HEMODIALYSIS

ANATOMY
 We

have two bean shaped kidneys and they lie on either side of the spine at the lower middle of the back. Each kidney weighs about 113 to 170 g ( 4.5 0z) and is 10 to 12 cm long, 6 cm wide and 2.5 cm thick. The right kidney is slightly lower than the left. The kidneys are well protected by the ribs and by the muscles of the abdomen and back. Internally, fat deposits surround each kidneys, providing protection.  Kidneys remove waste products and excess water from the blood. The kidneys process about 200 liters of blood every day which results in two liters of urine as a waste product.

They also regulate various minerals such as calcium, sodium, and potassium in the blood. They maintain a chemical balance and remove excess drugs from the body. They release hormones that regulate blood pressure and also control the production of red blood cells. They produce an active form of vitamin D that promotes strong and healthy bones. Many organs in the body depend upon the kidneys to function normally.

 Each
 The

kidney Nephrons has one units called nephrons.

million filtering

nephron, is the functional unit of the kidney, consisting of both vascular and tubular elements.  The kidneys receive 20% to 25% of the cardiac output under resting conditions, averaging more than 1 L of arterial blood per minute.  If the total number of functioning nephrons is less than 20% of normal, renal replacement therapy needs to be considered.

Formation of Urine

The healthy human body is composed of approximately 60% water. Water balance is regulated by the kidneys and results in the formation of urine. Urine is formed in the nephrons through a complex threestep process: Glomerular filtration, tubular reabsorption and tubular secretion. The various substances normally filtrated and reabsorbed are: Sodium, chloride, bicarbonate, potassium, glucose, urea, creatinine and uric acid.

Glomerular filtration
 The

normal blood flow through the kidneys is about 1200ml/min. Under normal conditions, about 20% of the blood passing through the glomeruli is filtered into the nephrons, amounting to about 180L/day of filtrate.  The filtrate normally consists of water, electrolytes and other small molecules.

 Glomerular

(Bowman’s) capsule  Proximal convoluted tubule  Loop of Henle  Distal convoluted tubule

Tubular Reabsorption and Tubular Secretion
 In

tubular secretion, a substance moves from the peritubular capillaries or vasa recta into tubular filtrate. Of the 180 L ( 45 gallons) of filtrate that the kidneys produce each day, 99% is reabsorbed into the bloodstream, resulting in the formation of 1000 to 1500 ml of urine each day.

 Filtration  Reabsorption  Secretion

Antidiuretic hormone
 Also

known as Vasopressin. It is a hormone that is secreted by the Posterior pituitary gland in response to changes in osmolality of the blood.  A dilute urine with fixed SG( about 1.010) or fixed osmolality (about 300 mOsm/L) indicates an inability to concentrate and dilute the urine, a common early sign of kidney disease.

Osmolarity and Osmolality
 Osmolarity

refers to the ratio of solute to water. Controlling either the amount of water or the amount of solute can change osmolarity. As little as a 1% to 2% change in the serum osmolarity can cause a conscious desire to drink and conservation of water by the kidneys.  The degree of dilution or concentration of the urine is also measured in terms of osmolality, the number of osmoles dissolved per kg of solution. The filtrate in the glomerular capillaries normally has the same osmolality as the blood 275 to 300 mOsm/Kg

Regulation of Water Excretion.
 Regulation

of the amount of water excreted is an important function of the kidney. With high fluid intake, a large volume of dilute urine is excreted.  A person normally ingests about 1300 ml of oral liquids and 1000 ml of water in food per day. Of the fluid ingested, approximately 900ml is lost through skin and lungs, 50 ml through sweat and 200 ml through feces.

Decrease renal perfusion pressure
Renin release Angiotension 1
Angiotension II Renal Autoregulation Efferent arterioles constrict GRF maintained Blood pressure Vasoconstriction Increased myocardial contractility Prostaglandin release

Circulating volume Aldosterone release Na & H2O reabsorption Potassium excretion ADH release

Regulation of Electrolyte Excretion
 SODIUM  Normal

serum sodium levels are between 135 to 145 mmol/L making sodium the most plentiful extracellular ion. Sodium plays important role in controlling the fluid and electrolyte balance. It is the only cation that exerts significant osmotic pressure; where sodium is inseparably linked to both blood pressures.  The regulation of sodium volume exerted depends on aldosterone, A hormone synthesized and released from the adrenal cortex.

POTASSIUM  Potassium is the most abundant intracellular ion; about 98% of the total body potassium is located intracellular.  To maintain a normal serum potassium balance the kidneys are responsible in exerting more that 90% of the total daily potassium intake. Several factors influence potassium loss through the kidneys.  Aldosterone causes the kidneys to excrete potassium, in contrast to its effect on sodium described previously. The acid based balance, the amount of dietary potassium intake, and the flow rate of the filtrate in the distal tubule also influence the amount of potassium secreted into the urine. Retention of potassium is the most life-threatening effect of renal failure.

Regulation of ACID-Base Balance
 The

normal serum Ph is about 7.35 to 7.45 and must be maintained within this range for optimal physiologic function (Yucha, 2004).  The Kidney performs two major functions to assist in this balance. The first is to absorb and return to the body’s circulation any bicarbonate from the urinary filtrate; the second is to excrete acid in the urine. Because bicarbonate is a small ion, it is freely filtered at the glomerulus.  The renal tubules actively reabsorbed most of the bicarbonate in the urinary filtrate.  CO2 is easily eliminated in the lungs unlike Phosphoric and Sulfuric acids.  A normal Kidney fxn excretes 70mEq of acid each day. This causes the urine until the pH reaches 4.5.

However, more acid needs to be eliminated from the body than can be secreted directly as free acid in the urine. These excess acids are bound to chemical buffers so that they can excrete in the urine. Two important chemical buffers are phosphate ions and ammonia. (NH3). When buffered with acid, ammonia becomes ammonium (NH4). Phosphate is present the glomerular filtrate, and ammonia is produced by the cells of the renal tubules and secreted into the tubular fluid. Through the buffering process, the kidney is able to excrete large quantities of acid in a bound form, without further lowering the Ph of the urine.

Auto Regulation of Blood Pressure
 Regulation

of blood pressure is also a function of a kidney. Specialized vessels of the kidney, called the vasa recta, constantly monitor blood pressure as blood begins its passage into the kidney. When the vasa recta detect a decrease in blood pressure, specialized juxtaglomerular cells near the afferent arteriole, distal tubule, and efferent arteriole secrete of the hormone renin.  Renin Release – Liver – ANGIOTENSINOGEN TO ANGIOTENSIN 1 – Lungs –Angiotensin II – Adrenal Glands - Aldosterone  The result is an increase in blood pressure. When the vasa recta recognize the increase in blood pressure, renin secretion stops. Failure of this feedback mechanism is one of the primary causes of hypertension.

Renal Clearance  Renal clearance refers to the ability of the kidneys to clear solutes from the plasma. A 24-hour collection of urine is the primary test of renal clearance used to evaluate how well the kidneys perform this important excretory function.  Renal clearance depends on several factors:
  

how quickly the substance is filtered across the glomerulus, how much of the substance is reabsorbed along the tubules, and how much of the substance is secreted into the tubules.

 Creatinine

– is an endogenous waste product of skeletal muscle that is filtered at the glomerulus.  Creatinine clearance is a good measure of glumerular filtration rate (GFR)  The adult GFR can vary from a normal of approximately 125 ml/min (1.67 to 2.2 mL/sec.) to a high of 200 ml/min (Porth, 2005). Creatinine clearance is an excellent measure of renal function; as renal function declines, creatinine clearance decreases.

Regulation of Red Blood Cells Production  When the kidneys sense a decrease in the oxygen tension in renal blood flow, they release erythropoietin. Erythropoietin stimulates the bone marrow to produce red blood cells (RBCs), thereby increasing the amount of hemoglobin available to carry oxygen. Vitamin D Synthesis  The kidneys are also responsible for the final conversation of inactive vitamin D to its active form ( 1, 25 dihydroxycholecalciferol).  Vitamin D is necessary for maintaining normal calcium balance in the body.

Secretion of Prostaglandins  The kidneys also produce prostaglandin E and prostacylin, which have a vasodilatory effect and are important in maintaining renal blood flow. Exertion of Waste Products  The kidney functions as the body main excretory organ, eliminating the body’s metabolic waste products.  The major waste product of protein metabolism is urea, of which about 25 to 30 g are produced and excreted daily. All of this urea must be excreted in the urine; otherwise it accumulates in body tissues.  Other waste products of metabolism that must be excreted are creatinine, phosphates, and sulfates.  Uric acid, formed as waste product of purine metabolism, is also eliminated in the urine.  The kidneys serve as the primary mechanism for excreting drug metabolites.

LABORATORY ASSESSMENT

Test Specific Gravity

Purpose Evaluates ability of kidneys to concentrate solutes in urine. Concentrating ability is lost early in kidney disease. Hence, these test findings may disclose early defects in renal function.

Normal Values 1.003 – 1.030

Urine Osmolality

300 – 900 mOsm/ kg/24 h, 50 – 1,200 mOsm/ kg/random sample

24 – hour Urine Detects and evaluates progression of Test renal disease. Test measures Creatinine volume of blood cleared of Clearance endogenous creatinine in one minute, which provides an approximation of the glomerular filtration rate. Then sensitive indicator of renal disease used to follow progression of renal disease.

Measured in mL/min/1.73m sq

Age Under 30 30-40 40-50 50-60 60-70 70-80

Male 88-146 82-140 75-133 68-126 61-120 55-113

Female 81-134 75-128 69-122 64-116 58-110 52-105

Serum Tests Creatinine Level

Measures effectiveness of renal 0.6–1.2 mg/dL (50-110mmol/L) function. Creatinine is end product of muscle energy metabolism. In normal function level of creatinine which is regulated and excreted by the kidneys remains fairly constant in the body. 7–18mg/dL Patients > 60, y:8-20mg/dL

Urea Nitrogen Serves as index of renal function. Urea (Blood Urea is nitrogenous end product of Nitrogen) protein metabolism. Test values are affected by protein intake. Tissue breakdown and fluid volume changes. BUN to creatinine ratio Evaluates hydration status. An elevated ratio is seen in hypovolemia. A normal ratio with an elevated BUN and cratinine is seen with intrinsic renal disease.

About 10:1.

URINALYSIS
Urine Color Possible Causes Colorless to Pale Dilute Urine due to diuretics, alcohol Yellow consumption, diabetes insipidus, glycosuria, excess fluid intake, renal disease. Yellow to Milky Pyuria, infection, vaginal cream. White Bright Yellow Multiple vitamin preparations. Pink to Red Hemoglobin breakdown, red blood cells, gross blood, menses, bladder or prostate surgery, beets, blackberries, medications (phenytoin, rifampin, phenothiazin, cascara, senna products)

Blue, Blue green

Orange to Amber

Dyes metheline blue, pseudomonas, species organisms, medications (amitriptyline, triamterene, phenylsalicylate) Concentrated urine due to dehydration, fever, bile, excess bilirubin or carotene, medications Old red blood cells, urobilinogen, bilirubin, melanine, extremely concentrated urine due to dehydration, medications (metronidazole, iron preparations, quinine, senna products, methyldopa)

Brown to Black

Problems asso. With voiding changes
Problem Frequency Definition Frequent voiding – more than every three hours Possible Etiology Infection, obstruction of the lower urinary tract leading to residual urine and overflow, anxiety, diuretics, benign prostatic hyperplasia, urethral stricture, Diabetic neuropathy.

Urgency

Strong desire to void Infection, chronic prostatitis, urethritis, obstruction of the lower urinary tract leading to residual urine and over flow, anxiety, diuretics, benign prostatic hyperplasia, urethral stricture, diabetic neuropathy. Painful or difficult voiding Lower urinary tract infection, inflammation of bladder or urethra, acute prostatitis, stones, foreign bodies ,tumor in the bladder.

Dysuria

Hesistancy Delay, difficulty in initiating voiding Nocturia Excessive urination at night

Benine prostatic hyperplasia, compression of urethra, outlet obstruction, neorogenic bladder.

Decreased renal concentrating ability, heart failure, diabetes mellitus, incomplete bladder emptying, excessive fluid intake at bedtime, nephrotic syndrome, cirrhosis with ascites Incontinence Involuntary loss External urinary sphincter injury, of urine obstetric injury, lesions of bladder neck, detrusor dysfunction, infection, neurogenic bladder, medications, neurologic abnormalities.

Enuresis

Involuntary Delay in functional maturation of voiding during CNS (bladder control, usually sleep achieved by five (5) years of age) obstructive disease of lower urinary tract, genetic factors, failure to concentrate urine, UTI, psychological stress. Polyuria Increased Diabetes mellitus, diabetes volume of urine insipidus voided Oliguria Urine output less Acute or chronic renal failure than 400 mL/d inadequate fluid intake

Urine output Acute or chronic renal failure less than 50 complete obstruction mL/d Hematuria Red blood cells Cancer of genitourinary tract, in urine acute glomerulonephritis, renal stones, renal tuberculosis, blood dyscrasia, trauma, extreme exercise, rheumatic fever, hemophilia, leukemia, sickle cell trait or disease Proteinuria Abnormal Acute and chronic renal disease, amount of nephritic syndrome, vigorous protein in the exercise, heat stoke, severe heart urine failure, diabetic nephropathy, multiple myeloma

Anuria

DISEASE BACKGROUND

Chronic Kidney Disease
Chronic kidney disease is a process during which kidney tissue is destroyed over a long period of time. Many people are unaware of their kidney disease until over 70% of their kidney function has been lost. When both kidneys are severely damaged, the only treatments available to replace the function of the kidneys are dialysis or kidney transplantation. The most common causes of kidney failure in Australia are diabetes mellitus, glomerulonephritis (inflammation of the kidneys’ filters) and hypertension (high blood pressure).

Symptoms of Chronic Kidney Disease
Some or all of these symptoms can develop once kidney function (measured using blood and urine tests) is below 30%:
          

Fluid retention causing breathlessness and swelling of ankles and feet Tiredness Headaches Poor memory and concentration Irritability Sleep disturbances Restless legs Itchiness Loss of appetite and nausea Weight loss Reduced libido and altered sexual function

Stages of Chronic Kidney Disease: Stages are based on the glomerular filtration rate (GFR). The normal GFR IS 125 ML/MIN/1.73 m².
Stage 1: GFR > 90 ML/MIN/1.73 m². Kidney damage with normal or increased GFR Stage 2: GFR = 60-89 ML/MIN/1.73 m². Mild decrease in GFR Stage 3: GFR=30-59 ML/MIN/1.73 m² Moderate decrease in GFR Stage 4: GFR= 15-29 ml/min/1.73 m² Severe decrese in GFR Stage 5: GFR < 15 ml/min/1.73 m² Kidney Failure

Why Dialysis is done?
 Dialysis

is done for persons whose kidneys are not well enough to remove waste products from their bodies. If dialysis is not performed, these people go into kidney failure and eventually die from the build up of poisonous products. Alternative Therapy may include placing a catheter into the abdominal cavity and using to instill a special cleaning fluid into the abdominal cavity. After a short while the fluid is removed and it brings some of the waste with it. This form of dialysis is called peritoneal dialysis.

DIALYSIS
 Dialysis

is a way of removing toxic substances from the blood, and restoring the body fluid volume and composition to close to normal.  Two kinds of dialysis are now common, though both types have long histories. Haemodialysis, using dialysers which are sometimes called artificial kidneys, pioneered by the Dutch physician Willem Kolff, initially at Gronigen University Hospital, and then at Kampen Hospital. Kolff treated his first patient with an experimental haemodialyser in 1943, and in 1956 introduced the first practical haemodialysis machine.
 Peritoneal

dialysis has a longer history but a shorter period of practical application. The first peritoneal dialysis of a patient was performed in 1923, but the procedure did not become accepted until 1959, until the when developments in tubing and catheters had made the technique safer.

Neither peritoneal dialysis nor haemodialysis bear much resemblance to the way the kidneys normally work. The kidneys have a filtration process which is essentially nonselective: with the exception of the proteins, all the constituents of the blood plasma are filtered, whether or not the body needs to excrete them or retain them. The selectivity comes after the filtration process, when the nephrons (kidney tubules) reabsorb some substances into the blood, secrete others, or simply allow the filtered substances to continue along the nephron to escape in the urine. No artificial kidney works like this.

Hemodialysis

Hemodialysis (also haemodialysis) is a method for removing waste products such as potassium and urea, as well as free water from the blood when the kidneys are in renal failure. With kidney failure, when the kidneys can no longer remove waste and excess water and acid from the blood and maintain the body’s chemical balance, a person must undergo kidney dialysis. In this procedure, blood from an artery in the person’s arm or leg flows through a tube and into a machine called a dialysis unit that works as an artificial kidney. The blood is filtered and cleansed in the dialysis unit and returned through another tube inserted into a vein in the same arm or leg. Usually dialysis is performed at a dialysis center (although it can be done at home) three times per week. The person can sleep, read, write, talk, or watch television during the 3 to 4 hours of each treatment.

 For

patients with chronic renal failure, hemodialysis prevents death, BUT does not cure renal disease nor it can compensate for the loss of endocrine and metabolic activities of the kidneys.

 Objectives:
 

Extract toxic nitrogenous substances To remove excess water

Equipment and Procedures
Dialysis Machine  The dialysis machine is about the size of a dishwasher. This machine has three main jobs:
 pump

blood and watch flow for safety  clean wastes from blood  watch your blood pressure and the rate of fluid removal from your body

Dialyzer  The dialyzer is a large canister containing thousands of small hollow fiber containing thousands of tiny cellophane tubules that act as semipermeable membrane, through which the blood passed. Dialysis solution, the cleansing fluid, is pumped around these fibers. The fibers allow wastes and extra fluids to pass from your blood into the solution, which carries them away. The dialyzer is sometimes called an artificial kidney.

Reuse. Your dialysis center may use the same dialyzer more than once for your treatments. Reuse is considered safe as long as the dialyzer is cleaned before each use. The dialyzer is tested each time to make sure it’s still working, and it should never be used for anyone but you. Before each session, you should be sure that the dialyzer is labeled with your name and check to see that it has been cleaned, disinfected, and tested.
Dialysis Solution
 Dialysis

solution, also known as dialysate, is the fluid in the dialyzer that helps remove wastes and extra fluid from your blood. It contains chemicals and important electrolytes in their ideal extracellular concentrations. that make it act like a sponge. Your doctor will give you a specific dialysis solution for your treatments. This formula can be adjusted based on how well you handle the treatments and on your blood tests.

 Needles

Many people find the needle sticks to be one of the hardest parts of hemodialysis treatments. Most people, however, report getting used to them after a few sessions. If you find the needle insertion painful, an anesthetic cream or spray can be applied to the skin. The cream or spray will numb your skin briefly so you won’t feel the needle. Most dialysis centers use two needles—one to carry blood to the dialyzer and one to return the cleaned blood to your body. Some specialized needles are designed with two openings for two-way flow of blood, but these needles are less efficient and require longer sessions. Needles for high-flux or high-efficiency dialysis need to be a little larger than those used with regular dialyzers.

 The

total volume of blood in the artificial kidney at any moment is small (about 500 ml), with a flow rate of about 300 ml/min, and a total dialyser membrane area of 1-3 m2; this means that the equivalent of the whole blood volume of about 5 litres in an adult circulates through the dialyser every 15-20 min.

HOW DIALYSIS WORKS

Diffusion, osmosis and ultrafiltration – principles of which hemodialysis is based. Diffussion- from Higher to lower ( blood to dialysate)

The semipermeable membrane impedes the diffusion of large molecules, such as RBCs and proteins

Osmosis - Higher solute concentration (the blood) to an area of lower solute concentration ( dialysate bath.

Excess water is removed from the blood An efficient way to remove water, negative pressure is applied or a suctioning force to the dialysis membrane.

Ultrafiltration – water moves from high pressure to an area of lower pressure.

 Buffer

system is maintained using dialysis

bath.

The dialysis bath is made up of Bicarbonate or acetate (metabolized to form bicarbonate.

 Anticoagulant,

Heparin – is administered to keep blood from clotting in the dialysis circuit.  Cleansed blood returned to the body.

ACCESS

Three primary methods are used to gain access to the blood: an intravenous catheter, an arteriovenous (AV) fistula, or a synthetic graft. The type of access is influenced by factors such as:

expected time course of a patient's renal failure  and the condition of his or her vasculature.  Patients may have multiple accesses, usually because an AV fistula or graft is maturing and a catheter is still being used.

 the

Figure 2. After the anastomosis is made, the flow of blood in the vein is greatly increased. The needle for use during the dialysis is placed in the vein anywhere along the area marked with an asterisk.

AV fistula
 AV

(arteriovenous) fistulas are recognized as the preferred access method.  To create a fistula, a vascular surgeon joins an artery and a vein together through anastomosis. Since this bypasses the capillaries, blood flows rapidly through the fistula. One can feel this by placing one's finger over a mature fistula. This is called feeling for "thrill" and produces a distinct 'buzzing' feeling over the fistula. Fistulas are usually created in the non dominant arm and may be situated on the hand (the 'snuffbox' fistula'), the forearm or the elbow.  A fistula will take a number of weeks to mature, on average perhaps 4-6 weeks.

During

treatment, two needles are inserted into the fistula, one to draw blood and one to return it.

 This

gives time for healing and for the venous segment of the fistula to dilate to accommodate two large-bore (14, 15, 16 gauge) needles.  The patient is encouraged to perform exercises to increase the size of these vessels ( squeezing a rubber ball for forearm fistula).

The

advantages of the AV fistula use are:

lower infection rates, because no foreign material is involved in their formation,  higher blood flow rates (which translates to more effective dialysis), and  lower incidence of thrombosis.  The complications are few, but if a fistula has a very high blood flow and the vasculature that supplies the rest of the limb is poor, a steal syndrome can occur, where blood entering the limb is drawn into the fistula and returned to the general circulation without entering the limb's capillaries.

Advantages: - Has true healing and vascularization ( acquisition of bld supply through formation of new bld supply) to resist/fight infection - Internal system allowing full range of function and motion - Can remain patent for decades  Disadvantages: - Four to sixteen weeks to mature - True aneurysms (ballooning)

AV grafts: an  AV (arteriovenous) grafts are much like fistulas inarteriovenous graft artificial vessel most respects, except that an
is used to join the artery and vein.  The graft usually is made of a synthetic material, often PTFE ( Polytetrafluoroethylene), but sometimes chemically treated, sterilized veins from animals are used.  Others:
 Impra

Vectra graft ( Thoralon – polyetherurethaneurea and siloxane) can be used in 24 hours.  Artegraft- natural collagen vascular graft. Can be used w/in 10 days.

If the vessels in your forearm are too small, a vein graft, using a vein from your leg or a graft using artificial material (gortex), is used to create your haemodialysis access, usually in your forearm and sometimes in your thigh. A synthetic (man made) tubing that is surgically placed under the skin, linking an artery and a vein. Grafts are inserted when the patient's native vasculature does not permit a fistula or in pt with compromised vascular system needs graft. They mature faster than fistulas, and may be ready for use several weeks after formation (some newer grafts may be used even sooner). However, AV grafts are at high risk to develop narrowing, especially in the vein just downstream from where the graft has been sewn to the vein. Narrowing often leads to clotting or thrombosis. As foreign material, they are at greater risk for becoming infected. More options for sites to place a graft are available, because the graft can be made quite long. Thus a graft can be placed in the thigh or even the neck (the 'necklace graft').

Infection From breaks in aseptic technique - inadequately prepared skin and poor patient hygiene  Maintain strict adherence to aseptic techniques during access Hematoma Swelling or mass of blood  From an infiltration - Venous needle went through both walls of graft  Pseudoaneurysm Dilation or bubble-like mass caused by a weakness in the graft wall  Graft Collapse  Thrombosis Clotting in the graft that forms an obstruction or reduces flow

CATHETER ACCESS
 Catheter

access, sometimes called a CVC (Central Venous Catheter), consists of a plastic large bore catheter with two lumens (or occasionally two separate catheters) which is inserted into a large vein (usually the vena cava, subclavian, via the internal jugular vein or the femoral vein) to allow large flows of blood to be withdrawn from one lumen, to enter the dialysis circuit, and to be returned via the other lumen. However, blood flow is almost always less than that of a well functioning

Non-tunneled catheter access is for short-term access (up to about 10 days, but often for one dialysis session only), and the catheter emerges from the skin at the site of entry into the vein.  Tunneled catheter access involves a longer catheter, which is tunnelled under the skin from the point of insertion in the vein to an exit site some distance away. It is usually placed in the internal jugular vein in the neck and the exit site is usually on the chest wall. The tunnel acts as a barrier to invading microbes, and as such, tunnelled catheters are designed for short- to medium-term access (weeks to months), because infection is still a frequent problem.

 In

this access a small soft tube called a catheter is placed in a vein in the neck, shoulder or groin area.  Usually temporary due to an increased risk for infection If dialysis is immediately necessary and the fistula or graft has not been created, then a temporary form of access, using a soft catheter placed into the veins in the neck or upper chest can be used (jugular or sub-clavian catheter, known as vascath or permacath). Most people would prefer to avoid these, as they have a high risk of infection.  Not preferred as a permanent access

 Assess Assessment Access the Patient and the Graft  Check
o  

for infection, thrombosis, or other potential problems
Swelling, redness, and drainage Pain and tenderness Localized warmth and fever

Confirm Direction of Blood Flow  Refer to surgeon’s chart

 Make

assessment - Side with the strongest pulse / thrill is the arterial Check for Pulse, Thrill, and Bruit Determine patency of A-V fistula - Palpate entire fistula from the arterial anastomosis along the main trunk - Palpate for pulse and thrill - Vibration or tremble of blood flow - Evaluate bruit with stethoscope

Determine
 Palpate

patency of graft

entire graft  Palpate for pulse and thrill  Evaluate bruit (sharp or harsh systolic sound/ murmur) with stethoscope

- Confirm the trill in the anastomosed vein - Thrill may be diminished some grafts - Use stethoscope

Complications of using dialysis
    

Gastric ulcer and other GI problems ( physiologic stress of chronic illness, medication) Bone pain and fructures ( distured calcium metabolism Hypotension S/S: Fliud overload Painful muscle cramping- due to fluids and electrolytes rapidly leave the Extracellular space Dialysis disequilibrium results from cerebral fluid shifts.

S/S: headache, nausea& vomiting, restlessness, Dec level of consciousness and seizures

PREOPERATIVE PREPARATION
 Do

not eat or drink anything for 8 hours before the operation.  Shower as usual on the morning of the operation.  You may be given medicine that will make you feel drowsy before you are brought to the operating room.  The doctor will tell you if you have to make any changes in your medicines before the operation.

OPERATION
 On

the morning of the operation, some blood may be taken to be examined for the level of chemicals in it.  A fine needle will be used to place an anesthetic in the skin of the wrist area to make it numb.  Also, you may be given medicine that will make you feel drowsy during the operation.  You may feel some tugging during the operation but not pain.  The operation usually takes about 2 hours.

POSTOPERATIVE CARE
 You

will be taken to a recovery room. When your blood pressure, pulse, and breathing are stable  You are completely alert, you should be able to go home that same day with a responsible adult.  Arrangements will be made for your medicine, follow-up office visit, and stitch removal.

Home Care
 Keep

the dressings dry until the stitches are removed.  If the dressings get wet replace with sterile ones. Do not use dressings that place pressure on the shunt or completely encircle the arm or wrist.  Exercise your natural shunt by squeezing a ball ten (10) times, four (4) times a day. This is not necessary if you have a graft shunt.

HOW TO PROTECT YOUR SHUNT
 All

of the following are to help prevent cutting off the flow in your shunt because that would cause the shunt to clot and stop the flow permanently.  Do not sleep on your shunt.  Do not wear jewelry or tight sleeves on the arm that has the shunt.  Do not carry anything hanging over the arm with the shunt.  Do not let anyone take your blood pressure or take blood from the arm with the shunt.

 Check
   

the shunt for any problems for any problem every morning and evening;
Loss of thrill over the shunt; Loss of pulsations over the shunt; Pain or hardness in the area of the shunt; A red or swollen incision, or one that is draining;

 If

any of the above are present, do not pick at your shunt. Use the telephone number given to you to contact the doctor or nurse promptly. If this is not possible, go to a hospital emergency room.  If there is bleeding from the needle puncture side, keep continuous gentle pressure on the puncture side for thirty (30) minutes with a piece of sterile gauze.  If it still bleeds when you remove the pressure, re-apply the pressure and call the doctor or go to hospital emergency room.

Nutritional and Fluid Therapy
 Goal:
 

To minimize Uremic symptoms and fluid and electrolyte imbalances; to maintain good nutritional status through adequate protein, calorie, vitamin and mineral intake; and To enable the patient to eat palatable and enjoyable diet

 Restricting

dietary protein to about 1.2 to 1.3 g/kg/day ideal body wt/ day
Protein with high biologic quality consisting of essential amino acid must be given to prevent poor protein use and maintain positive nitrogen balance. Foods w/ high protein content: eggs, meat, milk, poultry and fish

 Sodium

is restricted to 2 to 3g/ day  Fluids are restricted to an amount equal to the daily urine output pluss 500ml/day  Potasium restriction depends on the amount of residual renal function and frequency of dialysis.

Fluids.  Extra fluid can raise your blood pressure, make your heart work harder, and increase the stress of dialysis treatments.  Remember that many foods—such as soup, ice cream, and fruits—contain plenty of water. Ask your dietitian for tips on controlling your thirst. Potassium.  The mineral potassium is found in many foods, especially fruits and vegetables. Potassium affects how steadily your heart beats, so eating foods with too much of it can be very dangerous to your heart.  To control potassium levels in your blood, avoid foods like oranges, bananas, tomatoes, potatoes, and dried fruits.  You can remove some of the potassium from potatoes and other vegetables by peeling and soaking them in a large container of water for several hours, then cooking them in fresh water. You can remove some potassium from potatoes by soaking them in water.

Phosphorus.  The mineral phosphorus can weaken your bones and make your skin itch if you consume too much. Control of phosphorus may be even more important than calcium itself in preventing bone disease and related complications.  Foods like milk and cheese, dried beans, peas, colas, nuts, and peanut butter are high in phosphorus and should be avoided. Salt (sodium chloride).  Most canned foods and frozen dinners contain high amounts of sodium.  Too much of it makes you thirsty, and when you drink more fluid, your heart has to work harder to pump the fluid through your body. Over time, this can cause high blood pressure and congestive heart failure.  Try to eat fresh foods that are naturally low in sodium, and look for products labeled “low sodium.”

 Calories.

Calories provide your body with energy. Some people on dialysis need to gain weight. You may need to find ways to add calories to your diet. Vegetable oils—like olive, canola, and safflower oils—are good sources of calories and do not contribute to problems controlling your cholesterol. Hard candy, sugar, honey, jam, and jelly also provide calories and energy. If you have diabetes, however, be very careful about eating sweets. A dietitian’s guidance is especially important for people with diabetes.

PERITONEAL DIALYSIS

Goal
 To

remove toxic substances and metabolic wastes  To re-establish normal fluid and electrolyte balance.
 Treatment

of choice for pts with renal failure who are unable or unwilling to undergo hemodialysis or renal transplantation.

o

o

In contrast to haemodialysis, peritoneal dialysis, filters the blood inside the body. It uses the peritoneum or peritoneal membrane as the filter for dialysis. The peritoneum is a membrane that lines the wall of the abdomen and covers the abdominal organs. The surface of the peritoneum constitutes a body surface area about 22,000 cm2.

 Urea

is cleared at a rate of 15 to 20ml/min, creatinine is removed at a slower rate.  In peritoneal dialysate, it usually takes 36 to 48 hours to achieve what hemodialysis accomplishes in 6 to 8 hours.  Ultrafiltration (water removal) occurs through osmotic gradient created using a dialysate fluid with higher glucose concentration.  The high urea content of the blood in renal failure creates an osmotic attraction across the peritoneal membrane, so that water would tend to move from the peritoneal cavity into the patient. To prevent this, and ensure that water moves from the patient's blood to the dialysis fluid, an osmotically active substance is incorporated in the dialysis fluid. This is usually dextrose, but amino acids and glucose polymers can also be used.

Equipments
     

Determine the concentration of dialysate and medications to be added. ( Na, Cl, lactate, bicarbonate and glucose) Heparin – to prevent fibrin formation and resultant occlusion of the peritoneal catheter. Potassium chloride – prevent hypokalemia Antibiotics – to treat peritonitis NOTE: Add all medications BEFORE instilling the solution. Dialysate must be warmed to body temp to prevent pt discomfort, abdominal pain and to dilate vessels of the peritoneum to increase creatinine clearance.

Too Cold sol’n causes: pain, cramping and vasoconstriction

Before administering – the tubing is filled w/ prepared dialysate to prevent entrance of air. Air can cause discomfort and interfere w/ instillation and drainage of the fluid.

Inserting the catheter

Ideally – peritoneal catheter is inserted in the OR.  A rigid stylet catheter is inserted.  Skin prep is done  W/ anesthesia a small incision or stab wound in the lower abdomen, 3 to 5 cm below the umbilicus. – No large blood vessels = little bleeding  Ask pt to tighten his abdominal muscle by raising the head - Trocar is used to puncture the peritoneum
 Catheter

is threaded through the tocar and positioned.  Dialysate will be infused into the peritoneal cavity to push omentum ( peritoneal lining extending from the abdominal organs) away from the catheter.  Catheter is secued w/ purse string suture and antibacterial ointment and dressings over the site.

 Catheters

for long use ( Tenckhoff, Swan, Cruz) are made of silicone and are radiopaque.  Catheters have 3 sections:
 

Intraperitoneal section – w/ numerous openings and an open tip to let dialysate flow freely. Subcutaneous section – passes from the peritoneal membrane and tunnels through muscle and subQ fat to the skin External section – connection to the dialysate system.

 Most
 

of the catheters have two cuff (Dacron polyester)
Cuff stabilizes the catheter, limit movement, prevent leaks and provide barrier against microorganism. One cuff is distal to the peritoneum and the other cuff is placed subcutaneously.

Exchange
 An

exchange is defined as the infusion, dwell and drainage of the dialysate.  Dialysate (gravity) – peritoneal cavity ( peritoneal blood supply) – 5 to 10 min to infuse 2 to 3 L of fluid) – dwell time (diffusion & osmosis) – drainage ( completed w/in 10 to 30 min)

 Drainage

fluid is normally colorless or strawcolored and should NOT be cloudy.  Bloody drainage may be seen in the first few exchanges after insertion of a new catheter but should not occur after that time.  The entire exchange takes 30 to 45 minutes.  Removal of excess water is achieved by using a Hypertonic dialysate with high dextrose concentration that creates osmotic gradient.  Dextrose sol’n of 1.5%, 2.5% and 4.25% are available in sev volumes, from 1000ml to 3000ml.  The higher the dextrose concentration, the greater the osmotic gradient and the more water will be removed.

Complications Acute Complications
Peritonitis

Staphylococcus aureus & S. epidermidis ( gram positive), Pseudomonas aeruginosa, E. coli & Klebsiella ( gram negative)  Characterized by cloudy dialysate drainage, diffuse abdominal pain and rebound tenderness.  Large amount of protein through the peritoneum. Acute malnutrition and delayed healing may result.  Hypotension and other signs of shock may occur if S aureus is the resp. organism.  Unresolved peritonitis after 2 to 3 days of appro. Therapy, catheter must be removed. Antibiotic agents for 10 to 14 days.

 Leakage

Normal – after the catheter is inserted.

Leak stops spontaneously if the dialysis is withheld for several days for incision and exit time to heal. It may occur for months or years after catheter placement. Mgt: Reduce factors that may delay healing such as abdominal muscle activity and straining during bowel movement. Use small volumes (500ml) of dialysate, gradually increasing the vol up to 2000 to 3000ml.

 Bloody

Bleeding effluent/drainage can be observe

occasionally, esp. in young, menstruating women. (Hypertonic fluid pulls blood frm uterus thru fallopian tubes opening and into peritoneal cavity)  Other causes: Catheter displacement frm the pelvis, after an enema or minor trauma  Bleeding stops in 1 to 2 days  Frequent exchanges to prevent blood clots from obstructing catheter.

Approaches
 Several
  

different approaches :

Acute intermittent peritoneal dialysis (AIPD) Continuous ambulatory peritoneal dialysis (CAPD) Continuous cyclic peritoneal dialysis ( CCPD)

Acute intermittent peritoneal dialysis (AIPD)
 Indications:

signs & symptoms ( nausea, vomiting, fatigue, altered mental status)  Fluid overload, acidosis, and hyperkalemia  This permits a more gradual change in the pt’s fluid volume status and in waste product removal.  Treatment of choice for hemodynamically unstable pt.  Can be carried manually by a nurse or by a cycler machine.  Exchange times range from 30 minutes to 2 hours.  Common routine : Hourly exchange consisting of 10 minute infusion, a 30 min dwell time and 20 minute drain time.

 Uremic

 V/s,

wt, i&O, laboratory values and pt status are frequently monitored.  If the peritoneal fluid does not drain properly:
  

Turn pt frm side to side or raising the head of the bed Don’t push further the catheter Check the patency of the catheter by inspecting for kinks, closed clamps, or an air loc.

 Monitor

for complications ( peritonitis, bleeding, respiratory difficulty)  Measure Abdominal girth periodically to determine retaintion of dialysis sol’n.  Ensure that catheter remains intact and dressings remains dry.

Continuous ambulatory peritoneal dialysis (CAPD)
 CAPD

is done manually and does not require a machine. Performed at home by the patient or a caregiver.  Gravity allows the solution to enter and leave your body. The solution is exchanged 4 or 5 times, 24 hrs a day, 7 days a week at intervals scheduled throughout the day. o Exchanges can be performed in any clean area at home, work, school or even on vacation. Each exchange requires 30 minutes. A catheter will be put in and pushed all the way inside your abdomen. In certain cases, the end of the catheter may be put in just under your skin for 3 to 5 weeks. Your caregiver will put liquid through the catheter to check if it works well. He may also put blood thinner medicine in it to help prevent your catheter from getting clogged. The catheter is held in place with stitches, and the area is covered with bandages.

 Connect the lower end of the Y tubing to your

catheter, and connect the two other ends of the tubing to the dialysate bag, and the waste bag. Clamp the tubing that is attached to the catheter that goes into your abdomen. This will close off the tubing so that the dialysate does not go into your abdomen yet.  Flushing the tubing with dialysate liquid before doing CAPD may help prevent infections.  Allow 100 milliliters (ml) of fresh dialysate to flow out of the bag, and down the tubing into the waste bag. After this amount of dialysate has drained out, clamp the tubing that drains to the waste bag closed.

Continuous cyclic peritoneal dialysis ( CCPD)
 Combines

overnight intermittent peritoneal dialysis w/ prolonged dwell time during the day.  Peritoneal catheter is connected to a cycler machine ever evening and pt receives 3 to 5 two-three L exchanges during the night.  In the morning, the pt caps off the catheter after infusing 2 to 3 L of fresh dialysate. This dialysate remains in the abdominal cavity until the tubing is reattached to the cycler machine at bedtime.  Pt can sleep becoz the machine is not noisy.  Extra-long tubing allws pt to move and turn normally.

 Advantage:  Has

lower infection rate becoz of fewer opportunities for contamination with bag changes and tubing disconnections.  Pt free from exchanges throughout the day  Doesn't require needles  Portable - 24 hour technical and clinical support - Less restricted diet
 Disadvantage  Is

performed seven days a week  Have a permanent external catheter Requires storage space - Increased risk for infection.