Life Support Systems – A.A.

2018/2019
Hemodialysis Treatment

4 – Haemodialysis Treatment

Mr Pissanò suffers from renal failure with no residual renal functionality.

He undergoes haemodialysis treatment three times a week: in Tab. 1 the patient and the treatment
data are summarized.

Tab. 1 – Patient and treatment data

Body mass 75 kg

Mean blood volume 7.5 l

Mean hematocrit 43 %

Urea production rate 150 g/week

Treatment frequency 3 treat/week

Urea Concentration required at the end of the session 0.4 g/l

Ultrafiltration volume to extract 10 l/week

In the operating manual of the haemodialysis filter used in the treatment, the chart of the urea
clearance as a function of the blood flow rate is reported (Fig.1). We assume the dialysis fluid flow rate
as constant.

The chart in Fig. 2 represents the ultrafiltration flow rate as a function of the trans-membrane pressure
(TMP, the hydraulic pressure difference between blood and dialysate compartments).

450

400

350

300
CL [ml/min]

250

200

150

100

50

0
0 200 400 600 800 1000 1200 1400 1600

Q [ml/min]
B

Fig. 1 – Characteristic curve of the Fig. 2 - Characteristic curve of the

haemodialysis filter urea clearance. haemodialysis filter ultrafiltration.

Maria Laura Costantino, Giustina Casagrande

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Hemodialysis Treatment

Requests:
1. Calculate the mean urea concentration at the beginning of a dialysis session and the ultrafiltration
volume to be drained during each dialysis session.
2. Based on the urea clearance, evaluate the mean duration of the treatment (TD), in order to reach

the target urea concentration at the end of the session, which is specified in Tab. 1. Make the
calculation for each of the following blood flow rates: 250, 350, 500, 1000, 1500 ml/min.
3. For each pair of blood flow rate-dialysis time (QB, TD) determined at the point 2, evaluate the

TMP to apply, in order to drain the ultrafiltration volume calculated at the point 1.

Assumptions

• Model the patient as a reservoir containing a solution with a uniform urea concentration (single
pool model – Fig.3). Assume this solution volume composed by the total body fluids (equal to
about 57% of the body mass).
• Disregard the urea patient production during the dialysis session.
• Neglect the ultrafiltration flow rate when evaluating urea mass transfer.

Q B,r ,Cr(t)

V, C(t) Q B ,C(t)

CL

Dializzatore

Q UF

Fig. 3 – Single pool patient and haemodialysis circuit scheme.

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Hemodialysis Treatment

Solution
1) Mean urea concentration at the beginning of the treatment and ultrafiltration volume
Under the hypothesis of a uniform subdivision of the treatments over the week, with NT = 3 (number of
treatments per week), the mass of urea stored between two consecutive sessions can be evaluated as:
PU 150g / week
AU = = =50 g
NT 3treatments / week
This mass can be considered as homogeneously dissolved in the fluid volume V, that represents the
57% of the patient body mass. Considering the fluid density equal to the one of the water:
0. 57 ⋅ 75 kg
V= = 42.75 l
1 kg l
The mean urea concentration at the beginning of the treatment is given by the sum of urea
concentration at the end of the previous treatment and the accumulated mass of urea during the inter-
dialysis period in the volume V:

CI = CF + AU / V =0,4 [g/l] +50[g]/42,75 [l]= 1.57 g/l

This computation is related to the worst case. In real conditions we should calculate the concentration
related to the stored mass using the volume V+ that also involves the ultrafiltration volume, since this is
the volume gained by the patient between one treatment and the next one. The ultrafiltration volume
to be extracted per each treatment is:

VUF = VUFtot/NT=10 [l/week]/3 [treat/week]=3.33 l/treat

The initial concentration can be then calculated as follows:

CI = CF + AU / V+ =0,4 [g/l] +50[g]/46,08 [l]= 1.48 g/l.

2) Mean duration of the treatment

Assuming that the urea concentration C(t) in the patient is uniform (single-pool model), to obtain C(t)
during the treatment we need to write a variation equation on the “patient system”:
⎛ urea ⎞ ⎛ urea ⎞
⎜ ⎟ ⎜ ⎟
⎜ accumulation⎟ ⎛ urea⎞ ⎛ urea⎞ ⎜ production⎟ ⎛ residual ⎞
⎜ ⎟ ⎜ ⎟ ⎜ ⎟ ⎜ ⎟ ⎜ ⎟
⎜ during ⎟ = ⎜ flow ⎟ − ⎜ flow ⎟ + ⎜ during ⎟ − ⎜ renal ⎟
⎜ the ⎟ ⎜ rate ⎟ ⎜ ⎟ ⎜ ⎟ ⎜ removal ⎟
⎜ ⎟ ⎝ ⎠ inlet ⎝ rate ⎠ outlet ⎜ the
⎟ ⎝ ⎠
⎜⎝ treatment ⎟⎠ ⎜⎝ treatment ⎟⎠

Since the patient has no residual renal functionality and neglecting the urea production during the
treatment, the last two terms can be put equal to zero.
The hypothesis to neglect the ultrafiltration flow rate, brings to say that: QB,r = QB ; V, V+ = cost

The volume here considered should be V+, involving the total volume of body fluids plus the
accumulated ultrafiltration volume. The mass balance equation becomes:

dC ( t ) 1 dC ( t )
QB Cr(t) − QB C(t) = V+ QB(Cr(t)-C(t)) = (1)
dt V +
dt

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Hemodialysis Treatment

Under the same hypothesis, the clearance of the dialyzer can be written as:
C( t ) − Cr ( t )
K = QB (2)
C( t )

Matching the equations (1) and (2) in a system, we can obtain a linear 1st order differential equation
with constant coefficients:
𝑑𝐶(𝑡) 𝐾
+ !𝐶 𝑡 = 0
𝑑𝑡 𝑉
Solving this equation with the initial condition C(0)=CI =1,57 g/l we obtain a negative exponential

trend:
!
! !!
𝐶 𝑡 = 𝐶! 𝑒 !

At the end of the treatment we want an urea concentration of CF = 0.4 g/l, therefore for t = TD, it has
to be C(TD) = CF , and the duration needed for a treatment is:
!! !!
𝑇! = 𝑙𝑛 (3)
! !!

Based on the chart in fig. 1 and equation (3) it is possible to calculate different durations for the
treatment (Tab.3).
Tab. 3: treatment duration as a function of the blood flow rate

QB K TD TD
[ml/min] [ml/min] [min] [h : min]

250 200 301 05:01

350 250 241 04:01
500 300 201 03:21
1000 400 151 02:31
1500 450 134 02:14
3) Trans-membrane pressure
Assuming a constant ultrafiltration flow rate during the treatment, we can calculate it as:
QUF= VUF / TD .

From the chart in Fig. 2 it is possible to determine the trans-membrane pressure necessary to obtain
QUF.
Tab. 4: trans-membrane pressure drop as a function of the blood flow rate

QB [ml/min] 250 350 500 1000 1500

QUF [ml/min]
11,0 13,8 16,6 22,1 24,9
QUF [ml/h]
663 829 994 1326 1491
Δp [mmHg] 175 210 260 380 >500

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Hemodialysis Treatment

Additional observations:

• Haemolysis determination in a single treatment

Two different 15 G-diameter needles (outlet and inlet accesses) are used to connect the patient to the
dialysis circuit. The geometrical characteristics of the needles are reported in the table:

Geometrical characteristics of a 15 G diameter needle

External diameter 1.9 mm

Internal diameter 1.5 mm

Length 40 mm

The internal diameter of the needles is much smaller than the dimensions of any other component of
the circuit. For this reason an overall gross evaluation of the haemolysis induced by the dialysis circuit,
allows to calculate haemolysis only in the needles as they are for sure the most haemolytic elements of
the whole circuit.
To determine the degree of haemolysis risk for the treatment, we have to evaluate for each blood flow
rate, the shear stress intensity and the related time duration, at each time blood flows into the needles.
These values have to be compared, in the τ−t plane, with the Tillmann limit curve.
The wall shear stress in a cylindrical channel can be determined as:

⎧ 64
Qb 2 ⎪⎪λ = Re for laminar flow
τ=2λρ (4), with ⎨
π 2 D4 ⎪λ = 0.316 for turbulent flow
⎪⎩ Re 0.25

4 ρQb
where D is the needle diameter and the Reynolds Number Re = .
πµ D
The blood characteristics are assumed as: density ρ = 1060 kg/m3, and viscosity µ = 2.652 cP,
calculated by the Bull’s equation, at T = 37°C and Ht = 43%.
Assuming that the patient blood volume (Vb = 7.5 l) is processed by the machine n times during the
treatment, the processed total volume is equal to:
n ⋅ Vb = Qb ⋅ Td (5)
Since in the circuit two identical 15G diameter needles are present, the blood crosses a needle 2n
times, during each treatment. The transit time taken to cross each needle is:
π LD 2
tp = (6)
4Qb

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Hemodialysis Treatment

The total transit time during the treatment is Tp = 2 ⋅ n ⋅ tp , and using the equations (5) and (6):
π LD 2Td
Tp = (7)
2Vb
In Tab.5 shear stress intensity and time durations (calculated by using equations (4) and (7)) are
summarized, for each considered blood flow rate.
Note that, at a blood flow rate of 500 ml/min, the Reynolds Number gives transition flow conditions in
the needle. Therefore, the calculations are performed both for laminar and turbulent conditions (the
real value of τ will be an average value between them).

Tab. 5: Study of the haemolysis of the system

Qb [ml/min] 250 350 500 1000 1500

Re 1414 1979 2827 5655 8482
λ (laminar) 0.04527 0.03234 0.02264
λ (turbulent) 0.04333 0.03644 0.03293
τ [Pa] (laminar) 33.3 46.7 66.7
τ [Pa] (turbulent) 127.7 429.5 873.2
Tp [s] 0.330 0.265 0.221 0.165 0.147

The pairs of the calculated τ and Tp, are reported in Fig.4 together with the Tillmann limit curve.
Observing the position of these points, it is possible to point out that flow rates higher than 500 ml/min
would induce unacceptable haemolysis.

Fig. 4: Tilmann chart - Plot of the studied working conditions in the plane τ−t

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Hemodialysis Treatment

Blood flow rate optimization

The identification of the optimal blood flow rate to be set during a dialysis session, implies the following
considerations.

1. Social recovery of the patient: it increases with the decrease of the treatment duration; as
shown in Tab.2, the duration decreases with the increase of the blood flow rate. However, at very
high flow rates (high-flux dialysis: QB = 1000 ÷ 1500 ml/min), the decrease becomes less and less
significant, because the clearance has a non-linear trend as a function of QB.
TD [min]

QB [ml/min]

2. Cardiovascular impairments: the working point of the heart is very susceptible to the blood flow
rate through an external circuit. As the blood flow rate increases, the heart work increases more and
more, even if for a shorter duration. Therefore, the evaluation of the cardiac behaviour of the
patient cannot be avoided: it’s quite common for the dialysis patients to develop cardiovascular
dialysis related cardiovascular diseases.
3. Haemolysis: the most haemolytic component of the extracorporeal dialysis circuit is the needle.
Haemolysis increases with QB. Moreover, an increase in QB would make also the roller pump more

haemolytic, due to the fact that during dialysis treatments the pump is set as totally volumetric. The
haemolysis evaluation in the needles shows haemolysis to become harmful already at QB = 500

ml/min.
4. Technological considerations: with the increase of the blood flow rate, that would imply a
reduction in the duration of the treatment, also the TMP has to increase (Tab. 3) to allow a proper
ultrafiltration. In these conditions blood proteins undergo a polarization phenomenon which makes
them to adhere to the membrane, increasing the local oncotic pressure. For this reason a further

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Hemodialysis Treatment

higher TMP would be required. The technological problems to consider are related to the mechanical
resistance of the membranes and of the potting.
Δp - TMP [mmHg]

QB [ml/min]

Conclusions:
In conclusion, with the exception of Factor 1, all the other factors suggest the choice of low blood flow
rates.
Specifically Factor 3 has the highest weight in the choice of the QB with a maximum acceptable value

of 350 ÷ 400 ml/min.

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