DIALYSIS

Dr. Frank Edwin

CAUSES OF RENAL
FAILURE
Diabetes
Untreated high blood pressure
Inflammation
Heredity
Chronic infection
Obstruction
Accidents

1.Renal Failure Diagnosis

Symptoms: Anorexia, Nausea, Vomiting, Oliguria
? Precipitating factors

Signs: Anaemia, Hypertension, Fluid Overload etc

Biochemistry:
Blood
Urea >7mmol/l
Creatinine >120umol/l
Electrolytes: Rising K+

Creatinine Clearance (GFR <<120ml/l)

Urine: Proteinuria

May be Acute or Chronic

Acute Reversible or Irreversible

2. Treatment Options
No Treatment
Monitoring & Predialysis
Control symptoms
Preserve Residual Renal Function
Control rising BP (Antihypertensives)
Control Renal Bone Disease (Ca2+, Vit D)
Prevent/Treat Anaemias (Erythropoietin, Blood)

Dialysis
Renal Transplantation

Dialysis
Definition
Artificial process that partially replaces renal
function
Removes waste products from blood by
diffusion (toxin clearance)
Removes excess water by ultrafiltration
(maintenance of fluid balance)
Wastes and water pass into a special liquid
dialysis fluid or dialysate

Types
Haemodialysis (HD)
Peritoneal Dialysis (PD)
They work on similar principles: Movement

of solute or water across a semipermeable

membrane (dialysis membrane)

Diffusion
Movement of solute
Across semipermeable membrane
From region of high concentration to one of

low concentration

Ultrafiltration
Made possible by osmosis
Movement of water
Across semipermeable membrane
From low osmolality to high osmolality
Osmolality number of osmotically active

particles in a unit (litre) of solvent

Selection for HD/PD

Clinical condition
Lifestyle
Patient competence/hygiene (PD - high risk

of infection)
Affordability / Availability

1.

2.

Blood cells are too big to pass through the dialysis membrane,
but body wastes begin to diffuse (pass) into the dialysis solution.
3.

Diffusion is complete. Body wastes have diffused through the membrane,

and now there are equal amounts of waste in both the blood and the
dialysis solution.

The process of ultrafiltration in PD

11.

2
2.

Blood cells are too big to pass through the semi-permeable membrane,
but water in the blood is drawn into the dialysis fluid by the glucose.

3.

Ultrafiltration is complete. Water has been drawn through the peritoneum

by the glucose in the dialysis fluid by the glucose in the dialysis fluid. There is
now extra water in the dialysis

Haemodialysis
Dialysis process occurs outside the body in a

machine
The dialysis membrane is an artificial one:
Dialyser
The dialyser removes the excess fluid and
wastes from the blood and returns the filtered
blood to the body
Haemodialysis needs to be performed three
times a week
Each session lasts 3-6 hrs

Requirements for HD
Good access to patients circulation
Good cardiovascular status (dramatic

changes in BP may occur)

Performing HD
HD may be carried out:
In a HD Unit
At a Minimal Care / Self-Care Centre
At Home

HD Unit
Specially designed Renal Unit within a hospital
Patients must travel to the Unit 3x a week
Patients are unable to move around while on

dialysis; may chat, read, watch TV or eat

Nursing staff prepare equipment, insert the
needles and supervise the sessions

Minimal / Self-Care Dialysis

Patients take a more active role
Patients prepare the dialysis machine, insert

the needles, adjust pump speeds and

machine settings and chart their progress
under the supervision of dialysis staff
Patients must travel to the unit 3x / week
Patients need to be on a fixed schedule

Home Haemodialysis
Use of machines set up at home
Machines have many safety devices inbuilt
Thorough patient training
Requires the help of a partner at home every time
Suitability is assessed by the haemodialysis team
Ideal for patients who value their independence

and need to fit in their treatment around a busy

schedule

HD Access
2 types of access for HD:
Must provide good flow
Reliable access

A fistula: arterio-venous (AV)

Vascular Access Catheter

AV Fistula

AV Fistula

Vascular Access Catheter

AV Fistula Access
Matures in about 6 weeks
Ensure good working order

Avoid tight clothing or wrist watch on fistula arm

Assess fistula daily; notify immediately if not working
Avoid BP cuff on fistula arm
Avoid blood sampling on fistula arm (except daily
HD Rx)
Avoid sleeping on fistula arm
Grafts (synthetic) may be used to create an AV fistula

Vascular Access Catheter

Double lumen plastic tube
May be placed in Jugular, Subclavian or Femoral

vein
May be temporary or permanent
Temporary awaiting fistula or maturation
Permanent poor vessels for fistula creation e.g.
children and diabetics
Catheters must be kept clean, dry and dressed to
prevent infection

Effects of HD on Lifestyle

Flexibility:
Difficult to fit in with school, work esp if unit is far from home.
Home HD offers more flexibility
Travel:
Necessity to book in advance with HD unit of places of travel
Responsibility & Independence:
Home HD allows the greatest degree of independence
Sexual Activity:
Anxiety of living with renal failure affects relationship with
partner
Sport & Exercise:
Can exercise and participate in most sports
Body Image:
Esp with fistula; patient can be very self conscious about it

Problems with HD

Rapid changes in BP

fainting, vomiting, cramps, chest pain, irritability, fatigue, temporary loss of

vision

Fluid overload

esp in between sessions

Fluid restrictions
more stringent with HD than PD
Hyperkalaemia
esp in between sessions
Loss of independence
Problems with access
poor quality, blockage etc. Infection (vascular access catheters)

Pain with needles

Bleeding

from the fistula during or after dialysis

Infections
during sessions; exit site infections; blood-borne viruses e.g. Hepatitis, HIV

Peritoneal Dialysis (PD)

Uses natural membrane (peritoneum) for dialysis
Access is by PD catheter, a soft plastic tube
Catheter and dialysis fluid may be hidden under

clothing
Suitability
Excludes patients with prior peritoneal scarring e.g.
peritonitis, laparotomy
Excludes patients unable to care for self

Addendum to Principles (PD)

Fluid across the membrane faster than solutes;

therefore longer dwell times are needed for solute

transfer
Protein loss in PD fluid is significant ~ 8-9g/day
Protein loss s during peritonitis
PD patients require adequate daily protein
averaging 1.2 1.5g/kg/day
Other substances lost in the dialysate
Amino acids, water soluble vitamins, some
medications and hormones

Calcium and dextrose are absorbed from the

dialysate fluid into the circulation

Addendum to Principles (PD)

Standard dialysis solution contains:
Na+ 132 mEq/l
Cl- 96 -102 mEq/l
Ca2+ 2.5 3.5 mEq/l
Mg2+ 0.5 -1.5 mEq/l
Dialysis solution buffer:
Sodium lactate
Pure HCo3 HCo3- /Lactate combinations
Lactate is absorbed and converted to HCo 3- by

the liver
Dextrose solution strengths: 1.5%, 2.5%, 4.25%

Types
Continuous Ambulatory Peritoneal Dialysis

(CAPD)
Automated peritoneal Dialysis (APD)

CAPD
Dialysis takes place 24hrs a day, 7 days a week
Patient is not attached to a machine for treatment
Exchanges are usually carried out by patient after

training by a CAPD nurse

Most patients need 3-5 exchanges a day i.e.
4-6 hour intervals (Dwell time) 30 mins per exchange

May use 2-3 litres of fluid in abdomen

No needles are used
Less dietary and fluid restriction

CAPD Exchange

APD
Uses a home based machine to perform exchanges
Overnight treatment whilst patient sleeps
The APD machine controls the timing of

exchanges, drains the used solution and fills the

peritoneal cavity with new solution
Simple procedure for the patient to perform
Requires about 8-10 hrs
Machines are portable, with in-built safety features
and requires electricity to operate

PD Access
Done under
LA or GA

DIET
Why is diet important?
Managing the diet can slow renal disease
The need for dialysis can be delayed
The diet affects how patients feel

CONTROLLING YOUR
DIET

Foods to control are those containing:

Protein
Potassium
Sodium
Phosphorous
Fluid

PROTEINS
Animal protein
Dairy (milk, cheese)
Meat (steak, pork)
Poultry (chicken, turkey)
Eggs
Plant protein
Vegetables
Breads

MAJOR SOURCES
OF POTASSIUM
Milk

Legumes

Potatoes

Nuts

Bananas

Salt substitute

Oranges

Chocolate

Dried Fruit

SODIUM
Regulates blood volume and pressure

Avoid salt

Use Alternate food seasonings: lemon and limes,

spices, seafood seasoning, Italian seasoning,
vinegars, peppers

FLUIDS
Healthy kidneys remove fluids as urine
Check for fluid and sodium retention

Need to restrict fluid intake

PHOSPHOROUS
Phosphorus is a mineral which combines with

calcium to keep bones and teeth strong

Too little calcium and too much phosphorus
Need to control the phosphorus in the diet
Need to take a phosphate binder or a calcium

supplement

VITAMINS
Folic acid
Iron supplements
Do not take OTCs without consulting the

doctor.

MANAGING YOUR DIET

INDICATORS OF GOOD CONTROL:
Weight loss or gain
Blood pressure
Swelling of hands and feet
Blood samples

LAB MONITORING
Haemoglobin

Sodium

Albumin

Potassium

Calcium

Urea

Phosphorus

Creatinine

GFR
(24 hour urine)

Lifestyle Changes with PD

Flexibility
Can be performed almost anywhere
Least impact on work / school life (esp APD)

Travel
Dialysis supplies can be delivered to most parts of the
world; travel more flexible. APD machines are portable;
will fit into a car boot, can be carried by train/air

Responsibility
Requires more responsibility from patient but more
independence

Lifestyle Changes with PD

Sports/Exercise
Most are possible
Advice on swimming, lifting, contact sports

Sexual Activity
May affect relations based on patient anxiety

Delivery & Storage of Supplies

Home delivery and storage
A months supplies 40 boxes; space to store
Specially recruited and trained delivery staff

Problems with Treatment

Monotomy of treatment
The treatment never goes away against days off with HD
Body Image Problems
Esp with a permanent catheter
Abdominal stretching
Fluid Overload
Much less a problem than with HD
Dehydration
Less common than fluid overload
Abdominal Discomfort
Bloated feeling

Problems with Treatment

Poor drainage
Common problem esp with new patients
Fibrin plug
Catheter displacement
Leakage
Fluid may leak around catheter exit site. (May leak into
scrotum)
Stop PD temporarily
Resite catheter (use new one)
Infections
Exit site infections
Tunnel infection
peritonitis

Problems with Treatment

Hernia
Aggravation of pre-existing herniae (repair)
Evolution of new herniae

Declining effectiveness of the peritoneum

e.g. repeated infection
Effect of glucose in the dialysis fluid

Comparison of Dialysis Treatment Options

Home Dialysis

PD

Unit HD

Home HD

Convenient Sessions

Socializn with other CRF pats

Home Equipment/Supplies

Special diet/fluid allowance

Sports/exercises participation

Most

Most

Most

Full day activity -work/school

Not alwys

Direct assistpartner/family

Travel

Delivery of

Prior

Prior

supplies to most
destins easy.
Some notice req

arrangements
must be made
well in advance

arrangements must
be made well in
advance