Principles of Dialysis p y

Objecti es Objectives
U d t dth f ti f l Understand the functions of a normal
kidney in relationship to the artificial
kid kidney
Understand the transport mechanisms of
dialysis
Understand the components of the artificial p
kidney
Understandthecomponentsof dialysate Understand the components of dialysate
Functions of the Kidneys
R remove
R regulate R regulate
E endocrine
Functionsof theKidneys Functions of the Kidneys
Removal of waste Removal of waste
products
Urea breakdownof Urea - breakdown of
protein in the diet
Creatinine- end Creatinine - end
product of creatine
metabolism, ,
skeletal/muscle
breakdown
Functionsof theKidneys(cont) Functions of the Kidneys (cont)
Regulationof Regulation of
Fluid balance
l l b l Electrolyte balance
Sodium, potassium, calcium, phosphate,
magnesium magnesium
Acid/base balance
P t t b li id i Prevents metabolic acidosis
Functionsof theKidneys(cont)
Endocrine
Functions of the Kidneys (cont)
Endocrine
Production of Renin
Enzyme that controls blood pressure by affecting y et at co t osboodp essu ebya ect g
Na+ and fluid volume
Erythropoietin formation
controls red blood cell production in the bone
marrow
S i l i f Vi i D i Stimulates conversion of Vitamin D to its
active form calcitriol a hormone that
enhancesabsorptionof calciumfromthe enhances absorption of calcium from the
intestine
Renal Failure Renal Failure
Renal failureoccurswhensomething Renal failure occurs when something -
disease, injury, malformation - prevents the
kidneysfromperformingtheir many kidneys from performing their many
essential tasks.
Kid i h h b d h Kidneys are so important that the body has a
built-in backup - an extra kidney
Only one working kidney is needed to
maintain health
Understanding Dialysis
To understand Dialysis you must know
what kidney functions are replaced by y p y
dialysis:
Removal of wasteproductsfromtheblood Removal of waste products from the blood
Regulation of fluid balance by removing
excess fluid from the blood
Regulation of electrolyte and acid/base balance
in the blood
Further Understanding
Scientific Principles of dialysis include the
following: g
Solvents
Solutes Solutes
Semipermeable membranes
Transport mechanisms Transport mechanisms
Solutions and Membranes
Solutions
Solvent isafluid(water) Solvent is a fluid (water)
Solute is a substance that can be dissolved in a
solvent:
Potassium, Sodium and Calcium are examples
Semi-Permeable membranes Se e eabe e b a es
A thin layer of material with pores or openings that
allow some substances to pass through freely, while
keeping other substances out.
Transport Mechanisms
Necessary to move fluid and solutes
through the semi-permeable membrane g p
Mechanisms used in dialysis
Osmosis Osmosis
Diffusion
Filtration Filtration
Ultrafiltration
Osmosis
Movement of FLUID across a semipermeable
b f f LOWER l t membrane from an area of LOWER solute
concentration to an area of HIGHER solute
concentration.
Diffusion
M t f di l d ti l (S l t ) Movement of dissolved particles (Solutes)
across a semipermeable membrane from an
HIGHER l t t ti t area HIGHER solute concentration to an area
of LOWER solute concentration
Removes waste products from the blood
BUN and Creatinine
Principlesof Hemodialysis Principles of Hemodialysis
Adapted with permission of Amgen Inc.
Factorsthat Affect theRateof Factors that Affect the Rate of
Diffusion
Molecular Size
small molecules move faster than larger g
molecules
Membrane Permeability
pore size, number, thickness, design
Surface Area
th t th f f th the greater the surface area of the
semipermeable membrane, the more rapidly
diffusion occurs
Factorsthat Affect theRateof Factors that Affect the Rate of
Diffusion (cont)
Temperature
molecules move faster as temperature
iincreases
Concentration Gradient
differenceintheconcentrationof solutesof the difference in the concentration of solutes of the
two different fluids
Flow Geometryy
countercurrent flow in dialysis blood flows
one direction while dialysate flows the opposite
way whichincreasestherateof diffusion way which increases the rate of diffusion
Principlesof Hemodialysis Principles of Hemodialysis
OsmosisandDiffusion Osmosis and Diffusion
The end result of both is that movement will
continueuntil theconcentrationof molecules continue until the concentration of molecules
equilibrates (becomes equal) on both sides of the
membrane
Concentrations do not equilibrate during dialysis
as dialysate passes through the dialyzer once on
the way to the drain
Filtration
Process of passing fluid through a filter or
semipermeable membrane. p
Filtration is controlled by hydrostatic pressure.
Fluidalwaysmovesfromanareaof higher Fluid always moves from an area of higher
pressure to an area of lower pressure
Regulatesfluidbalanceintheblood Regulates fluid balance in the blood
Ultrafiltration
Controlled fluid removal by manipulation of
hydrostatic pressure. Ultrafiltration uses both
positive and negative pressure:
Positive pressure = pressure exerted by the blood
flowingthroughthedialyzer flowing through the dialyzer
Results from blood being pushed by blood pump
Negative pressure =pressureappliedtothedialysate Negative pressure pressure applied to the dialysate
side by the machine
Pulls excess fluid from blood compartment to
dialysate compartment drain
FluidRemoval Fluid Removal
Adapted with permission of Amgen Inc.
TransmembranePressure(TMP) Transmembrane Pressure (TMP)
The pressure difference across the semipermeable p p
membrane is called the TMP
Highest positive pressure is found post pump in the arterial
header of thedial er header of the dialyzer
Lowest pressure is found in the venous header as the blood
leaves the dialyzer
Water molecules in the blood can pass through the
membrane as long as the pressure exerted by the blood
isgreater thanthat of thedialyzer is greater than that of the dialyzer
TMP was used to determines how much water crosses
themembraneuntil theadvent of UF control systems the membrane until the advent of UF control systems
Electrolyte
An electrolyte is any substance that, in a
solution, conducts an electrical current. ,
In water, the molecules of many substances
ionize, or separate into particles called ions, , p p ,
which carry electrical charges.
Electrolytes in the blood are necessary for y y
the body to send signals to the nerves and
muscles.
Two Types of Electrolytes
Anions (-) negatively
charged particles.
Cations (+) positively
charged particles.
Chloride
Sulfates
h h
Potassium
Sodium
l i Phosphates
Bicarbonate (Acetate)
Calcium
Magnesium
Functions of Electrolytes
Maintain fluid balance
Conduct nerveimpulses Conduct nerve impulses
Cause muscle contraction
Aidi l i ( l i ) f bl d Aid in coagulation (clotting) of blood
TheArtificial Kidney The Artificial Kidney
Alsocalledadialyzer Also called a dialyzer
It contains two compartments:
Bl d ddi l t Blood and dialysate
Compartments are separated by a semi-
permeable membrane
Hollow fibers
Compartments are encased in a clear plastic
cylinder which acts a support for the fibers y pp
Dialyzers Dialyzers
Design Blood
Semipermeable membrane
In
Dialysate
Support Structure
Internal Compartments
Blood
Out
Outer
Casing
Blood
Dialysate
Membrane
Potting
Bl d
Dialysate In
g
Material
Blood
Out
What is a semi-permeable p
membrane?
A thin layer of material with pores that allow
smaller moleculestopassthroughbut not smaller molecules to pass through but not
larger molecules
Bloodcellsaretoolargetopassthrough Blood cells are too large to pass through
Waste products, excess chemicals, and excess
fl id th h fluid can pass through
What isBiocompatibility? What is Biocompatibility?
Compatiblewithlivingtissue Compatible with living tissue
Patients must be able to tolerate the dialyzer
membrane it must be biocompatiblewiththem membrane it must be biocompatible with them
When blood is exposed to a foreign material,
immunecellsinbloodreact todefendthebody immune cells in blood react to defend the body
All dialysis membrane materials react to some
degreewithimmunecellsinblood degree with immune cells in blood
Effects may be subtle or life threatening
Hemodialyzers Hemodialyzers
Syntheticmembranesareconsideredtobe Synthetic membranes are considered to be
more bio-compatible
Examples of synthetic membrane p y
Polysulfone
Polyacrylonitrile (PAN) y y ( )
Note: Patients can develop sensitivity (allergic-
type reaction) to any membrane
Membranes Membranes
Conventional
small surfacearea small surface area
removes small molecular size particles well
KUF 2-7mL/hr/mmHgg
High Efficiency
removessmall tomiddlesizemoleculeswell removes small to middle size molecules well
KUF 7-15mL/hr/mmHg
HighFlux High Flux
removes small, middle, and larger molecular size
particles
KUF - >15mL/hr/mmHg
Dialysate Dialysate
Composedof concentratedelectrolytes Composed of concentrated electrolytes,
bicarbonate and treated water
El t l t t ti i th di l t Electrolyte concentration in the dialysate
determine what is removed or given to the patient
Tailoredtoeachpatientsneedsbasedonblood Tailored to each patient s needs based on blood
chemistries
Regulateselectrolyteandacid/basebalancein Regulates electrolyte and acid/base balance in
the blood
Dialysate
Enables the removal of
Wasteproducts Waste products
Excess fluid
P l f Prevents excess removal of
Essential electrolytes
Excessive fluid depletion
Dialysis Prescription
Contains physician orders for the dialysate necessary to
meet the needs for each patient
C l i P i dS di Calcium, Potassium and Sodium
Contains physician orders for the dialyzer necessary to
meetstheneedsfor eachpatient meets the needs for each patient
Surface area available for dialysis is related to dialyzer
size
Contains physician orders for a target weight and length of
dialysis treatment
Containsphysician orders for abloodflowrate Contains physician orders for a blood flow rate
UnderstandingthePrinciplesof Understanding the Principles of
Dialysis
Means you understand the need for each
i di l i h di l d patient to dialyze using the dialysate and
dialyzer ordered by the patient's physician
QUESTIONS?