 Da
remove Accommodation
solutes
Biocompatibility Least Best
o clearance of
solutes, Adsorption Low High
especially
Table 4: Comparison of Cellulose and Synthetic membranes

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MODULE 4: Hemodialysis Devices

o have the thickest fiber walls = 30-55 Determining Dialyzer

microns
o solutes are removed by convection, Clearance
diffusion, adsorption
o clearance of solutes, especially Manufacturers test dialyzers in vitro,
middle molecules, depends mainly using watery fluids that are thinner than
on UF rates blood. When measured during actual use
o remove solutes up to 15,000 Da, on patients, a dialyzer’s real clearance can
clearing ß2m to some extent differ from the manufacturers stated values
o membrane biocompatibility is very by ±10 – 30%. The clearance of urea (a
good small molecular weight solute) is most often
o highly adsorptive can quickly keep used to test the overall effectiveness of a
the blood from touching the dialyzer.
membrane
Dialysate
Measuring Dialyzer
Effectiveness Purpose of Dialysate
- a fluid that helps remove uremic
wastes, e.g. urea and creatinine,
A dialyzer’s effectiveness is checked
and excess electrolytes
by testing its clearance. Clearance is
- replaces needed substances,
expressed as the amount of blood (in mL)
such as calcium and bicarbonate,
that is completely cleared of a certain
which helps keep the body’s pH
solute in one minute of treatment, at a
balance
given blood flow rate (Qb) and dialysate
- patient’s blood  one side of
flow rate (Qd).
the membrane (blood
compartment)
Sample Problem:
- dialysate  on the other side of
A dialyzer has a stated urea
the compartment
clearance of 250mL/min at a Qb of 300 mL.
- Dialysate and blood never mix,
In one minute, 250 ml of blood would be
unless the membrane breaks
cleared of urea by the dialyzer. If 300mL of
- is prescribed to have a desired
blood is pumped through the dialyzer in
levels of solutes the patient
one minute, only 250 mL of blood will be
needs and none of the ones that
cleared of urea.
must be removed completely
- osmolality (solute particle
** The dialyzer’s surface area is
concentration) of dialysate
fixed. So either Qb or Qd must be increased
should closely match the blood
to increase clearance. Qb is always a factor
to keep too much fluid from
that limits clearance, since there is a limit to
moving across the membrane
how quickly blood can flow out of the
- concentration gradient created
patient’s vascular access.
decide the diffusion rates of

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MODULE 4: Hemodialysis Devices

each solute across the  Calcium chloride

membrane  Glucose
- unwanted solutes leave the  Acetic acid (to lower the dialysate’s
blood and move into the pH)
dialysate; desired solutes stay in Bicarbonate concentrate
the blood  Sodium bicarbonate
- some solutes are added to  In some cases, sodium chloride
dialysate in amounts that can
cause them to enter the - Association for the
patient’s blood e.g sodium, Advancement of Medical
bicarbonate, and chloride Instrumentation (AAMI) has set
standard symbols to match the
concentrates

Almost all of the hemodialysis

machines today can use the varied dialysate
formulations. With the correct and precise
dilution of the concentrates to the
prescribed amount of water, right
concentration of electrolytes is achieved
that is vital to the cellular function.

Concentrate Proportioning Ratios

Typical Range of Substances in Dialysate
Dialysate
Figure 4: Concentration gradient & diffusion rates
 Sodium (Na+)
Composition of Dialysate - a major electrolyte of the body’s
- prescribed by the doctor blood plasma and interstitial
- starts out as two concentrated fluid
salt solutions: acid and - normal sodium concentration in
bicarbonate diluted with precise the blood = 135 – 145 mEq/L
amounts of treated water to - sodium concentration in the
make the final dialysate dialysate is most often kept in
- there are three formulations, the same range
which must match the right acid - level can be adjusted by a
concentrate with the right dialysate delivery system during
bicarbonate concentrate a treatment according to a
doctor’s prescription. This is
Acid Concentrate called sodium modeling.
 Sodium chloride
 Potassium chloride

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Sodium Modeling
 creates more efficient fluid
shifts in the body
 removes fluid faster
 provides for better control of
blood pressure and fluid
removal
 can increase thirst and body
weight, and hypertension
between dialysis treatments
 Potassium (K+)
- a major electrolyte of the
intracellular fluid
- kept precise amounts within the
body on both sides of cell
membranes to send nerve
signals
- normal plasma potassium level =
3.5 – 5.5 mEq/L
- dialysate range (depending on
the patient’s needs) = 0 – 4
mEq/L
 Magnesium (Mg++)
- vital to the nerves and muscles
- triggers enzymes that are key to
carbohydrate use
- normal plasma magnesium level
= 1.4 – 2.1 mEq/L
- dialysate range = 0.5 – 1.0 mEq/L
 Calcium (Ca++)
- found in the body in
extracellular (outside the cells)
and intracellular (inside the
cells) fluid
- builds bones and teeth, helps
muscles move, is needed for
blood clotting, and helps send
nerve signals
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MODULE 4: Hemodialysis Devices
Figure 5: Dialysate Contents
- normal range of calcium in the
plasma = 8.5 – 10.5 mg/dL (4.5 –
5.5 mEq/L)
- dialysate calcium = 2.5 – 3.5
mEq/L
 Chloride (Cl‫)־‬
- concentration in dialysate
depends on the contents of
chemicals such as sodium
chloride, potassium chloride,
magnesium chloride, and
calcium chloride
- normal plasma chloride levels =
98 – 111 millimoles per liter
(mM/L)
- dialysate chloride ranges = 100 -
124 mEq/L
 Glucose (C6H12O6)
- may be added to dialysate to
prevent loss of serum glucose
and to reduce catabolism
- dialysate glucose range = 0 – 250
mg/dL
- can be two to three times higher
than normal (70-105 mg/dL),
 Hemodialysis Nurse Training Course
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MODULE 4: Hemodialysis Devices

Parts Parts Parts Parts

Type/Style
Acid Bicarb Water Dialysate

Drake-W illock 1.00 1.83 34

COBE Labs 1.00 1.72 42.28

Fresenius 1.00 1.225 32.775

Table 5: Concentrate Proportioning Ratios

which aids in UF because it has - added to dialysate to help

an osmotic (water-pulling) effect maintain patients’ pH; healthy
kidneys regulates bicarbonate to
 Bicarbonate (HCO3) keep the body’s pH within the
- used by the body to neutralize very tight limits necessary for
acids that are formed when cells cells to survive
metabolize proteins and other - can reduce dialysis-related
foods used for fuel problems e.g. hypotension,
- a buffer (a substance that tends muscle cramps, nausea, and
to maintain a constant pH in a fatigue after treatment
solution) even if an acid or base
is added Hemodialysis Delivery
- metabolic acidosis = too much
acid in the blood; typical with Systems
CKD patients since they in the
urine cannot excrete enough Purpose
acids - mixes and delivers dialysate
- pumps blood through the
Substance Concentration in Dialysate dialyzer
- monitors various dialysis
Sodium 135 to 145 mEq/L
parameters to ensure a safe
Potassium 0 to 4 mEq/L treatment
- monitors patient and machine
Calcium 2.5 to 3.5 mEq/L safety parameters including
Magnesium 0.5 to 1.0 mEq/L blood flow, dialysate flow,
dialysate temperature,
Chloride 100 to 124 mEq/L conductivity, venous and
Bicarbonate 32 to 40 mEq/L arterial pressure, blood in
dialysate leaks, patient blood
Glucose 0 to 250 mg /dL pressure, etc
Table 6: Typical Range of Substances in Dialysate
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- two major subsystems: the
dialysate delivery system and
the extracorporeal blood circuit
 Dialysate Delivery System
- controls the amounts of water
and chemicals in dialysate, and
checks its conductivity,
temperature, pH, flow rate, and
pressure
- tests the dialysate for the
presence of blood
 The Proportioning System
- dialysate is made by mixing fresh
concentrate with fixed amounts
of treated water
- mixing is controlled by the
internal mechanical and
hydraulic design of the delivery
system
- water and concentrate ratio is
dependent on center’s policies
and procedures (See table on
concentrate proportioning
ratios)
Figure 6: Single-patient dialysate delivery system
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MODULE 4: Hemodialysis Devices
Concentrate Proportioning Ratios
- Two ways in making dialysate:
(both rely on a continuous supply
of fresh concentrate and water
to a mixing chamber)
 Fixed-ratio pumps
 uses diaphragm or piston pumps
to deliver set volumes of
concentrate and water to a
mixing chamber
 Servo-controlled mechanisms
 have conductivity control
sensors that constantly check
the dialysate’s total ion
concentration
Dialysate Flow Process
- mixed  warmed  monitored
for conductivity, temperature,
pressure, and flow rate 
dialysate
- after dialysate leaves the
dialyzer  passes through a
blood leak detector  drain
 Hemodialysis Nurse Training Course
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MODULE 4: Hemodialysis Devices

** Blood in the dialysate could mean mixture of the first concentrate

a tear in the membrane. So blood leak (most often acid) with water; the
detectors are often treated as other sensor measures the final
extracorporeal (outside the body) – alarms, dialysate after the second
even though they check the dialysate. concentrate is added
- multiple monitoring system/
 The Monitoring System redundant monitoring: use
- wrong dialysate = less effective conductivity sensors to make the
dialysis treatment or may cause dialysate itself and a second set
illness or death to a patient of sensors to check the mixtures,
- dialysate must be checked apart from the ones that control
throughout each treatment to the mixing
ensure that it is the right - conductivity is checked at the
concentration and temperature, point of mixing and again before
and that it is flowing at the right the dialysate enters the dialyzer
rate o used so two sensors
would have to fail before
 Conductivity a patient could be
- how much electricity the fluid harmed
will conduct - maybe stated in micromhos/cm,
- electrolytes or salts (chemicals in millimhos/cm,
dialysate except for glucose) microsiemens/cm, or
break apart in water to form millisiemens/cm
positive and negative charged - most dialysate delivery systems
ions have internal, preset
- electrolyte conductivity levels of conductivity limits
the dialysate is checked by the - when the dialysate
proportioning system concentration moves outside the
- is checked by placing a pair of
 Common type of conductivity
electrodes in the dialysate;
alarms:
voltage is applied to the
 Low conductivity - caused by:
electrodes, and the current is
o lack of concentrate in one
measured which gives the
or both of the
estimated total ion
concentrate jugs
concentration of the dialysate
 High conductivity - due to:
- a sensor cell may be used
o poor water flow to the
instead of electrodes
proportioning system
- hemodialysis delivery systems
o untreated incoming
have two or more independent
water
conductivity monitors - with
o use of the wrong
separate sensors and monitoring
dialysate concentrate
circuits: one sensor measures the

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preset safe limits, it triggers a
conductivity monitoring circuit;
the circuit stops the flow of
dialysate to the dialyzer and
shunts it to the drain called
bypass, thus keeping the wrong
dialysate from reaching the
patient
- the circuit also sets off audible
and visual alarms to alert the
staff
- the proportioning system must
have enough of both
concentrates to complete the
whole treatment
- the conductivity alarm should be
working before each treatment,
and the machine readings must
be checked against an
independent meter
 Temperature
- dialysate is kept in the range of
37°C to 38°C (98.6°F to 104°F)
for diffusion to be effective
 too-hot dialysate = hemolysis
 too-cool dialysate = patient is
cold and reduce diffusion =
↓dialysis efficiency
- the high limit should be set at no
higher than 41°C (105°F) and
many alarm systems have a low
setting, which should not be
below 33°C (91°F)
- water must be heated to a
certain temperature before
mixing with the concentrates
- some systems use a heat
exchanger before the heater, to
save energy  used dialysate
transfers its heat to the incoming
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MODULE 4: Hemodialysis Devices
cold water, warming it before it
enters the heater
- most systems use a heater
controlled by a thermistor, a
type of thermostat  a separate
temperature monitor is placed in
the dialysate path before the
dialyzer with preset limits, and
works independently of the
heater control thermistor
- with some delivery systems, the
patient is the only “monitor” of
low temperature
- whenever the temperature is
either too hot or cold, a circuit
sets off audible and visual alarms
and triggers bypass to shunt
dialysate to a drain
- before each dialysis treatment,
check the dialysate temperature
alarm to ensure that it is working
properly
 Flow rate (dialysate)
- flow to the dialyzer is controlled
by a flow pump
- may be preset or according to
the doctor’s prescription
- higher dialysate flow rates
improves dialyzer efficiency,
though little improvement
occurs above 800 mL/min
- dialysate flow rates range from
0-1,000 mL/min
 Dialysate flow rate audible and
visual alarms may be set off by:
o low water pressure
o dialysate pump failure
o a blockage in the dialysate
flow path
o a power failure

- a high/low conductivity,
high/low pH, high temperature,
or in some cases blood leak
alarm, can trigger the delivery
system to switch into bypass
mode
- check the delivery system before
each treatment to be sure that
the bypass mode works properly
for all dialysate alarm conditions
 Blood leak detector
- used to check for blood in the
used dialysate
- can sense very small amounts of
blood, less than can be seen with
the naked eye
- shines a beam of light through
the used dialysate and onto the
photocell or photoresistor
Figure 7: Blood leak detector
Blood detection process:
dialysate with blood  pass through the
beam of light  even a tiny amount of
blood will break the light beam detector
senses a break  audible and visual alarms
triggered  blood pump stops  venous
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MODULE 4: Hemodialysis Devices
line clamps (to prevent further blood loss)
 system may turn into a bypass mode 
dialysate is shunted to the drain
- Hemastix® (strip that reacts to
blood) should be used to check
the extent of the leak. The test
must be taken where the
dialysate leaves the dialyzer:
 If blood or pink color
can be seen in the
dialysate path, there
is a major leak
 Clear dialysate and a
positive Hemastix
test suggest a minor
leak
 Clear dialysate and a
negative Hemastix
test mean a false
alarm
- depending on the center’s
procedures for a blood leak,
treatment should be stopped
without returning the patient’s
blood to prevent the
contaminated blood from
infecting the patient
- the blood leak detector’s basic
sensitivity is usually preset by
the manufacturer; adjustments
can be made within this limited
range.
 pH
- a measure of how acidic or
alkaline (basic) a solution is
- is based on the number of acid
ions (hydronium ions) or alkali
(base) ions (hydroxyl ions) it
contains

- A solution with:
o An equal number of acid and
base ions is neutral and has a
pH value of 7.0
o More acid ions is acidic and
the pH value will be less than
7.0
 White vinegar is an acid,
with a pH of 2.9
o More base ions is alkaline
and the pH will be greater
than 7.0
 Bleach (sodium
hypochlorite) is alkaline
with a pH of 11.0
 The pH of blood is
normally from 7.25-7.45;
a weak base
- dialysate must have a pH close
to blood so it does not change
the blood pH; in general, the
range of dialysate pH is from 7.0-
7.4
- whether or not the delivery
system has a pH monitor, at the
start of each treatment, an
external test must be done to
ensure that the dialysate pH is in
a safe range
- the most accurate pH measure
uses a pH electrode, which puts
out a small voltage when placed
in a solution; the voltage is read
by a detection circuit that
converts the signal into a pH
value and displays it
- test strips coated with a
chemical that changes color
based on pH are another way to
measure it
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MODULE 4: Hemodialysis Devices
 Ultrafiltration Control
Ultrafiltration
 occurs during the treatment when the
pressure on the blood side of the
dialyzer membrane is more positive
than the pressure on the dialysate
side
 this pushes fluid in the blood across
the membrane into the dialysate
compartment where it is then
expelled in the drain
 the difference between these
pressures is the TMP
TMP and dialysate pressure
 determines how much fluid from the
blood is forced across the
membrane
 before, dialysis machines used a
manual system of setting the TMP or
a negative dialysate pressure for
achieving fluid removal but with the
volumetric dialysis today, TMP is
automatically calculated and set by
entering the desired fluid removal
(in mL) and the treatment time
 fluid removal accuracy is more
precise than earlier UF control
systems due to:
o the in-vitro KUf values
reported by dialyzer
companies, however, in vivo
KUf is often somewhat lower
(5% - 30%)
o clotting of the dialyzer fibers
reduces the KUf by reducing
the surface area of the
membrane
o changes in the blood pump
speed lead to changes the
venous pressure
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o an increase or decrease in monitor the flow rate of the

the dialysate flow, or a kink dialysate
or blockage in the dialysate
lines changes the dialysate  Extracorporeal Circuit
pressure - second major subsystem of the
hemodialysis delivery system
UF control systems - carries blood from the patient’s
 UF control is the means by which access to the dialyzer and back
the dialysis machine removes fluid to the access
from the patient and accurately - includes the:
measures it o arterial and venous blood
 Ultrafiltration rate (UFR) is the tubing
amount of fluid removed in a o blood pump
specific period of time o heparin pump
 Types: o dialyzer
o Volumetric control - uses o venous line clamp
two chambers that fill and o blood flow monitors
drain to control the volume o pressure monitors
of dialysate going to and o air monitors
coming from the dialyzer Components and Monitoring
o Flow control - uses sensors in o Blood tubing
the fluid path to and from - during treatment: blood through
the dialyzer to control and blood tubing flows from the

Figure 8: Volumetric Control System

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Figure 9: Flow Control System
patient’s vascular access (arterial
needle)  dialyzer  back to
the patient’s access (venous
needle)
- with a small inner diameter of
the blood tubing causing only
about 100-250ml of blood is
outside the patient’s body at any
time
- two divisions: arterial (red) and
venous (blue)
- typically, smooth on the inside
to reduce clotting and air
bubbles
Parts of blood tubing:
 Patient connectors:
o tip or Luer-Lok® connector
found at the end of the
arterial and venous blood
tubing segments connecting
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MODULE 4: Hemodialysis Devices
the tubing to the patient’s
needles or catheter ports
 Dialyzer connectors:
o Luer-Lok connectors at the
other end of the blood
tubing segments connect the
tubing to the dialyzer
o arterial blood tubing
segment = arterial end of the
dialyzer; venous blood tubing
segment = venous end of the
dialyzer
 Drip chamber / bubble trap:
o checks the arterial or venous
pressure in the blood circuit
o uses a monitoring line with
transducer protectors
o collects or “traps” any air
that accidentally gets into
the extracorporeal circuit
o keeps blood clots in the
extracorporeal circuit from

reaching the patient, by
using a very fine mesh screen
(venous chamber)
 Blood pump segment:
o a durable, pliable, larger
diameter part of the arterial
blood tubing threaded
through the blood pump
roller
 Heparin infusion line:
o most often found on the
arterial blood segment just
before the dialyzer
o heparin may be given during
treatment to the patient
through a very small
diameter tube that extends
out of the blood tubing
 Saline infusion line:
o allows saline to be given to
the patient during dialysis
o most often found on the
arterial blood tubing
segment just before the
blood pump, so saline can be
pulled into the circuit
o if the saline infusion line is
not clamped correctly, too
much fluid or air can enter
the extracorporeal circuit
 Transducer protectors
o a mechanical device inside
the machine that converts air
pressure into an electronic
signal, which display venous
pressure, arterial pressure,
and TMP
o damaged by moisture
o barrier between blood in the
tube and the transducer in
the machine
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MODULE 4: Hemodialysis Devices
o connected to the machine’s
venous and/or arterial ports
via a small tubing segment
on top of the drip chamber
o use membranes with a
nominal pore size of 0.2
microns that are
hydrophobic when wetted,
to keep fluid from passing
through; if these filters get
wet, they prevent air flow
o wet or clamped venous
transducer protector causes
TMP problems
o a loose or damaged
transducer protector on a
pre-pump arterial drip
chamber port could allow air
into the bloodline circuit
o change wet transducer
protectors right away and
inspect the machine side of
the protector for
contamination or wetting
(Centers for Disease Control
and Prevention); if a fluid
breakthrough is found on the
removed transducer
protector, the machine’s
internal transducer protector
(a back-up) must be
inspected by a qualified
technician
Other components of the extracorporeal
circuit:
 Blood pump / blood flow rate
o moves blood from the
patient’s arterial needle
through the blood tubing, to
the dialyzer, and then back

to the patient through the
venous needle
o a roller pump is the most
common type of blood
pump; uses a motor that
turns a roller head
o speed of the roller head set
by the staff determines
blood flow rate
o blood flow rates (BFR) can be
varied between 0 mL/min
and 600mL/min according to
the prescription
o some machines count blood
pump turns and calculate the
number of liters processed in
a treatment; knowing the
number of liters prescribed
to be processed allows
calculation of the blood flow
rate: divide liters processed
by minutes of treatment
o for an effective treatment,
the blood flow rate must be
accurate and reflect the
doctor’s prescription
o if the rollers are too tight
(pump occlusion), the blood
pump segment may crack or
RBC may be destroyed;
otherwise, blood may escape
out the back of the segment,
reducing blood flow
below the prescribed
level
o Pump occlusion must be
checked periodically
and adjusted per the
manufacturer’s
instructions; checked
when the tubing size or
manufacturer changes
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MODULE 4: Hemodialysis Devices
o all blood pumps have a way
to allow hand cranking in
case of emergency such as a
power failure
 Extracorporeal pressure monitors
o pressure in the
extracorporeal circuit
depends on blood flow rate
and resistance to the flow
o resistance occurs in every
part of the extracorporeal
circuit: access needles or
catheters, blood tubing, and
dialyzer that are overcome
by a blood pump
o pressures are displayed in
millimeters of mercury
(mmHg) on a gauge, meter,
or screen
o extracorporeal pressure
monitoring is needed to
calculate TMP and ensure
patient safety
o pressure monitors have
upper and lower limits and
may be set; others, have a
preset range within which
staff can choose a midpoint;
o when pressure exceeds the
high or low setting, the
system will trigger audible
Figure 10: Blood pump
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MODULE 4: Hemodialysis Devices

and visual alarms, stop the  Different pressure and safety

pump, and clamp the venous monitors:
line
o extracorporeal blood  Arterial pressure
pressure alarm must be  pressure from the patient’s
checked to ensure access to the blood pump
functionality before  also called pre-pump
treatment pressure
o a pre-pump or post-pump  with a fistula or graft = less
drip chamber may be placed than zero or negative arterial
on the arterial bloodline pressure due to the
o a monitoring line or pressure resistance from the vascular
gauge connection at each access and the pulling of the
drip chamber is used to blood pump
check arterial and/or venous  Predialyzer pressure
pressure in the  pressure between the blood
extracorporeal circuit pump and the dialyzer
 also called as post-pump
pressure, predialyzer
pressure, or post-pump
arterial pressure
 pressure in this segment
of the blood tubing is
greater than zero, or
positive
 monitored to detect
clotting in the dialyzer;
suspect clotting if there is
a large pressure
differential on each side
of the dialyzer
 Venous pressure
 pressure from the
monitoring site to the
venous return
 also called postdialyzer
pressure
 positive pressure readings
 Air detectors
o continuously check the
blood in the venous tubing
Figure 11: Pressure monitoring devices on arterial and venous
bloodlines segment for air and foam

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Figure 12: Pressure alarm triggers

o checks for air at the venous calibrated by qualified

drip chamber or at the blood technicians
tubing just below it o when senses air, it triggers
o are ultrasonic devices that audible and visual alarms,
check for changes in a sound stop the blood pump, and
wave sent through a cross- clamp the venous blood
section of the blood path tubing to keep air from
o since sound travels faster getting into the patient’s
than air than liquid, any air in bloodstream
the blood will raise the speed o must always be used during
at which the sound wave the dialysis treatment and
passes through the blood, venous line clamps engaged
setting off an alarm with the tubing; must be
o sensitivity limits are most checked regularly before
often preset by the each treatment to ensure
manufacture, but can be functionality

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Figure 13: Air Detector Alarm
 Heparin system
o blood tends to clot when it
touches the artificial material
of the lines and the dialyzer,
thus, heparin, an
anticoagulant, is used to
prevent clotting in the
extracorporeal blood circuit
o heparin may be given in a
variety of ways:
 intermittently - (on
and off) during
dialysis; a prescribed
amount is injected
into the arterial
bloodline at
prescribed times
 bolus - the full
prescribed amount is
given all at once just
before the treatment
 continuous infusion -
a prescribed rate
throughout the
treatment; an
infusion pump is used
and the pump slowly
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MODULE 4: Hemodialysis Devices
injects the heparin
into the circuit
o heparin is stopped 30
minutes to 1 hour before
the end of the treatment
so blood clotting can go
back to normal
o heparin is infused into the
heparin line on the arterial
blood tubing before the
dialyzer and heparin lines
are placed after the blood
pump segment to avoid
negative pressure which can
draw air into the
extracorporeal circuit
o heparin pumps have variable
speeds that can be set to the
physician’s prescription
o heparin is
Sorbent Dialysis
 can be used for acute, home, and
chronic dialysis treatments
 needs no water treatment system
 does not contain water and
concentrate proportioning pumps;
uses premixed chemicals are added
to 6 L of tap water
Figure 14: Heparin infusion line
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MODULE 4: Hemodialysis Devices

Sorbent Dialysis Process: and is continuously displayed.

water and chemicals  Sorbent cartridge has four chemical

↓ layers which regenerates dialysate
cycled through a sorbent regenerative and treats water, purifying the 6L of
cartridge to purify the dialysate dialysate made with tap water\
↓  sorbent cartridge = continuous
dialysate (collected in a disposable bag) dialysate disinfection system =
↓ keeping bacteria and endotoxin
circulated to the dialyzer levels below 1 cfu mL and 0.5
↓ EU/mL, respectively
removal of electrolytes  can do short (3-5 hour) treatments
↓ at Qd up to 400 mL/min, or long and
used dialysate is then cycled through the slow (5-8 hour) treatment at Qd of
cartridge 200-300 mL/min, depending on
↓ which cartridge used
electrolytes & ultrafiltrates are chemically  using the sorbent cartridge = no
converted back into fresh dialysate continuous water source, floor
↓ drain, or water treatment system
storage bag  can be used anywhere with an
electrical outlet (or suitable
Each increase in the total volume of generator)
dialysate is a direct reflection of total UF
Conclusion
 Knowledge of
the hemodialysis
devices including
the dialyzer,
dialysate and the
delivery system
keeps the
patient from
danger.
 The delivery
system is
featured with
monitoring
capacities thus
enforcing safety
and quality of
each
hemodialysis
Figure 15: Sorbent regenerative cartrige

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MODULE 4: Hemodialysis Devices

treatment.
 However, the dialysis staff is still the
most inevitable monitor of all to
keep patient safe. Alarms are of no
use if it was not checked and
verified for functionality before it is
being used.
 Moreover, it is crucial to master the
components of these dialysis
devices as they play a very
important role in hemodialysis
efficiency.
 If all these devices are maintained,
patients will definitely lead patients
to live full and active lives.
 Thus, utmost care, skill at finding
and troubleshooting problems and
one’s attention to detail will make
all the difference in patient’s
outcomes.
Figure 16: Sorbent dialysis system

79