Principles of dialysis

The dialysis process

The concept of dialysis, that is partition (separation) of substance between two solutions by use of
semipermeable membrane, is quite simple. Extracorporeal dialysis employs the artificial kidney (dialyzer)
as semipermeable membrane, while   Intracorporeal   dialysis employs the peritoneal membrane.

 Physical principles of dialysis

Diffusion, Ultrafiltration and Osmosis are the basic physical principles of dialysis. Diffusion is the net
directional movement of molecules occurring from a solution of higher concentration to a solution of low
concentration. Ultrafiltration is the movement of solvent across a semipermeable membrane in response
to a pressure difference applied across the membrane. If the solutes dissolved in the solvent is small
enough to permeate the membrane, they are dragged along with the solvent and cross over to the other
side, and this called Convection. Osmosis the movement of the solvent (e.g. water) from the side of low
concentration to the side of higher concentration.
Diffusion
If two solution of different composition are placed on different side of a semipermeable membrane,
solutes will move from the solution with the highest concentration to the solution with the lowest
concentration. The rate of movement will depend on:
1. The concentration gradient for the solute between the two solutions   
2. Permeability of the membrane to the solute
3. Surface area of the membrane.
4. The size of the solute is highly correlated with its molecular weight. The heavier, larger solute
moves more slowly along the concentration gradient than smaller lighter solutes. Thus, dialysis is
most effective in removing small solutes and less effective in removing larger solutes,
particularly those over 1000 Dalton.
Molecular weight in Dalton of some nonionic substances
Substance Molecular weight in Dalton
BUN 28
Urea 60
Creatinine 113
Ethanol 46
Methanol 33
Glucose 180
Vit B12 1355
Albumin 68000
 5. Blood protein affects the diffusive transport of solute across the membrane by two different
mechanisms:
A. the binding of the solute to protein: Diffusible substance may bind to proteins forming
dialysis membrane impermeable complex. Such solutes are no longer available for
diffusion (40-50% of measured calcium in patient blood is available for diffusion). The
percentage of the total concentration of a diffusible solute (actually free to diffuse) is
described as “solute activity”.
B. the Gibbs-Donnan effect: Blood proteins are dialysis membrane impermeable, negatively
charged and tend to accumulate at the membrane surface during dialysis. Coresponding
numbers of membrane permeable cations such as sodium, calcium, magnesium must then
retain in the blood to preserve elecroneutrality. This results in imbalance in the
concentration of ions across the dialysis membrane. The protein-induced ion transport
asymmetry is called the “Gibbs-Donnan effect”. It indirectly affects the magnitude of the
concentration gradients required to drive diffusion across dialysis membrane.
As solute movement continues over a peroid of time, the concentration falls in the solution of higher
concentration, rises in the solution with the lower concentration, and the two solutions approach each
other in composition i.e Equilibrium. As a result of this dissipation of the concentration gradient, the
transfer of solute slows with the time.The maximum rate of solute transfer occurs initially when the
concentration gradient is greatest.

Schematic diagram of diffusion

No hydrostatic pressure is applied
[Van Stone et al 1994, Physiology of peritoneal dialysis in handbook of dialysis 2 nd edition]
 The dissipation of the concentration gradient can be minimized and the transfer of solute optimized by
increasing the volume of the fluids.
a) In a static system (comparable to peritoneal dialysis) this is accomplished by replacing the
recipient fluid with fresh solution at periodic intervals.
b) In a flowing system (comparable to hemodialysis) this accomplished by increasing the flow rate
of parent fluid (blood) or recipient fluid (dialysate).
Both artificial and natural membranes are more permeable to small solutes than large solutes. Thus,
dialysis is most effective in removing small solutes and less effective in removing larger solutes,
particularly those over 1000 daltons.The surface area of the membrane available for diffusion affects the
amount of solute transferred.
 
Mechnisms of solute removal in intermittent hemodialysis and continuous renal replacement therapy
  IHD CRRT

Small solutes (lees than 300 D) Diffusion Convection (CVVH)

Diffusion (CVVHD)

Middle molecules (500-5000) Diffusion Convection

Convection Diffusion

LMW protein (5000-50 000) Convection Convection

Diffusion Adsorption
Adsorption
Large molecules (m0re than 50 000 Convection Convection

Ultrafiltration
The process of water removal from the blood stream is called ultrafiltration; the fluid removed is
the ultrafitrate.  The UF during dialysis is performed for the purpose of removing water accumulated by
ingestion of fluid or by metabolism of food during the interdialytic period. It is essential to prescribe and
control the fluid removal rate so that total fluid removed during dialysis will be equal to the total fluid
gained since the previous dialysis or from the dry weight.
 
 Schematic diagram of osmotic ultrafiltration
No hydrostatic pressure is applied. Triangles represent osmotic agent introduced to right compartment.
This causes an early water shift to the right (ultrafitration), but this is later reversed if the osmotic agent is
also small enough to diffuse along the concentration gradient from right to left. Thus only solutes of such
size that they do not easily permeate the semipermeable membrane are capable of exerting a sustained
osmotic force.   [Sorkin MI et al 1994, Physiology of peritoneal dialysis in handbook of dialysis
2nd edition]
  
 Schematic diagram of hydrostatic  ultrafiltration
The application of external pressure forces movement of water from left to right.  Low molecular weight
constituents will be swept through the membrane with this water (solvent drag.). In dialysis setting the
pressure gradient is generated by manipulation if dialysis fluid parameters such as pressure volume or
flow.
[Von Stone MI et al 1994, Physiology of peritoneal dialysis in handbook of dialysis 2 nd edition]
 
Mechanism of Ultrafiltration
 A) In Hemodialysis:
1. Hydrostatic pressure
The primary driving force for ultrafiltration is the hydrostatic pressure difference across
the membrane, which is the  Transmembrane Pressure (TMP), expressed in millimeters mercury
(mmHg). The TMP is determined by the average or mean pressure in the blood
compartment minus the mean dialysate compartment pressure.The relationship of ultrafiltrate to
TMP is entirely dependent on the membrane (Dialyzer) properties. The permeability of dialyzer
membranes to water is high, varies consonsiderably, and is a function of membrane thickness and
pore size.The total capacity of the dialyzer for ultrafiltration is given by the Ultrafiltration
Coefficient (KUF). 
The KUF is defined as the number of milliliters of fluid per hour that will be transferred
across the membrane per mmHg pressure gradient across the membrane .The KUF of most
dialyzer ranges from 2 to 6 ml/hour. The relationship between ultrafiltration, KUF and TMP is
expressed as:

Ultrafiltration rate (ml/hr) = KUF X TMP

How do you calculate UF rate from KUF?

If one needs to remove 2 kg during a period of 4 hours
1. Add the volume of saline that will be given at the end of dialysis (usually 300 ml) and the
amount of ingested fluid during dialysis (e.g., 100ml).
2. This means that 2.4 L will have to be removed during 4 hours dialysis i.e.2.4 X 1000 /4 =
600 ml/hour.
3. When using a dialyzer with KUF value of 4.0 ml/hour, the TMP will need to be set at
600/4 =150 mm Hg. N.B. (If the dialyzer KUF is 6 the TMP should be = 100 mm Hg).
 2. Osmotic Ultrafiltration
Osmotic ultrafiltration does play an indirect role in total ultrafiltration; water shifts from
intracellular to the extracellular compartment which occur during hemodialysis (so-called plasma
refilling) can be optimized by introduction of an effective concentration of an osmotic agent into
the extracellular space. Sodium is employed in some dialysis practice especially during sodium
profiling

B) In peritoneal dialysis:
1. Osmotic Ultrafiltration
The primary driving force for ultrafiltraion in peritoneal dialysis is the Osmotic gradient
(Osmotic Ultrafiltration). Osmosis is the movement of the solvent (eg water) from the side of low
concentration to the side of higher concentration through a semipermeable membrane.The result of
this movement of water will be equalization of total solute concentration on both sides of the
membrane.
Osmotic ultrafiltraion during peritoneal dialysis is achieved by adding large amount of glucose to
dialysis solution. Peritoneal dialysis solution ordinarily contain 1.36 % (1.5), 2.27 % (2.5), 3.86 %
(4.25). The osmotic pressure generated by glucose will draw water from the blood and tissues into the
dialysate.
2. Hydrostatic pressure
The hydrostatic ultrafiltraion effect is of minor importance
 Indications and contraindications of dialysis
 
Indications for Dialysis -In Chronic Renal Failure
   In patients with chronic renal failure factors to be considered before initiating dialysis should
include comorbid conditions and patient preference. Timing of therapy is dictated by serum chemistries
and symptoms.
 A) Absolute indications
Uremic Pericarditis
Uremic Encephalopathy or Neuropathy
Pulmonary edema (unresponsive to diuretics)
Severe Hypertension
Severe hyperkalemia
Intractable acidosis
Severe Bleeding diathesis
Persistent gastrointestinal symptoms
S.Creatinine more than 12 mg/dl, BUN more than 100 mg/dl
 B) Relative indications
Mild encephalopathy or neuropathy
Severe edema (unresponsive to diuretics)
Progressive gastrointestinal symptoms
Recurrent GI “itis”: stomatitis, gastritis, dudenitis, pancreatitis
Ascitis without hepatic disease
Anemia refractor to Erythropoietin
Mild Bleeding diathesis
Pruritus
Infectious complications
Depression
 C) Early indications
Decrease ideal body weight
Decrease in muscle mass (decrease s creatinine or its clearance)
Decrease in s.albumin to less than 4 g/l
GFR less than 15 ml/min (by I iothalamate)
S. Creatinine >10 mg/dl and bun >100 mg /dl
 Decrease in s.transferrin
Low total cholesterol
Growth retardation in children
 D) Specific indications for peritoneal dialysis
Patients with cardiovascular or hemodynamic instability
Hemodialysis patients with vascular access failure or can not be created (e.g. diabetic patients)
High risk of anti coagulation
Patients in the older age group (over 65) and small children
Severe hemodialysis-related symptoms or disequilibrium
Social reason
Indications for Dialysis other than chronic renal failure
1. Acute renal failure
2. Poisons and Drug intoxication
3. Hypercalcaemia
4. Hyperuricemia
5. Hypothermia
6. Metabolic alkalosis (special dialysis solution required)
 
Dialyzable drugs and Poisons (partial list)
a) Barbiturates            : Phenobarbital -Pentobarbital -Amobarbital
b)  Alcohol's                 : Methanol -Ethanol -Ethylene glycol -Isopropanol
c) Analgesics               : Acetylsalicylic acid -Methylsalicylate
d) Metals                     : Calcium -Potassium -Sodium -Lithium
e) Endogenous toxins  : Uric acid -Uremic toxins -Hyperosmolar state
f) Halides                     : Bromide
g) Miscellaneous          : Theophylline -Mannitol -Radiocontrast -Thiocynate - Boric acid -Aniline

NB:
1. Dialysis for poisoning should be considered only when supportive measures are  ineffective or there
is impending irreversible organ toxicity.
2. Hemoperfusion is required in some cases
 
Factors to be considered in determine drug’s dialyzability:
1. Dialysis related factors:
 Dialyzer membrane characteristics
Surface area
Blood flow rate
Dialysate flow rate
Degree of ultrafitration
Duration of dialysis
 
2. Drug related factors   :
Availability of the drug in the plasma
Drug pharmacokinetic characteristics
Drug molecular weight (<500 cross the membrane more readily)
Drug solubility (water soluble are dialyzable than lipid soluble)
 
Factors Determinants for Dialysis
Factors determining the mode of chronic dialysis should include medical and non medical factors which
have an impact on the treatment modality. Physicians have the responsibility to discuss the therapeutic
options and offer their advice and recommendations about the choices. In general renal transplantation
should be recommended as the preferred mode of renal replacement therapy in whom surgery and
immunosupression is safe and feasible.

A. Medical Factors
Age
Comorbid medical illnesses    
Patient survival    
Patient rehabilitation      
Quality of life  
B. Non Medical Factors
Government-imposed Economic limitations
Physician  and Patient bias
Resource availability
Social ,Religious ,Cultural mores
Availability of transplantation
Family support
Cost , race , sex , reimbursement
 Contraindications of Dialysis therapy
 Principally there is no absolute contraindication to dialysis therapy. Advanced age in and of itself is not a
contraindication to dialysis therapy. Many elderly are physiologically equivalent to young patients.
A. Relative contraindications to dialysis therapy
Advanced malignancy (except multiple myeloma)
Alzheimer’s disease
Multi-infarct dementia
Hepatorenal syndrome
Advanced liver cirrhosis with encephalopathy
Hypotension unresponsive to pressors
Terminal illness
Organic brain syndrome
B. Contraindication for Peritoneal dialysis
Absolute
Peritoneal fibrosis           
Pleuroperitoneal leak       
Relative Minor
Chronic Ostomies
Severe hypercatabolic state
Fresh aortic prosthesis
Recent Abdominal surgery
Recent Thoracic surgery
Extensive Abdominal adhesions
Quadriplegia
Blindness
Physical handicaps
Mental Retardation
Relative Minor
Polycystic Kidney disease
Diverticulosis
Obesity
Peripheral vascular disease
Hyperlipidemia
Social
.
 

Hemodialysis

Definitions
Vascular access
Membranes used for hemodialysis
Dialysate
Hemodialysis machine
Hemodialysis procedure
Anticoagulation in hemodialysis
Patients' monitoring during dialysis
Complications during hemodialysis
Chronic complications of hemodialysis
 DEFINITIONS
Hemodialysis (HD)
The blood passes through an extracorporeal circulation where it is separated from dialysis fluid
by artificial semi-permeable membrane. Solutes move across the membrane only by diffusion. The
dialysissolution comprises water and electrolytes. The dialysis membrane is usually made from
cuprophane, a cellulose derivative. Newer synthetic membranes of polymeric structure are more
permeable to water and solutes and more biocompatible with the blood than cuprophane membranes.

 Hemofiltration (HF)
Hemofiltration is a form of dialysis in which  a negative pressure is created on the side of a
highly permeable dialyzer (Hemofilter) opposite to the blood comartment.This sucks the plasma fluid and
the solute dissolved in it across the membrane.This process is known as ‘Convection’. High volume of
plasma is ultrafiltrated simultaneously replaced by pyrogen free hemofiltration fluid intavenously. The
basic difference between hemodialysis and hemofiltration is in the principle of solute transport. During
hemodialysis the solute is removed by diffusion and the fluid by ultrafiltration. By contrast, during
hemofiltration, the solute removal is accomplished by convection, that is solvent drag.

Continuous Arterivenous Hemofiltration (CAVH)

CAVH is an extracorporeal treatment in which fluid, and electrolyte, and low molecular weight
solute are removed from the body by convective transport.
The technique utilizes the patient arterial pressure to move the blood in the circuit and an ultrafiltrate with
the same characteristics of plasma is generated. The substitution of the amount of fluid lost by
ultrafiltration with sterile replacement solution permit: (1)To correct electrolyte and acid base imbalance.
(2)Lower the patient’s BUN concentration

Hemodiafiltration (HDF)
A combined hemodialysis and hemofiltration procedure. Dialysis solution and highly permeable
membrane are used to obtain diffusion and ultrafiltration. The fluid balance is maintained by infusing a
hemfitration fluid.

 Isolated Ultrafiltration (IUF)

 Isolated Ultafiltration is a method whereby fluid, electrolytes and substance with low molecular
weight are removed from the plasma water by means of convection. Half to one and a half liters can be
removed per hour using conventional hemodialyser. No diffusion occurs during this procedure.When UF
precedes or follows hemodialysis; the combined process is called Sequential UF, or Sequential dialysis.

Hemoperfusion (HP)
HP is a process whereby blood is passed through a cartridge packed with activated charcoal or
carbon, (i.e. the cartridge paced instead of dialyser in the blood circuit). It is more effective than
hemodialysis in clearing the blood of many protein-bound drugs, because the charcoal will compete with
the plasma protein in for the drug, adsorb the drug, and thereby remove it from the circulation. Similarly,
hemoperfusion will remove many lipid soluble drugs from the blood much more efficiently than
hemodialysis. Hemoperfusion is preferred than Hemodialysis in Glutethimide, Methaqualone,
Theophylline and Phenobarbital drug poisoning.
 VASCULAR ACCESS

 Acute Hemodialysis Vascular Access–Noncuffed Catheters (Guide 2 DOQI)

A. Hemodialysis access of less than 3 weeks’ duration should be obtained using a noncuffed, or a
cuffed, double-lumen percutaneously inserted catheter.
B. These catheters are suitable for immediate use and should not be inserted before needed.
C. Noncuffed catheters can be inserted at the bedside in the femoral, internal jugular, or subclavian
position.
D. The subclavian insertion site should not be used in a patient who may need permanent vascular
access.)
E. Chest x-ray is mandatory after subclavian and internal jugular insertion prior to catheter use to
confirm catheter tip position at the caval atrial junction or the superior vena cava and to exclude
complications prior to starting hemodialysis.
F. Where available, ultrasound should be used to direct insertion of these catheters into the internal
jugular position to minimize insertion-related complications.
G. Femoral catheters should be at least 19-cm long to minimize recirculation. Noncuffed femoral
catheters should not be left in place longer than 5 days and should be left in place only in bed-
bound patients.
H. Nonfunctional noncuffed catheters can be exchanged over a guidewire or treated with Urokinase
as long as the exit site and tunnel are not infected.
I. Exit site, tunnel tract, or systemic infections should prompt the removal of noncuffed catheters
 Temporary vascular access:
A. Catheters             B.Quinton-Scribner external arteriovenous shunt
A. Catheters
 1. Single lumen, 1961
 2. Double lumen, 1980s
These catheters made of Teflon, Silastic, or Polyurethane
Veins used:  Femoral vein                 Subclavian vein                     Internal jugular vein
Indication:
1. Acute renal failure  
2. ESRF patients whose permanent access is immature
3. Patients on peritoneal dialysis requiring temporary hemodialysis 
4. Patient for plasmapheresis
5. Patients for venovenous or arteriovenous continuous renal replacement therapy.
Contraindication of Subclavian and Internal jugular vein catheterization
1. Patients with acute respiratory distress (cannot be supine or in Trendelenberg position.
2. Patients with subclavian vein stenosis
3. Abnormal coagulation parameters
Nursing management (Guide)
 All of these catheters are prone to infection therefore aseptic technique when initiating and
terminating dialysis is of outmost importance.
 The caps and ports should be wrapped in a dressing soaked in Betadine for 5 minutes before
initiating and ending dialysis.
 The exit site should be cleaned with Peroxide and Betadine after every treatment, and a sterile
dressing should be applied. The appearance of the exit site especially redness or drainage must
be documented
 Careful heparinization is necessary and should be guided by manufacturer's instruction and
according to the size (or dead space) of each catheter. Indwelling heparin should be aspirated
before dialysis to avoid excessive heparinization. A preferable method of maintaining catheter
patency is the instillation of 1000-5000 U of heparin into the catheter immediately after
dialysis. The volume necessary to deliver heparin depends on the size (dead space) of the
catheter. Clamp the catheter firmly and once to avoid blood suction into the tip of the catheter
by dropper action
 Do not attempt to instill saline into a clotted catheter. This will force the clot into the vascular
system.
 Minimal handling of the catheter is strongly advocated, and then only experienced personnel. If
the catheter is needed for parentral nutrition or blood transfusion a Leuer-lok connections
should be used to prevent air embolus or blood loss.
Bases for cannula selection
 1. Subclavian and internal jugular vein catheter can be lift in place for several weeks while femoral
catheter almost always removed within 3 days.
2. Once subclavian and internal jugular vein catheters patient can be dialyzed as an outpatient while
patient with femoral catheter must be hospitalized.
3. Femoral catheter is easily insertable while subclavian and internal jugular vein catheters insertion
requires a skilled operator.
4. Complication from femoral catheterization usually minor and never life threatening in contrary to
subclavian and internal jugular vein catheters insertion.
5. New femoral catheter insertion for each dialysis is the best approach in bacteraemic patients
 
Complications
 

  Femoral Subclavian Jugular

Early Pain at insertion site Pain at insertion site Pain at insertion site
  Bleeding Bleeding Bleeding
Puncture of the Puncture of subclavian artery Puncture of carotid artery
femoral artery, pneumothorax Pneumothorax
Intestinal perforation Hemothorax Hemothorax Arrthmias
  Brachial plexus injury  
Puncture of superior vena cava
Mediastinal haemorrge
Peric.temponade
Arrhythmias
Late Groin hematoma Infection Infection
  Retroperitoneal Catheter clotting Catheter clotting
hematoma Subclavian vein thrombosis or Thrombosis and stricture are
Infection stricture quite low incidence 
Catheter clotting
 
Management of technical problems
1. Poor blood flow
 Lowering patient's head if using subclavian or Jugular vein
 Turning patient's head to opposite side if using subclavian or Jugular V
 Apply external pressure to the exit site
 Rotate the catheter shaft 180 degrees
 Reverse the lines (last resort)
 Replace the catheter if the catheter has been in place for less than week.
2. Clotting        
 Proper heparinization postdialysis
  Clamp the catheter firmly and once to avoid blood suction into the tip                             
of the catheter by dropper action
 Finrinolytic agents such as urokinase or streptokinase
 Replace the catheter if the catheter has been in place for less than week.
3. Kinking           
 Replace the catheter if the catheter has been in place for less than week.

Tunneled Cuffed Catheter Placement: Type and Location: (DOQI)

A. Tunneled cuffed venous catheters are the method of choice for temporary access of longer than 3
weeks’ duration. (They also are acceptable for access of shorter duration.) In addition, some
patients who have exhausted all other access options require permanent access via tunneled
cuffed catheters. For patients who have a primary AV fistula maturing, but need immediate
hemodialysis, tunneled cuffed catheters are the access of choice. Catheters capable of rapid flow
rates are preferred. (Evidence/Opinion)
B. The preferred insertion site for tunneled cuffed venous dialysis catheters is the right internal
jugular vein. Other options include: the right external jugular vein, the left internal and external
jugular veins, subclavian veins, femoral veins, or translumbar access to the inferior vena cava.
Subclavian access should be used only when jugular options are not available. Tunneled cuffed
catheters should not be placed on the same side as a maturing AV access, if possible. (Evidence)
C. Fluoroscopy is mandatory for insertion of all cuffed dialysis catheters. The catheter tip should be
adjusted to the level of the caval atrial junction or into the right atrium to ensure optimal blood
flow. (Atrial positioning is only recommended for catheters composed of soft compliant material,
such as silicone.) (Opinion)
D. Real-time ultrasound-guided insertion is recommended to reduce insertion-related complications.
(Evidence/Opinion)
E. There is currently no proven advantage of one cuffed catheter design over another. Catheters
capable of a rapid blood flow rate are preferred. Catheter choice should be based on local
experience, goals for use, and cost. (Evidence/Opinion)

 
 Permanent Vascular Access For Hemodialysis
Patient Evaluation Prior to Access Placement
Consideration
Patient History  
History of previous central venous catheter
Dominant arm
History of pacemaker use
History of severe congestive heart failure
History of arterial or venous peripheral catheter
History of diabetes mellitus
History of anticoagulant therapy or any coagulation
disorder
Presence of comorbid conditions, such as malignancy
or coronary artery disease, that limit patient’s life
expectancy
History of vascular access
History of heart valve disease or prosthesis
History of previous arm, neck, or chest surgery/trauma
Anticipated renal transplant from living donor
Physical Examination
Physical Examination of Arterial System
Character of peripheral pulses, supplemented by hand-
Relevance
Previous placement of a central venous catheter is associated with central
venous stenosis.
To minimize negative impact on quality of life, use of the nondominant arm is
preferred.
There is a correlation between pacemaker use and central venous stenosis.
Accesses may alter hemodynamics and cardiac output.
Previous placement of an arterial or venous peripheral catheter may have
damaged target vasculature.
Diabetes mellitus is associated with damage to vasculature necessary for
internal accesses.
Abnormal coagulation may cause clotting or problems with hemostasis of
accesses.
Morbidity associated with placement and maintenance of certain accesses may
not justify their use in some patients.
Previously failed vascular accesses will limit available sites for accesses; the
cause of a previous failure may influence planned access if the cause is still
present.
Rate of infection associated with specific access types should be considered.
Vascular damage associated with previous surgery or trauma may limit viable
access sites.
Temporary access may be sufficient.
 
An adequate arterial system is needed for access; the quality of the arterial
 held Doppler evaluation when indicated
Results of Allen test
Bilateral upper extremity blood pressures
Physical Examination of Venous System
Evaluation for edema .
Assessment of arm size comparability
Examination for collateral veins
Tourniquet venous palpation with vein mapping
Examination for evidence of previous central or
peripheral venous catheterization
Examination for evidence of arm, chest, or neck
surgery/trauma
Cardiovascular Evaluation  
Examination for evidence of heart failure
system will influence the choice of access site.
Abnormal arterial flow pattern to the hand may contraindicate the creation of a
radial-cephalic fistula.
Pressures determine suitability of arterial access in upper extremities.
 
Edema indicates venous outflow problems that may limit usefulness of the
associated potential access site or extremity for access placement
Differential arm size may indicate inadequate veins or venous obstruction
which should influence choice of access site.
Collateral veins are indicative of venous obstruction.
Palpation and mapping allow selection of ideal veins for access.
Use of central venous catheters is associated with central venous stenosis;
previous placement of venous catheters may have damaged target vasculature
necessary for access.
Vascular damage associated with previous surgery or trauma may limit access
sites.
Accesses may alter cardiac output.
 Arteriography is useful to avoid extremity ischemia in patients with diminished pulses in whom
access in the extremity is still desired. However, the Work Group concluded that arteriography is only
rarely required.
 Venipucture in the non-dominant forearm should be minimized in patients with chronic renal failure
 Permanent V. Access should be created when creatinin clearance drops to ~ 15 ml/minute or 3-6
months prior to initiation of hemodialysis.
 The risk of subclavian vein stenosis in patient who have had previous subclavian catheter is high
therefore angiographic assessment is recommended prior to access placement.

Types of permanent V. Access

A. Arteriovenous Fistula                         
B. Arteriovenous Graft
A. Arteriovenous Fistula (1966)
Description:
The arteriovenous fistula consists of surgical anastomosis of an adjoining artery and vein. The diversion
of the arterial blood causes the used veins to become enlarged and prominent and stronger because of the
greater flow of the arterialized blood through them.

 
Selection of Permanent Vascular Access and Order of Preference for Placement of AV Fistulae (Guide 3
DOQI)
 1. The order of preference for placement of AV fistulae in patients with kidney failure who will
become hemodialysis dependent is:
a. A wrist (radial-cephalic) primary AV fistula (Evidence)
b. An elbow (brachial-cephalic) primary AV fistula (Evidence/Opinion)
2. If it is not possible to establish either of these types of fistula, access may be established using:
a. An arteriovenous graft of synthetic material (eg, PTFE) (Evidence) or
b. A transposed brachial basilic vein fistula (Evidence)
3. Cuffed tunneled central venous catheters should be discouraged as permanent vascular access.
 
Types and blood vessels used:
 Radiocephalic Fistula       : Anastomosis of Radial artery   and Cephalic vein
 Brachiocphalic Fistula      : Anastomosis of Brachial artery and Cephalic vein
 BrachioBasailic Fistula     : Anastomosis of Brachial artery and Basilic vein
Ulner artery is infrequently used
Anastomosis:
End of the vein to side of the artery  
End of the vein to end of the artery
Side of the vein to side of the artery
Surgical Technique: The details of the surgical technique are beyond the scope of the Tips
Postoperative Care:
1. Elevate the arm to minimize edema.
2. Avoid tight dressings
3. Check the fistula daily for, thrill, hematoma, and evidence of ischemia
4. After 4-5 days some exercises could be started
a. A tourniquet may be placed around the upper arm to cause distention of the veins, leave it for
about 30 minutes and may be repeated several time each day.
b. Hand exercise, such as squeezing rupper ball, while the tourniquet is in place.
c. Warm compresses to speed the venous distention.
5. Arteriovenous fistula could be used after 2 months.
 
B. Arteriovenous Graft (1974 / 1977)
Description: A biologic, semi biologic or prosthetic graft implanted subcutaneously and attached to an
artery and vein. It is used in patients who do not have adequate vessels to create an arteriovenous fistula.
It can be used after 2-3 weeks.
 
Type and Location of Dialysis AV Graft Placement
If a primary AV fistula cannot be established, a synthetic AV graft is the next preferred type of
vascular access Grafts may be placed in straight, looped, or curved configurations. Designs that provide
the most surface area for cannulation are preferred. Location of graft placement is determined by each
patient's unique anatomical restrictions, the surgeons's skill, and the anticipated duration of dialysis)
1. Subcutaneous autogenous vein grafts. A segment of patient's own vein is attached to an artery a
vein and used for dialysis after becomes prominent and healing.
2. Bovine grafts: Carotid artery from cattle is used after special processing.
3. Synthetic grafts: Many synthetic materials are available [Macron, Polytetfluoroethylene (PTFE)]
inserted surgically and require 2 weeks to mature. Polytetrafluoroethylene (PTFE) tubes are
preferred over other synthetic materials.
4. PTFE graft with transcutaneous device for needle free access. The system is accessed through
self-sealing device with locking ring. A special set attaches to the blood tubing.
Surgical Technique: The details of the surgical technique are beyond the scope of the Tips
Postoperative care: As in Arteriovenous fistula
 
Access Maturation  
A. A primary AV fistula is mature and suitable for use when the vein’s diameter is sufficient to allow
successful cannulation, but not sooner than 1 month (and preferably 3 to 4 months after construction.)
B. The following procedures may enhance maturation of AV fistulae:
 1. Fistula hand-arm exercise (eg, squeezing a rubber ball with or without a lightly applied
tourniquet) will increase blood flow and speed maturation of a new native AV fistula. (Opinion)
2. Selective obliteration of major venous side branches will speed the maturation of a slowly
maturing AV fistula. (Opinion)
3. When a new native AV fistula is infiltrated (ie, presence of hematoma with associated induration
and edema), it should be rested until swelling is resolved
C. PTFE dialysis AV grafts should not routinely be used until 14 days after placement. Cannulation of a
new PTFE dialysis AV graft should not routinely be attempted, even 14 days or longer after
placement, until swelling has gone down enough to allow palpation of the course of the graft. Ideally,
3 to 6 weeks should be allowed prior to cannulation of a new graft.
D. Patients with swelling that does not respond to arm elevation or that persists beyond 2 weeks after
dialysis AV access placement should receive a venogram or other noncontrast study to evaluate
central veins.
E. Cuffed and noncuffed hemodialysis catheters are suitable for immediate use and do not require
maturation time. (Evidence)
 
Using Permanent Vascular Access
Poor vascular access is a limiting factor to patient survival on hemodilysis. Therefore great care
must be taken to maintain adequate vascular access.
Kind of the needle 
Sixteen, fifteen and fourteen gouge needles are used for hemodialysis. Smaller diameter (higher gouge)
needles seriously limit the blood flow rate.
Higher flow rate may be possible by using bigger diameter needle, but at considerable increase in
negative pressure which increased the possibility of sucking air into the system or damaging the intima of
vessels. Resistance to the flow occurs in long needles, therefore the shortest practical needle is desirable.
The selection of the needle depends on:
1. Amount of subcutaneous tissue to be penetrated
2. Size of the vein (access).
3. Angulation of the vein.
Placing The Needle in the Access:
1. Aseptic technique is essential.
2. Local anesthesia may be used in some patient.
3. Localize the fistula or graft; depth ; angulations ; maximum thrill ; and site of insertion ; hence the
angle of needle insertion is decided (~ 45 degree).
 4. Insert the inlet (Arterial) needle proximal to the fistula or close to arterial anastomosis of the graft by
3 cm at least, to avoid intimal damage and the subsequent thrombosis.
5. The return ( venous )needle should inserted pointing toward the heart approximately 5 cm proximal
to the arterial needle. This opposite direction meant to avoid recirculation. Such event may be
undetected , the patient gets poor dialysis.
 

 
Remarks :
A. Black blood syndrome : When recirculation is quite severe the blood  becomes very acidic (pH
<7 ) the RBCs cannot carry oxygen and the blood appears very
B. If venous needle cannot be inserted ,often vein can be found in another limb or single needle
technique to be used.
C. Insert the needles at least 2 cm or more from the previous sites each time to ensure complete
healing of the vein.
D. Initiate heparenization after insertion of both needle,.( to avoid hematoma ).
Removing the needle
  It is important to maintain adequate pressure either by hand or tight pressure dressing  over the
puncture site for 15-20 minutes after needles is removed.
Care required between dialysis
1. Good hygienic condition is important. Instruct the patient to wash fistula arm with water and soap
predialysis.
2. Advise the patient to remove the dressing  few hours after dialysis .
3. Advise the patient to avoid trauma to the access or to sleep on the same arm.
4. Educate the patient to:
a) Feel the bruit over the fistula (Touch)
b) Observe for signs of infection; redness, pain, swelling, exudates (Look).
What to say to the patient to protect his access?
 Make sure your nurse or technician checks your access before each treatment.
 Keep your access clean at all times. 
 Use your access site only for dialysis. 
 Be careful not to bump or cut your access.
 Don't let anyone put a blood pressure cuff on your access arm.
 Don't wear jewelry or tight clothes over your access site.
 Don't sleep with your access arm under your head or body.
 Don't lift heavy objects or put pressure on your access arm.
 Check the pulse in your access every day.

 
 Membranes used for hemodialysis

Types of semipermeable  membranes  used for hemodialysis:

 
1. Organic Cellulose (C6H10O5) membranes and its derivatives :
  Cellulose is the most common type of dialyzer membrane. It is  obtained from treated wood
products and cotton with heat and chemicals and formed into sheets or extruded through dies as hollow
fibers ;e.g. regenerated cellulose, cuprammonium cellulose (cuprophan), cuprammonium rayon,
saponified cellulose ester. Cellulose acetate and triacetate are other widely used cellulose substances.
Nature: The membrane is visualized as a thin sheet with tiny pores. These pores are small enough to hold
back blood cells and plasma proteins, yet large enough to permit water molecules and many solutes to
pass through. Selective permeability is improved by making the membrane thinner, increasing the
numbers of channels between fibers , or increasing the diameter of passages.
Positive and Negative features: Hollow fibers have minimal compliance and permit precise TMP
calculation. They are inexpensive. Cellulose membranes however have more incompatibility problems
than do synthetic membranes specially cuprophan.
 
2. Synthetic membranes:
  Synthetic membranes include
Polyacrylonitrile (AN ,PAN)                    
 Polysulfone
Polycarbonte polymide                              
Polymethylmethacrylate (PMMA)
Ethylene-vinyl alcohol copolymer
Nature: They are a thin , smooth luminal surface, supported by a sponge-like wall structure. All have
ultrafiltration coefficients of 20 to 70 ml/hr/mmHg or more.
Positive features: Middle molecule clearance is greater than cellulose membranes. B. Microglobulin is
removed by adsorption to the membrane 100 mg /treatment. They have better biocompatibility with blood
than cellulose membrane.
Negative features: Very expensive. Automated ultrfiltration control is required because of very high
water permeability Significant protein loss by adsorption. Backfiltration from the dialysate and risk of
bacterial or endotoxin contamination, due to high hydraulic permeability
Membrane biocompatibility:
Material used in manufacture of dialysis membrane is associated with some degree of blood-material
interaction. Complement activation that occurs during dialysis with cellulose membrane is instigated by:
1)Free hydroxyl radicals on the membrane surface. 2) A cellulose material called Limulus-Amebocyte-
Lysate-Reactive-Material (LALRM). This activation leads to release of histamine, thromboxane,
interleukin 1, and tumor necrosis factor as well as direct action on blood cells. The clinical manifestation
varies from minimal symptoms to severe anaphylactic reaction. (See membrane reactions)
Dialyzers
A. Types of Dialyzers (Artificial kidneys)
  Dialyzers consists of a series of parallel flow paths designed to provide a large surface contact
area between blood and dialysate. The dialyzing membrane has pores varying between 11-30 um. The
membranes are protected  by dialyzer shell with 4 ports ,2 for blood and 2 for dialysate  Dialyzers are
broadly classified as:
1. Coil dialyzer      
2. Parallel Plate dialyzer      
3. Hollow Fiber dialyzer
Coil dialyzer :( are of historic interest)
 Basically consists of a flattened cellulose tubing  wrapped as a coil and through which patient’s
blood flow during dialysis.The blood channels was long to obtain the needed surface area, and
resistance was high. UF was unpredictable and blood leak were frequent.
Parallel Plate dialyzer
 Structure: 
 Sheets of membranes are placed between supporting plates The plates have ridges and
grooves to support the membrane and allow flow of dialysate along it.
 Resistance to blood flow is low.  The surface area vary from 0.25 to 1.5 msq.
 Advantages:
 Blood volume is about 50-100 ml at 100 mmHg increases with high TMP (bulging
sheets)
 Heparin requirement usually low, minimal clotting in the blood compartment.
 Ulttrfiltration is reasonably predictable and controllable.
 Disadvantages:
  Formation of local thrombi around inlet and outlet ports and corners due to uneven blood
flow at these parts. These may lead to bacterial growth and endotoxin formation ,
therefore plates are not often reused.
Hollow  Fiber dialyzer
 Structure:
 It consists of numerous hollow fibers (capillaries) through which the patient’s blood flow.
The hollow fibers are tiny its diameter ~150-250 um. The wall thickness as little as 7 um.
The number of fibers may be 20,000 or more ,depending upon length ,kind of
membrane , and surface area of the dialyzer. Hollow fiber is the most commonly used
dialyzers
 Advantages:
 It contained low blood volume in relation to surface area 60-90 ml (low priming volume).
 Resistance to blood flow is low.
 Ultrafiltration can be precisely controlled,
 They are well adapted to reuse.
 Disadvantages:
 Deaeration of the fiber predialysis is necessary to prevent air lock of the fibers.
 Uneven blood distribution at the inflow header space leads to relative stagnation
centrally, with reduced perfusion and clotting of some center fibers with the subsequent
high residual blood volume and aggravation of anemia.
 More heparin is required for most of the patients.
 Adverse patient reaction due to residual toxic products of sterilizing agent.

B. Dialyzer specifications
Data about the dialyzer includes the following  information which guides the dialysis personnel to
select proper dialyzer for each patient :
1. Type of the dialyzer :(see the previous tip)
2. Material of the membrane :(see the previous tip)
3. Ultrafiltration Coefficient ,(KUF). (see the previous tip for Ultrafitration)
The KUF is defined as the number of milliliters of fluid per hour that will be transferred
across the membrane per mmHg pressure gradient across the membrane The KUF of most
dialyzer ranges from 2 to 6 ml/hour. If KUF is low (or high) the permeability to water is low (or
high). In vivo KUF is often lower by 5-30% than in vitro value The relationship between
ultrafiltration, KUF and TMP is expressed as:
 Ultrafiltration rate (ml/hr) = KUF X TMP
4. Clearance.  Usually reported at blood flow rates of 200,300,and 400 ml/minute
a. Urea :  A high efficiency dialyzer with thin, large surface area, wide pores, good design
will remove a higher percentage of waste products. The efficiency of a dialyzer in
removing urea can be described by a constant referred to as Mass transfer urea
coefficient -KoA  .This constant influence the relation between the blood flow rate to the
clearance. clearance .Dialyzers of low efficiency have in vitro KoA value of less than 300
; used for acute dialysis  and small  patient. Dialyzers of moderate efficiency have in vitro
KoA value of 300-600;higher efficiency dialyzers have KoA more than 600-700.Once
KoA of the dialyzer is known a nomogram can be used to predict the blood water urea
clearance (Kw) at given blood (Qb) and dialysate (Qd) flow rate. The in vitro KoA is
usually overestimated ,therefore  in vivo value should be estimated from another
nomogram.
b. Creatinine ,Vit.B12: The dialyzer creatinine clearance is ~ 80% of urea clearance.
Vitamin B12 dialyzer clearance range is 30-60 ml/minute. It is used as indication for
clearance of higher molecular weight.

Molecular weight of some nonionic substances in mol wt:

 BUN     = 28      Urea      = 60        Creatinine = 113         Albumin  = 68000
 Glucose =180     Vit B12 = 1355    Ethanol     = 46           Methanol = 33

5. Surface area of the dialyzer:

Normally large surface area of the dialyze have high urea clearance. However dialyzer
design and the thinness of the membrane are quit important. Large surface area is an undesirable
feature when an unsubstituted cellulose membrane is used. It increases the degree of complement
activation.
6. The priming volume : It is related to the membrane surface area; usually 60-90 ml in hollow
fibers. If this added to the priming volume of the blood lines(100-150 ml), the total extracorporeal
circuit will be 160-270 ml
7. Mode of dialyzer Sterilization
 Exposure of the dialyzer to Ethylene Oxide gas
 Gamma irradiation - becoming popular
 Steam autoclaving - becoming popular
 Dialysate
The term dialysate refers to the fluid and solute that have crossed a membrane i.e. effluent
dialysis fluid. However, in current renal jargon all dialysis fluid, fresh or used is called dialysate.
Dialysate is sometimes called “bath". The composition of dialysate is nearly correspond  to that of plasma
water.
Composition and function of dialysate
Composition of dialysate: There are five compounds
1. Sodium chloride
2. Sodium acetate or Sodium bicarbonate
3. Calcium chloride
4. Potassium chloride
5. Magnesium chloride.
Glucose may be included in some formulas.
The use of bicarbonate in concentrate causes calcium and magnesium precipitate because of high pH.  
Function of Dialysate:
1. It carries away the waste materials and fluid removed from the blood by dialysis.
2. It prevents removal of essential electrolytes.
3. It avert excess water removal during dialysis.
Types of dialysate: 
Two types of dialysis solutions are discussed in the following 2 tips
1. Acetate Dialysate
2. Bicarbonate Dialysate
Acetate Dialysate
Acetate is physiologically compatible with blood and metabolized to bicarbonate in the liver. It is
mixed with water in proportioning system, usually 1 part concentrate and 34 parts of water, to form the
dialysate. A typical composition of acetate containing dialysate (after mixing) contains, Sodium 135-145
mEq/L, potassium 0-4 mEq/L, Calcium2.5-3.5 ,Magnesium 0.5-1 mEq/L, Acetate 35-38 mEq/L, Chloride
100-119 mEq/L, Dextrose 11 mEq/L ,PCo2  0.5 mmHg.
Advantages:
1. Stable during storage
 2. Not prone to bacterial contamination
3. A wide variety of formulations are available 
4. The delivery system is simple and less costly
Disadvantages:
1. Serum bicarbonate may decrease early during dialysis.
2. Acetate accumulation contribute to cardiovascular instability with vasodilatation and
hypotension, nausea , vomiting, and post dialysis fatigue.
3. Acetate dialysate is not suited for high efficiency or high flux dialysis. Serum bicarbonate
is depleted and acetate level may exceed the rate at which the liver can metabolize it.
Therefore cardiovascular instability may be severe and disequilibrium may occur.
Bicarbonate Dialysate
Calcium and magnesium will not remain in solution with bicarbonate because of low hydrogen
ion content (high pH). To solve this problem, two separate concentrate are used. The proportioning
(delivery) system mix and monitor three liquids instead of two.
1. .The “A” concentrate 
2. .The “B” concentrate OR powder. 
3. Purified water
 The “A” -indicating acidified- concentrate contains sodium ,calcium , magnesium and
potassium, chloride. To maintain low pH enough to keep the calcium and magnesium in
solution when mixed into dialysate  a small amount of acetic acid is included.
 The “B” -indicating bicarbonate-concentrate contains the sodium bicarbonate. Sodium
chloride may be included in some preparation to raise the total conductivity.
 Dry concentrates:  Manufacturers utilizes a delivery system that accepts a closed container
of dry (powder) bicarbonate onto a special holder. Warm water passes  through the column
producing a saturated solution of bicarbonate that is proportioned with water then with the
A concentrate by conductivity controlled feed back system (e.g. Bicart.). The advantage of
this technique avoid the problems of bacterial growth in bicarbonate concentrate and
reduces the cost of storage.
 
 Chemicals in bicarbonate concentrates in mEq/L(after mixing)
  Component Na K Ca Mg Cl Hco3 CH3COO
Concentrate A 81 2 3.5 0.7 87.2 - 4
  Concentrate B 59 - - - 20 39 -
Total 140 2 3.5 0.7 107.2 39 4
  The proportioning system mix the two components simultaneously with purified water to form
the product of dialysis solution, just before it goes to dialyzer. During mixing carbon dioxide will
be generated as a result acid and bicarbonate reaction. The carbon dioxide generated will form
carbonic acid , which lower the pH of the final bicarbonate containing solution to ~ 7-7.4 . In this
pH calcium and magnesium remain in solution.
 
 Negative features of bicarbonate dialysate
1. Liquid “B” is not stable. Some stabilizer or dry sodium bicarbonate may be mixed. The mixing
process requires care to avoid much loss of Co2 ; it must be used within 24 hours.
2. Bicarbonate concentrate is very susceptible to bacterial contamination which should be avoided .
If the container has been opened for more than 72 hours it should not be used. All containers for
mixing, holding, or dispensing B concentrate must be scrupulously sanitized at regular intervals.
3. Many formulation of “A” concentrate are available therefore care must be exercised to ensure that
the concentrates selected are correct for the delivery system being used.
 Hemdialysis Machine
 
Hemodialysis machine consists of  : 
1. Blood pump
2. Dialysate delivery system
3. Safety monitors      
4. Options
5. System disinfection:
 
BLOOD PUMP
Function : It circulate the blood through the dialyzer back to the patient.
Kinds    : Presently peristaltic roller pumps which works by progressive compressing special segments of
the blood tubing are used.
Pump occlusion: Occlusion means that the roller  compress the tubing segments against the semicircular
housing sufficiently to close the lumen completely at that point. Consistent pump flow rates require
precise occlusion. Overocclusion may crack the tubing and rupture of the pumping segment. If occlusion
is incomplete, there will be backflow of the blood with each stroke, inaccurate flow rate and red cell
damage The flow rate for adult is ~ 4 times patient body weight ml/minute, up to 600ml/minute in high
efficiency and high-flux dialysis.
 
DIALYSATE DELIVERY SYSTEM  :
Function
 Appropriate blending of concentrate and water for preparation of final dialysate.
 To monitor dialysate for temperature, composition, and blood leak
 To control dialysate pressure or ultrafiltration rate.
 To regulate the dialysate flow rate through the dialyzer.
 Deareation of water
 Provide protective mechanisms to isolate the blood circuit and the patient from unsafe dialysis.
 System for disinfection and cleaning
Types  
 Single batch system   
  Continuous proportioning system  
 Sorbent regenerative system
A. Single batch system     (is of historic interest)
B. Continuous proportioning system (early1960s)
Central: All the dialysis solution used for dialysis is produced by mixing the concentrate with purified
water and pumped to each machine
 Advantage : Cost effective
 Disadvantage :Not permitting dialysate composition modification
Individual : Each dialysis machine proportions its own concentrate with the purified water.
 Advantage 
1. Permitting dialysate composition modification by selecting different concentrate or altering
the mixing ratio.
2. There is significant saving in time.
3. Less bacteriologic and chemical contamination. 4. Reduced the risk of human error.
 Disadvantages 
1. Complex sophisticated system  
2. Costly 
3. Troubleshouting may be difficult and needs a factory-trained service technician.
Methods of mixing in proportioning system 
1. Matched pumps 
2. Matched metering valves
3. Matched hydraulic-accumulation cylinders  
4. Electronic feedback circuit. Details of mixing are beyond the scope the Tips
C. Sorbent regenerative system  for renewing dialysate. At present it is rarely used.
 
Heating  
 The physiological range of dialysate temperature is 36-42 c
 Temperature below 36 patients will complain of cold and uncomfortable.
 Temperature above 42 protein denature can occur and above 45 red blood cells will hemolyze. 
cardiorespiratory arrest and death (from hyperkalaemia and hypoxemia )as a consequence of
overheated may occur. 

Deaeration or Degassing  
 Water contains considerable amount of dissolved air and microbubbles. Once negative pressure is
applied and water is warmed the air comes out of the solution as expanding microbubbles. 
Bubbles causes:
1. Artifacts on conductivity, temperature sensors and flow meters
2. When bubbles cross the membrane into the blood foaming occur and increases potential for clot
formation, hemolysis and occlusion of the fibers.
3. It decreases the surface area of the dialyzer
4. It block the dialysate flow channels subsequently dialysate pressure drops and the dialysate
surface area incompletely utilized for solute transport
Deareation devices uses warmers along with negative pressure (- 600 mmHg) to bring the dissolved air
out of the solution.  An air trap or coalescing filter then capture the air and vents them out. 

Dialysate pressures
The dialysate delivery system must be capable of generating positive and negative dialysate pressures
(~ - 400 to + 200).
 In dialysis machines without an ultrafiltration controller the dialysate pump is located at the line
leading from the dialyzer to the drain. This allows the machine to create a negative pressure in the
dialysate compartment of the dialyzer. The negative pressure is generated by partial occlusion of
dialysate hose proximal to the dialyzer. To increase the rate of ultrafiltration, negative dialysate
pressures (suction pressures) are often required. Transmembranous pressure is a resultant of the
blood compartment and dialysate compartment pressures.
 High positive pressure is required in situation in which ultrfiltration coefficient or the blood
compartment pressure are high to limits the rate of obligatory ultrafiltration. Higher positive
pressure (+ 350) may be necessary with high-flux membranes However, backfiltration occurs
when dialysate pressure is greater than that of blood compartment, e.g. at the blood outlet.
Transport of endotoxin fragments into the blood in such membranes.

Dialysate Flow
The standard dialysate flow rate is 500 ml/minute.  When high-efficiency and high-flux  dialyzer are used
high dialysate flow rate between 700 and 1000 is required along with high blood flow rate.    High flow
rates are needed  for:
1. Optimum use of dialyzer surface area for solute transport. 
2. With high dialysate flow rate a positive dialysate pressure is generated which limits the rate of
obligatory ultrafiltration.
 

SAFETY MONITORS:
A. Monitors for blood circuit    
1. Arterial pressure monitor 
Locations:  Proximal to the blood pump      
Function: 
1. It reads the arterial pressure at the segment between the patient's needle site  and
proximal to the blood pump which represent the negative pressure created by the roller
pump.
2. It identifies how much suction is being placed on the arterial wall and guard against
excessive suction on the vascular access, e.g. .if suddenly the arterial pressure increases
from 100 to 200 mmHg this could indicate clotted or dislodged needle, low patient BP or
kink in the arterial line.
3. Resistance within the needle (function of the gauge and needle length).
4. It provide an index of vascular access blood supply relative to the flow demand by the
blood pump.
5. A guide to appropriatence of needle placement or kink or obstruction in the blood
segment between the patient and the monitor.    
Mechanism: The pressure is  monitored by mechanical or electronic manometers (pressure
transducers) . Electronic transducer is more sensitive and have rapid response

2. Venous pressure monitor 

Location: Just distal to the dialyzer, usually attached to the top of the venous air trap.
Function: 
1. It reads the venous pressure at the segment between the point after the dialyzer and
before the blood reenters the patient's body.
2. It represent the resistance of the blood returning to the patient via the venous needle  e.g.
if suddenly the venous pressure increases from 50 to 150 mmHg this could indicate kink
in the venous line, clotted air trap or the venous  needle may be clotted or maligned.
Sudden dropping venous pressure occurs when the venous needle is pulled out, wet
transducer or clotted arterial chamber.3. It may indicate venous stenosis proximal to the
needle site.  
 Mechanism:  As in arterial pressure monitor.

3. Venous air trap and air detector

Location: 1. Just distal to venous pressure monitor. 
                2. Often second air trap on the arterial line is also used.
Function: To prevent air entry into the patient or to the dialyzer. It is used also to measure the
pressure in that segment of blood circuit.
Mechanism: When air bubbles entered the blood circuit a sensor reacted through ultrasonic
transducer or light beam by stopping the blood pump, clamping the venous line, and activating
audiovisual alarms.
 
B. Monitors for dialysis solution circuit
1. Conductivity
Location :   Before dialysate reaches the dialyzer
Function    To guard against excessive diluted or concentrated dialysis solution.
Mechanism : When conductivity meter (conductivity probe) detects high or low conductivity  the
machine automatically sounds an alarm and puts the dialysate into bypass mode so that   no
dialysate flow to the dialyzer.
Exposure of the blood to hyperosmolar dialysate can lead to hypenatraemia and other electrolyte
disturbances. Exposure of the blood to hypoosmolar dialysate can results in  hyponatraemia and
rapid hemolysis.
 
2. Temperature
Location:    Before the dialyzer
Function:    To avoid high temperature
Mechanism: Through a temperature sensor, high temperature activate an audiovisual alarm
simultaneously with bypass mechanism.

3. Bypass  valve or mechanism

If the conductivity or Temperature found to be out of limits a bypass valve is activated to divert
dialysate around the dialyzer directly to the drain.

4. Blood leak detector

 Location : In the effluent dialysate line
Function: It guards against undetected blood loss during dialysis. The maximum limit to
hemoglobin present in dialysate is 70 mg/L (corresponding to blood loss of ~0.4 ml/minute ) after
which the blood pump is stopped.
Mechanism: A beam of light is directed through a column of dialysate onto a photoelectric cell. 
A change in translucence and light scatter in dialysate reduces the light received by the photocell,
stopping blood pump and activating audiovisual alarms.

5. Dialysate pressure or transmembranous monitor

Function : To monitor the ultrafiltration with an upper limits avoids excessive level (the usual
preset range 0 to -500 mmHg). Excessive TMP may lead to rupture of the dialyzer and secondary
deareation (cause air accumulation).
Mechanism: The monitor may have automatic or manually set limits, so that extrusion outside the
limits trigger an audiovisual alarm.

OPTIONS IN HEMODIALYSIS MACHINE:

1. Heparin pump
2. Bicarbonate 
3. Variable sodium  
4. Controlled Ultrafiltration 
5. Programable ultrafiltration
6. Dialysate urea sensor [on-line Kt/V monitor]
7. Single blood pathway.

SYSTEM DISINFECTION:
All dialysis unit s must have written policies the deal with the dialysis fluid pathway and dialysis
machine. Disinfection procedure should be done on regular base according to manufacturer's instructions.
Target: To control bacterial contamination. HIV, HCV and HBV viruses are known to be inactivated by
common household bleach.
Methods
1. Heat disinfection requires temperature greater than 85-90 C
2. Chemicals disinfection such as formaldehyde ,  sodium hydrochloride and acetic acid
Machine surfaces, patient's chairs, surrounding furniture, equipment should be routinely wiped with 10%
bleach solution following every patient dialysis. Blood spills should be cleaned immediately.  Leak proof
bags should be used to transport linen soiled with blood or body fluid
 
ALARM DURING HEMODIALYSIS- PROBLEM SOLVING GUIDE LINES]
When an alarm is activated during dialysis do the following:
1. Identify which alarm has been activated.         
2. Identify the cause.
3. correct the cause                                            
4. Resume dialysis if safe to do so
Problem Management

1.Power  Turn the system off and on; if still no power, check the power cord; make sure power is available
   Check the fuse
 

2. Arterial and venous  Check to see that blood pump is running and connected properly
Pressure  Check to see if blood flow rate has changed
   Determine if patient has coughed or moved
 Check to see  if the monitor line is leaking
 Check the blood line for kinks or leaks
 Ensure the monitoring lines are connected to  proper drip chambers
 

2.1 High venous pressure  Manipulate the needle and or the line. If the access is small, a tourniquet must be used, being certain
  the blood pump is off ..Recantation with new needle if needed ,the original one should be left in
place until the end of dialysis. to avoid undue bleeding as the patient is heparinized
 Adjust the blood flow rate , Proper heparnization , Treat access problem ,and Proper needle and
needling
 Extreme care must be exercised when dialyzing a patient with high venous pressure
 -This increases the baseline TMP and obligatory  ultrafiltration will occur
 -Single-needle device is occasionally impossible to use, because with high  venous pressure ,venous
return will be impaired and blood recirculation will be high
 

2.2 Increase  in negative Management of increased negative pressure:  

pressure: (Excessive inflow
suction)
3.Air detector alarm
 
 4. High  Positivedialysate
pressure alarm
5.Low Negative dialysate
pressure alarm      
6.HighTemperaturealarm
7.Low Temperature alarm
 Manipulation of the arterial needle is similar to that of venous needle. In most cases the needle may
have to be replaced with the same precaution as with venous needle
 Treat the cause. 
 Proper needling   
 Asses the access
 Check for air leaks around tubing joints.
 Excessive undetected negative pressure
 Check for unattended intravenous solution administration.
Management of air embolism if present
 Clamp the venous line and stop the blood pump.
 Place the patient in Trendelenberg position on the left side with the chest and head tilted downward
to trap the air at the apex of right ventricle away from the outflow tract.
 Cardiorespiratory support ,Oxygen 100%.
 Occasionally percutaneous aspiration of the air foam from the heart may be necessary.
 Other measures include IV Dexamthsone to reduce brain edema ,Heparin /Dextran to improve the
microcirculation.
 Check to see if drain is occluded or kinked
 Check to see if dialysate hoses are leaking air
 Check to see if dialysate hoses are kinked
 Determine temperature of dialysate (to dialyzer) in the line actually high
 Check to ensure incoming water temperature is blew 90 F
 Determine temperature of dialysate”to dialyzer” in  the line  is actually Low
 Turn the mode selector switch to “dialyze”
 Allow adequate time for the system to stabilize and come to proper temperature range
 Check to ensure incoming water temperature is above 40 F
8.High conductivity alarm  Check to see if water is flowing too slowly or turn off
 Check for kink in the concentrate out line
 Make sure that the system  has had time to stabilize
 Analyze the dialysate to confirm high conductivity at the “to dialyzer” line connection :
1. .If normal, there is malfunction in the machine itself (change it)
2. .If high again concentrate should be changed
3. Check the conductivity before resuming dialysis   
 Be certain that the dialysate flow rate is proper.

  9.Low Conductivity alarm  Turn the mode selector switch to “dialyze”

 Connect the concentrate line to the system
 Drop the concentrate line into the concentrate container
 Check for kinks in the “concentrate” in line
 Make sure the filter on the “concentrate in” is clean
 Allow adequate time for the system to stabilize
 Change the concentrate container if it is dry
 If the concentrate container has not run dry ,a sample of dialysate should sent to the laboratory for
sodium and chloride                
 Analyze the dialysate to confirm low conductivity at drain
1.If low conductivity is confirmed  ; change the concentrate bottle (recheck again)
2.If the conductivity still low after changing the concentrate , a different machine should be  tried
 Be certain that the dialysate flow rate is proper
10.Blood Leak alarm  Make sure the blood leak detector is clean
 Check the effluent for traces of blood
 .Check the dialysate lines for gross blood leak
Exclude 1.bilirubin in dialysate in jaundiced patient
2.air bubbles in dialysate             3.dirty sensor
 If a leak confirmed and you can not mange the cause
1.reduce dialysate compartment pressure to -50 mmHg to avoid bacterial entery to the
blood
2.Dicontinue dialysis
N.B. Review the previous tips and the manual for each machine if needed.
 Hemodialysis Procedure
 

                           Schematic representation of dialysis system

GENERAL REASSESSMENT
Acute or chronic dialysis prescription should be reviewed. evaluated. and carried out accurately
to obtain the maximal efficiency for dialysis. The patient's physiologic status is assessed to ascertain the
necessity of adjusting any dialysis orders.  All machine parameters are assessed to ensure that the
prescribed procedure is correctly implemented. The goal is to initiate and terminate the dialysis procedure
safely and comfortably with no or minimal complications.

RINSING AND PRIMING

Technical and nursing personnel have a great responsibility to assure proper and safe connections, flow
paths, and overall adequacy and safety of the system.
Adherence to the manufacturer's procedure for rinsing is mandatory.

Importance of rinsing and priming :       

1. Rinsing and priming the dialyzer assure adequate removal of allergens (e.g. ethylene oxide ) and
reduction of the incidence of anaphylactic membrane reactions         
2. Microbubbles are also removed when the venous end of the dialyzer pointed upward.
The dialyzer should be used within 5-10 minutes to avoid leaching of residual ethylene oxide or other
leachable allergens into the rinsing fluid.
Dialyzer should be rerinsed briefly immediately prior to dialysis if more than 10 minutes has elapsed.
PATIENT MONITORING PREDIALYSIS:  
Weight , Pulse Rate , B.P.Laying   & Standing  Temperature, Fluid status, Blood investigations and
Vascular access patency and freedom from infection

OBTAINING VASCULAR ACCESS

Poor vascular access is a limiting factor to patient survival on hemodilysis. Therefore great care must be
taken to maintain adequate vascular access.
 Percutaneous venous cannula ( Femoral,  Subclavian,  Jugular )
      Residual heparin or clot is first aspirated from both catheter lumen
      Check the patency of each lumen by irrigating with a saline filled syringe.
Heparin loading dose is administered in the venous limb and flushed with saline.
      Initiate dialysis after 3 minutes
 AV fistula and graft: (see the previous tip; Using permanent vascular access)
      Heparin loading dose is administered in the venous needle and flushed with saline.
      Initiate dialysis after 3 minutes

INITIATTING DIALYSIS
 Set the blood flow rate at 50 then 100 ml/minute, untill the blood fills the blood circuit.
 The Priming fluid in the lines and dialyzer is disposed of to drain until the blood reaches the
venous air trap. In unstable patient the priming fluid is usually given to the patient t maintain the
blood volume.
 Increase the blood flow rate to the desired level after the circuit is filled with blood (150-250 in
acute cases).
 Initiate the dialysis solution flow and adjust the TMP.

ALARMS 
Blood circuit
Arterial pressure
Venous pressure
Air detector
Dialysis solution circuit
Conductivity
Temperature
Blood leak
PATIENT MONITORING DURING DIALYSIS 
Pulse rate , BP every 30 to 60 minutes in chronic dialysis, but at least every 15 minutes in acute
dialysis, Food & Fluid intake, Complications during dialysis and any particular observations.

TERMINATION OF DIALYSIS
a. Saline rinse: The blood is returned by pumping sterile normal saline into the arterial side until the blood
is displaced.  After the bubble trap the fluid should be very pale pink in color (to assure that the
patient has lost the least amount of red cells).
b. Saline-Air rinse: The blood is forced by pumping a small amount of saline into the arterial line, then
the line is opened to allow air into the circuit to push the saline and blood. Again the fluid entering the
patient should be very pale pink in color.
c. Air-Saline rinse: It begins with an infusion of air to displace the blood until it reaches the end of the
dialyzer. At this point the saline is pumped into the arterial line to displace the air.   At the same time
the air is allowed to escape at the level of venous chamber while the saline is being infused to the
patient. It is effective, but air embolism is a potential risk.
NB: I- Constant visual monitoring of venous line is required to avoid air infusion into the
           patient in b and c methods.
      II- Hollow fiber dialyzer are rinsed by saline rinse method because complete removal
           of blood by air from tiny diameter of hollow fiber is difficult.

PATIENT MONITORING POSTDIALYSIS    

Weight  ,  Pulse Rate  , BP Laying &Standing ,Temperature, Blood investigations and Vascular
access patency. All patients parameters and any unusual occurrences should be documented on patient's
file.

EQUIPMENT CARE
The care of dialysis machine is the responsibility of the staff and  of the biomedical technicians.
Scheduled maintenance recommended by the manufacturer should followed meticulously for the safe and
efficient function of the equipment.
 Anticoagulation for Hemodialysis
Mechanism of clotting in extracorporeal circuit:
Clotting of blood in extracorporeal circuit may be initiated when blood comes into  contact with cannulas,
lines, and the dialysis membranes.
Steps of clotting:
1. Coating of the circuit with plasma proteins.
2. Platelet adherence and aggregation
3. Generation of Thromoxane A2.
4. Activation of intrinsic coagulation cascade.
5. Thrombin formation and fibrin deposition.
 Predisposing factors:
1. Reduced anti coagulant.
2. Reduced blood flow rate.
3. Increased whole blood hematocrit [EPO therapy]
4. Increased extracorporeal hematocrit [excessive ultrafiltration].
5. Blood transfusion and Lipid infusion during dialysis..
 Signs of blood clotting in the extracorporeal circuit :
1. Dark-colored blood
2. Dialyzer :
 Presence of black streaks in the dialyzer
 Reduced residual dialyzer  volume
 Presence of clots at arterial header.
3. Lines -Foaming at the drip chambers and venous trap.
 Clot formation at the drip chambers and venous trap.
4. Pressure
 Increased difference between the postpump and venous pressure when there is clots at
arterial chamber or the dialyzer.
 Increase in postpump followed by increase in venous pressure if the clots are distal to
the venous chamber
 Increased venous pressure when venous needle is clotted
 Anticoagulants
1. Heparin       a.Crude heparin   b.Low molecular weight heparin
2. Antiplatelet agents
 a. Protaglandins PGI 2 , PGE 2 ,eporostemol and iloprost
 Potent inhibitors of platelets aggregation
 Less effective than heparin
 Side effects include ; hypotension ,flushing, headache ,nausea and vomiting
b. Aspirin , NSAID , Sulphinpyrazone and Ticlopidine
 Antiplatelets + Counteract platelet factor 4 and prevent its heparin neutralizing effects
 Not suitable to maintain anticoagulation -May be used as heparin sparing
3. Protease inhibitors  [Nofomostat, Gabexate]
 Inhibitors for both coagulation/fibrinolysis cascade and platelet aggregation.
 Adequate anticoagulant effect and reduce bleeding complications.
4. Hirudin
 It is polypeptide thrombin inhibitor.Unlike heparin does not require cofactor to act
 Does not cause platelet stimulation or aggregation
 
Heparin and Heparinization 
 
Nature of Heparin
Heparin is an anionic sulfated mucopolysaccharide of variable molecular weight [8000 to 14000
d] .Low Molecular Weight Heparin fractions [4000-6000 d] are obtained from crude Heparin .  Heparin is
strongly acidic And is neutralized by strong basic compounds such as protamine ,toluidine and quinidine .
The half life is about 90 minutes and the peak anticoagulant activity is reached 5-10 minutes

Mechanism of action:
  Heparin alone does not have anticoagulant effect. In the blood it combine with a protein fraction
called heparin cofactor [antithrombin III].
The complex of Heparin -Antithrombin III prevents  clotting at the three stages of coagulation 1-It binds
and inactivate Thrombin
                   2- It binds and inactivate Activated factor X
                   3-It binds and inactivate Activated factor XI
Low Molecular Weight Heparin [LMWH] inhibits coagulation Activated factor X , XII and kallikrin, but
little inhibition on Thrombin, factor X and XI therefore PTT and thrombin time are minimally
prolonged,thus reducing bleeding risk.
 Side effects : Bleeding             Pruritus                Allergy   
                        Osteoporosis      Hyperlipidemia     Thrombocytopenia
 
Monitoring clotting times during hemodialysis
 Several laboratory method are used:
1. Activated partial thromboplastin time [APTT or PTT]
2. Activated clotting time [ACT]
3. Lee White clotting time [LWCT]

Heparinization  \   Test                                           PTT              ACT              LWCT

                                Baseline                        60-85 sec        120-150
sec      4-8 min
  Standard    - During dialysis               120-140          200-250            20-30
                    -At end of dialysis             85-105           170-190             9-16
  Tight          -During dialysis                 85-105            170-190            9-16

 The goal  is to maintain the PTT or ACT at the baseline value plus 80% during dialysis and plus 40%
only at the end of dialysis to minimize bleeding risk after withdrawal of access needles.

 Techniques of heparin administration

1. Intermittent infusion
An intravenous loading dose of heparin [25-50 units/kg of body weight] is given via the last
needle placed ,and smaller maintenance doses are repeated intermittently throughout the procedure.
Clotting times are monitored at intervals and the dose is adjusted accordingly.
2. Continuous infusion
The patient is given the loading dose followed by slowly infusion of the maintenance dose to the
blood circuit at a constant rate throughout the dialysis .Clotting times are done at intervals and the
rate is adjusted accordingly.
Remarks
1. In continuous infusion the loading dose of heparin is lower than with intermittent .In the
former the dose is required only to prolong the clotting times to the baseline plus 80% 
while in the later it is required to prolong the clotting times to above the base line plus
80%.
2. The dose of heparin is depending on sensitivity to heparin of the individual patient
,heparin half life and potency of heparin preparation
3. For a patient with an average heparin half life of 1 hour, stopping heparin administration
approximately 1 hour prior to the end of dialysis .
 4. During heparinization tendency to bleed is potentated by uremic platelet dysfunction and
by endothelial abnormalities.
3. Regional heparinization:
Administration of heparin “regionally” into the arterial line blood  and neutralizing it by
administration of protamin sulfate into dialyzed blood before returns to the patient.
Protamin is strongly basic compound acts by combining chemically with the strongly acid
heparin to form a stable complex with no anticoagulant effect.
Dissociation of heparin-protamin complex may occur up to 10 hour post dialysis causing
bleeding problem, this is called heparin rebound. Flushing ,bradycardia ,hypotension ,and dyspnea are
other side effects of protamin .
4. Tight heparinization:
Tight or low dose heparinization is indicated for patient at slight to moderate risk for bleeding
e.g. pericarditis and recent surgery
Loading dose 10 units/kg  followed by small additional doses according to the target clotting
times. Continuous administration is preferable in tight heparinization to avoid fluctuation in clotting
during dialysis.
 
Hemodialysis without heparin [heparin free dialysis] :
 Indications In patients with high bleeding risk
1. Pericarditis 
2. Recent surgery with bleeding complications or it will be dangerous e.g. cardiac vascular , eye,
renal transplant and brain surgery
3. Blood disease ; coagulopathy , thrombocytopenia
4. Intracerebral hemorrhage
5. Any active bleeding

Methods of heparin free dialysis

1. Heparin rinse
 Rinse the extracorporeal blood circuit with 3000 units heparin/liter
 Flush the heparin containing saline with unheparinized saline or patient blood.
2. High blood flow rate
 Set the blood flow rate as high as possible , 250-300 ml/minute if it can be tolerated.
3. Saline rinse
 Rinse the dialyzer with 100-200 ml of saline .Adjust the UF rate to remove the excess fluid
 Patient Monitoring During Dialysis
 
Patient monitoring is a series of repeated or continuous observation of the patient’s appearance
and physiologic state before, during and after dialysis procedure. These observations are charted and
made part of the patient’s permanent record. The objectives are to provide as comfortable and safe
procedure as possible for the patient and to detect as early as possible  any complication during dialysis.

General Observations 
Monitoring Predialysis:        Weight , Pulse Rate , B.P.Laying &Standing  , Temperature
Monitoring During  Dialysis: Pulse Rate , BP , Food &Fluid intake
                                                   Particular Observations
Monitoring Postdialysis:       Weight  ,  Pulse Rate  , BP Laying &Standing ,Temperature

Weight:
The weight of the patient is a good index of how well , or how poorly , the patient is controlling his fluid
balance between dialyses. The pre and postdialysis weight provide the best indication of the amount of 
ultrafiltration needed during the procedure. The patient should be weighted immediately before and after
each dialysis, wearing the same articles of clothing and using the same scale. the patient should weigh
himself or herself daily. One should strive to keep the interdialysis weight gain below  1.0 kg/day
The dry weight  is the target postdialysis weight that ideally would results in removal the excess body
fluid.. The dry weight for each patient must be determined on trial-and-error basis. If the dry weight is set
too high the patient will have clinical evidence of fluid overload. On the other hand if it set too low the
patient may suffer from malaise ,dizziness ,weakness , cramps , and frequent hypotension episodes.
 Pulse Rate:
At the start of dialysis, pulse , temperature, BP observations serve as baseline A rapid pulse may indicate
low hematocrit or fluid overload. An increase in pulse rate during dialysis my be associated with 
decreasing blood volume from ultrafiltration and may occur before blood pressure drop. Arrhythmia may
indicate some complications e.g. ,cardiac instability, electrolyte disturbance ......etc.,it should be brought
to the physician’s attention.
 Temperature:
High temperature suggests infection or complicating illness. The patient should be questioned as to other
symptoms The vascular access should be inspected carefully for evidence of infection, swabs and cultures
should be collected ,and evaluation by the physician is mandatory. Temperature during dialysis may be
the result of warm dialysis fluid , a pyrogen reaction or  showering of the bacteria from the infected
access.
Blood Pressure: 
Blood pressure is the pressure exerted by the blood against the walls of the arterial blood vessels during
systole and diastole of the heart. It results from the pumping force of the heart and the resistance of the
vessels.
Usually BP is measured indirectly with a cuff-type sphygmomanometer. Occasionally both arms are used
to complete the blood circuit, in such instance, the cuff can be wrapped  around  the midthigh area and the
stethoscope applied at the bend of the knee. The BP obtained by this method, however, will be 20-40 mm
Hg higher than arm pressure.                                                                                                                        
For patients on dialysis, normal BP is largely individual matter. That is, we are interested in changes that
may occur than in absolute values. The patient’s BP should be monitored every 30 minutes for an acute
dialysis and every 30-60 minutes for chronic dialysis. A systolic value greater than  200 or diastolic
greater than 110 should be brought  to   physician’s     attention. Predialysis hypertension is usually 
volume  related. Lowering dialysate sodium concentration (not below 135-140 mEq/L) and restriction of
salt fluid intake is of great help to control predialysis hypertension. Most of the patient are instructed not
to take antihypertensive medication prior to dialysis .In severely hypertensive patient , patients being
dialyzed in the afternoon and those patient if hypotension during dialysis is not a problem., they can take
their antihypertensive medication safely.
Causes ,prevention ,and management  of interdialytic hypotension were discussed previously.
Food and Oral Fluid intake:
 There are several reasons for watching food and oral fluid intake during dialysis. The amount of
fluid removed by ultrafiltration  is estimated by the net change in the weight from the predialysis
to the postdialysis state. The quantity of food or fluid ingested should be taken into consideration
in making this calculation. A pint of fluid is equals to half kilogram. Although it is permissible
for most patients to eat during dialysis ,if desired ,it is best to limit this to a small meal or snack.
 Digestion may contribute to development of hypotension and vomiting. This is distressing and
increases the risk of aspiration as well as interfering with a smooth dialysis.
 Ice chips can be used as water substitute, it is effective  in alleviating the sensation of thirst than
water. The disadvantage of ice is that is water, and people tend to disregard this fact. A 200 ml of
ice chips is equivalent to 150 ml of water.
 It is not recommended that to oral fluids be given in large amount as a control   for excess
ultafiltration. Such fluids may reach the intracellular compartment during dialysis and then be
difficult to remove. Also, oral fluid is always hypotonic, contributing to hyponatremia.  
Particular Observations:
General condition  and response of the patient during the procedure .Nausea ,Vomiting ,Apprehension,
Shortness of breath, Chest pain, Sweating, Pallor, Restlessness or agitation , Irritability, Itching,
Flushing , Childish or Hysterical behavior, Sleepiness ,and complaints of pain are some of many points to
be noted.

Laboratory tests
The plasma urea nitrogen and s creatinine are monitored monthly. The midweek, predialysis level is
commonly followed. The plasma urea level is largely determined by the amount of protein ingested, while
the plasma creatinine level depends on the muscle mass. Factors other than protein can affect plasma urea
.If the plasma urea is higher than expected many factors should be excluded e.g. Increased dietary intake,
Hypercatbbolic state , GIT bleeding , V.Access Recirculation, Dehydration. On the other hand if it is
lower than expected; Decreased dietary protein intake, Increased dialysis treatment, and Liver diseases
should be excluded. For patients with high predialysis  S.Potassium diet control and resin exchange is
necessary.
 Monitoring S Calcium, S Phosphate and Alk Phophatase are helpful tests to prevent and treat
renal bone disease These values are usually checked monthly predialysis. The target   plasma
calcium should be at the upper level of normal and plasma phosphate should be at the lower level
of normal.
LFTs are usually checked monthly ,and may unmask silent liver disease ,especially Hepatitis or
Hemosidrosis. The aim of monitoring Hemogram ,S Iron ,Tranfserrin ,Ferritin is to detect and treat
Hematological Abnormalities in dialysis patient
 
Frequency Test
Monthly 1-Renal profile (Urea ,Creatinine, Electrolyte)
2-S.Calcium ,Phosphate ,Alk Phosphatase
3-LFTs(TSP-S Albumin, AST, ALT ,S Bilirubin)
4-Blood Glucose
5-Hemogram (WBCs ,Hb, PCV, MCV, PLAT.,)
6-S Iron ,Transferrin
7-KT/V
Every 3 months 1-HBsAg,Anti HBsAg
2-Anti HCV
3-HIV
4-S.Aluminum
Every 6 months 1-S.Ferritin
2-PTH
Yearly 1-Skletal Survey
2-X-Ray Chest
 3-ECG

Complications during Hemodialysis

 
MEDICAL COMPLICATIONS
Common Complications during Hemodialysis
1. Hypotension (20-30% of dialyses)
2. Muscle Cramps (5-20% of dialyses)
3. Nausea  and Vomiting (5-15%of dialyses)  
4. Headache (5% of dialyses)
5. Chest Pain (2-5% of dialyses)
6. Back Pain (2-5%of dialyses)
7. Itching (5% of dialyses)
8. Fever and chills (<1%of dialyses)
Serious complications during hemodialysis
1. Disequilibrium syndrome
2. First use syndrome
3. Arrhythmia
4. Cardiac tamponade
5. Intracranial bleeding
6. Seizures
7. Hemolysis
8. Air embolism
Mechanical Complications 
1. Rupture dialyzer
2. Clotted dialyzer
3. Air embolism
4. High conductivity
5. Low conductivity
6. Low water pressure
7. High venous pressure
8. Abnormal arterial pressure
9. Electrical failure
10. Needle-site bleeding
11. Hemolysis
 Management of Medical and Mechanical Complications During Hemodialysis
Complication Management

Hypotension 1. Place the patient  in trendlenberg position (if respiratory status allows).
2. A bolus of 0.9 saline (100-250 ml) should be administered through the venous line.
Alternative to 0,9 saline :

 3%saline 50-100 ml                                 

 Dextrose  50 % 25-50 ml.
 Human Albumin 20 % 50-100 ml.            
 Mannitol.
 Pressor agents egg Dopamine.
3. Reduce the UF rate near to zero.
4. Discontinue dialysis in severe cases
Disequilibrium In mild cases : Treat the symptoms  ,
syndrome                        Reduce blood flow rate,
                   Hypertonic saline dextrose solution can be administered.
In severe cases: Stop dialysis ,treat the seizures 
                       Supportive measures of coma ,
                       Mechanical ventilation if necessary,
                       IV mannitol may be of benefit.

Angina 1. Nasal oxygen should be initiated.

2. Reduce blood flow rate and stop ultrafiltration.
3. Sublingual nitroglycerin if blood pressure is maintained.
4. Sedation.     
5. Treat the possible cause.
6. Dialysis with bicarbonate dialysate bath.
7. In severe cases discontinue the procedure .
8. ECG and Further investigation may be required to exclude myocardial infarction.

Air Embolism 1. Clamp the venous line and  stop the blood pump.
2. Place the patient in Trendelenberg position on the left side with the chest and head tilted downward to trap the air
at the apex of right ventricle away from the outflow tract.
 3. Cardiorespiratory support , Oxygen 100%.
4. Occasionally percutaneous aspiration of the air foam from the heart may be necessary
5. Other measures include IV Dexamthsone to reduce brain edema ,Heparin /Dextran to improve the
microcirculation.

Seizures 1. Discontinue dialysis.               

1. Ensure airway patency
2. Collect blood sample for glucose, calcium, electrolyte, urea and creatinine.
3. Administration of 5-10 mg Diazepam slowly IV. Repeat after 5 minute intervals, if seizures persist, to a maximum
30 mg.
4. Give glucose IV if hypoglycemia is suspected.
5. Give calcium gluconate IV if hypocalcaemia is suspected.
6. Treat other electrolyte disturbance.
Muscle Cramps 1. Concomitant occurrence of hypotension and cramps may respond to treatment with  100ml  of 0.9 % saline
2. Hypertonic saline or dextrose [ Leads to dilatation of the  muscle bed blood vessels restore blood volume].
 *Hypertonic dextrose( 50 ml of  10 % dextrose.) is preferred for treating non diabetic patient to avoid  thirst  produced by
saline. 

Nausea and 1. Reduce blood flow rate if acetate dialysate is being used by 30 % during first hour of dialysis
Vomiting 2. Reduce ultrafiltration rate
3. Metoclopramide Hcl [Primperan] 10 mg IV, or Prochlorperazine [Stemetil]12.5-25 mg IV
4. Treat the cause / Use bicarbonate containing dialysate
Headache 1.Reduce blood flow rate if acetate dialysate is being used by 30 % during first hour of dialysis
2.Acetaminophen tab [Paracetamol] 500 -1000 mg PO during dialysis.
3.Treat the cause / Use bicarbonate containing dialysate

Itching 1. Drug therapy :  

Antihistamines,e.g. Diphenhydramine ,Hydroxyzine
Parenteral lidocaine infusion
Oral activated charcoal

2. General measures.
Relieve the dry skin with topical emollients e.g. Lubricating                      solutions  , Camphor and Menthol
containing creams
 Switch from ethylene oxide to gamma ray-sterilized dialyzer.

3. Phototherapy:   Ultraviolet light-B delivered in a conventional light box giving 2 treatments   per week for 4 weeks..
4. Control of calcium and phosphorous metabolism: 

Needle-site 1. Direct pressure is the simplest and effective measure. It should be aseptically and with extreme care to avoid AV
bleeding access occlusion.
2. Apply gelfoam to the puncture site
3. Adjust heparin dose

Hemolysis 1. Clamp the blood lines                     

2. Turn the blood pump off
3. Do not reinfuse the blood                
4. Leave the needle in place
5. Draw blood for: Type and cross match    CBC    Electrolyte  Trace metals,
6. Save dialysate and blood samples for further evaluation     
7. Discard the dialyzer line
8. Evaluate the problem by reviewing the following
Check conductivity
.Check the dialysate temperature
Look for kinks in the blood line in the pump
.Check dialysate for ;Electrolyte Formaldehyde-Chlorine-Trace metal
9. Check the IV priming solution
10. Resume dialysis to prevent hyperkalemia and blood transfusion  if
necessary                                                                                                       

Ruptured An immediate decision must be made to:

Dialyzer                          1- Reinfuse the blood (or not)
                         2-Change the ruptured dialyzer as quickly as possible.
                         3-Resume dialysis if safe to do so
[Usually less than 1% of blood present in dialysate trigger the blood leak alarm]

Clotted dialyzer 1.When a dialyzer clots , the dialyzer ,the arterial line, the venous line may need to be replaced.
 2.In clotted dialyzer without rupture , the entire dialysate circuit does not need to be set up again or recleaned
3.Correct the cause

High Venous 1-Manipulate the needle and or the line. If the access is small, a tourniquet must be used, being certain the blood pump is
Pressure off.. Recannulation with new needle if needed, the original one should be left in place until the end of dialysis. to avoid
undue bleeding as the patient is heparinized
 2-Adjust the blood flow rate, Proper heparnization, Treat access problem, and Proper needle and needling
 3-Extreme care must be exercised when dialyzing a patient with high venous pressure
     *This increases the baseline TMP and obligatory ultrafiltration will occur
*Single-needle device is occasionally impossible to use, because with high venous pressure ,venous return will be
impaired and blood recirculation will be high.

 Abnormal 1- Manipulation of the arterial needle is similar to that of venous needle. In most cases the needle may have to be replaced
Arterial Pressure with the same precaution as with venous needle
2-Treat the cause.      3- Proper needling    4-Asses the access

High 1.Evaluate the incoming water and check for kink the line.
Conductivity 2.The water pressure and filters should be also checked
3.Recheck the conductivity: If normal, there is malfunction in the machine itself(change it)
         * If high again concentrate should be changed
         * Check the conductivity before resuming dialysis  

Low 1.Change the concentrate container if it is dry

Conductivity 2.If the concentrate container has not run dry, a sample of dialysate should sent to the laboratory for sodium and chloride
3.Recheck the conductivity with second conductivity meter:
*If low conductivity is confirmed; change the concentrate bottle (recheck again)
*If the conductivity still low after changing the concentrate, a different machine should be  tried

Membrane  Type A
Reactions 1-Stop dialysis                                     
2-Clamp the blood lines
3-Do not reinfuse the blood                   
4-Discard the dialyzer and the line
   5-Cardiorespiratory resuscitation 
   6-Antihistaminic ,Steroids ,Epinephrine can be given
 Type B
   1-Oxygen therapy
   2-Treat as in angina during dialysis
              
Disequilibrium syndrome
 Definition: It is a set of systemic & neurological symptoms and EEG finding that occur during or soon
after acute  dialysis
Pathogenesis:
1. Rappid removal of solute from the extracellular fluid  compartment  results  in an osmolar
gradient between brain and blood  hence results in cerebral edema.
2. A fall in pH of spinal fluid has been also noted to occur.
 Clinical manifestations :
Mild Severe
Headache Hypertension
Fatigue Agitation
Nausea Confusion
Vomiting Seizures
Muscle cramps Stupor
Restlessness Coma
 
Prevention:
1. Limit the amount and rate of dialysis.
2. Use  of high dialysate sodium levels.
3. Use bicarbonate dialysis.
4. Intavenous infusion of:
Hypertonic dextrose
Hypertonic saline
Mannitol
Management:
In mild cases :
Treat the symptoms,
Reduce blood flow rate,
Hypertonic saline or dextrose solution can be administered.
In severe cases:
Stop dialysis, treat the seizures
Supportive measures of coma
Mechanical ventilation if necessary,
IV mannitol may be of benefit.
N.B. If coma is due to disequilibrium, the patient should improve within  24 hours.
             
 Intradialytic Hypotension
 Causes
A-Decreased Plasma Volume :
1. High ultrfiltration rate
2. Fluctuation in the ultrafiltration rate.
3. Target dry weight set low
4. Low dialysate  sodium.
5. Dialyzers with large surface area
6. Increased blood flow rate.
7. Increased dialysate flow rate
B-Decreased Compensatory Related Vaso Constriction:
1. Acetate dialysate.
2. Dialysate temperature 37-38’c.
3. Low dial ysate calcium.
4. Antihypertensive medications.
5. Biocompatible dialyzer membrane
C-Cardiac Related Factors:
1. Failure to increase cardiac rate :
Ingestion of B blockers.
Uremic autonomic neuropathy.
Aging
2. Inability to increase cardiac output :
Poor myocardial contractility due to aging.
Hypertension.
Atherosclerosis.
Myocardial calcification.
Valve disease.
Amylodosis.
D-Other Causes:
1. Pericardial  temponade.
2. Myocardial infarction.
3. Occult hemorrhage.
4. Septicemia.
 5. Arrhythmia.
6. Anaphylaxis.
7. Hemolysis.
8. Air embolism.

Management of Intradialytic Hypotension

A. Measures to Ameliorate :
1. Accurate evaluation of dry weight ; is the most important step in minimizing intradialytic
hypotension . limit weight gain to less than 1 kg / day .
2. Dosing of antihypertensive drugs . Give the daily dose after dialysis ( not before ) .
3. Adequate dialysate sodium concentration (or high sodium) has been effective in reducing
intradialytic hypotension.
4. Bicarbonate dialysis & avoid acetate dialysis in those patient.
5. Cooled dialysate ; in some patient ; dialysate temperature of 35.5’c may be adequate to overcome
the predisposition to hypotension.
6. Sequential UF is less likely to cause hypotension.
7. Oxygen supplementation during  dialysis specially in elderly is valuable to overcome
predisposition to hypotension (to avoid hypoxemia).
8. Dialysate calcium concentration of 7.5 mg /dl may prevent hypotension
9. Infusion of Human Albumin before dialysis is also helpful.
10. The use of biocompatible dialyser decrease the incidence of hypotension 
11. Placement of pressurized leg boos in patients with sever peripheral edema.
12. Treatment of anemia by EPO.
B. Treatment of Acute hypotension:
1. The patient should be placed in trendlenberg position (if respiratory status allows this ).
2. A bolus of 0.9 saline (100-250 ml) should be administered through the venous line.
Alternative to 0,9 saline :
3% saline :50-100 ml
Dextrose  50 % : 25-50 ml.
Human Albumin 20 % :50-100 ml.
Mannitol.
Pressor agents e,g Dopamine.
3. Rreduce the UF rate near to zero.
4. Discontinue dialysis in severe cases.
Membrane Reactions
(Dialyzer reactions-Membrane Hypersensitivity-First use Syndrome)
Reactions occur with new dialyzer were grouped under the term first use syndrome. However , similar
reactions occur with reused dialyzer.These reactions appear to be two varieties :
1-Anaphylactic type (type A)
2-Non specific type (type B)

Anaphylactic type (type A)

This type of reaction occur at the first 20-30 minutes of dialysis, usually first 5 minutes. It occur in less
than 15% of patients when new dialyzer is used or with 5/100,000 dialyzer sold. Atopic patient are prone
to develop these reaction.
Manifestations
Severe reaction: Dyspnea -Sense of impending doom-Heat sensation at fistula site and throughout the
body-Cardiac arrest and death may supervene.
Mild reaction: Itching-urticaria - Cough- sneezing-Coryza or watery eye-Abdominal pain and Diarrhea
Etiology
1. Ethylene oxide (used to sterilize HF dialyzers) hypersensitivity, often after inadequate rinising.
High IgE antibodies were found in those patient. It is uncommon nowadays.
2. Polyacrylonitrile membrane associated reactions mediated by bradykinin system .
3. ACE inhibitors magnify the effect of the membrane because ACE participate in bradykinin
inactivation.
4. Contaminated dialysate with bacteria when high flux dialyzer is used with less frequent cleaning
and sterilization.
5. Reuse probably due to bacterial or endotoxin contamination of the water used during the reuse
procedure further more formaldehyde and glutaradehyde can cause allergic reaction.
6. Complement activation ; it is conceivable that complement activating membranes and acetate
dialysate  may act as co factor in precipitating reaction in some patients, especially those with
history of atopy.
7. Heparin allergic reaction should be suspected when other causes reasonably excluded.
8. Others -Azide substances used to package some water pretreatment ultrafiltrers .Acetate causes
adenosine release when metabolized can exacerbate bronchoconstriction
Management:
1. Stop dialysis
2. Clamp the blood lines
 3. Do not reinfuse the blood
4. Discard the dialyzer and the lines
5. Cardiorespiratory resuscitation
6. Antihistaminic, Steroids ,Epinephrine can be given
Prevention:
1. Proper rinsing of dialyzer prior to use
2. Change suspected ethylene oxide sensitized patient to gamma or steam sterilized dialyzer
3. Stop ACE inhibitor therapy in affected patients.
4. Change the membrane if the reaction occur while using it.

Non specific type (type B)

The non specific type of membrane reactions are more common than anaphylactic type but less severe.
Manifestations:
1. It occur within several minutes to one hour
2. Chest pain which may be associated with backache.
Etiology:
Complement activation is the most likely cause .It is less common with reused dialyzer. In reused filters
the membrane will be coated with protein layer ,furthermore the toxic substances are washed during the
previous dialysis
Prevention
Change the dialyzer membrane to characterized by release of activated complement fragments such as
cellulose or Hemophan may be of benefit.
Management:
1. Oxygen therapy
2. Treat as in angina during dialysis

Muscle cramps during hemodialysis

Etiology
1. Hypotension and significant volume of fluid removal by UF - Cramps most commonly occur in
association with hypotension & may persist after restoring BP. UF reduce extracellular volume
->>>>>skeletal muscle irritability.
2. Patient below dry weight: Sever prolonged cramps beginning during the later part of dialysis and
persisting after dialysis occur when the patient has been dehydrated to below dry weight.
 3. Electrolyte disturbance:Acute decrease of plasma sodium (due to the use of low sodium
dialysate) will result in constriction of blood vesseles, subsequently muscle cramps occur.
Hypokalemia also can cause muscle cramps.
Prevention
1. Prevention of hypotension episodes & excessive UF(previous tip).
2. Increasing the dialysis solution sodium level to 140mEq/L or more.     
3. Other strategies:\
a. Qunine  sulphate tab 180-300mg ,2 hr. predialysis. 
b. b)Diazepam or Oxazepam   2 hrs pre dialysis .
c. c)Stretching excercise. to the affected muscle group.
N.B. Side effect of the drugs limit its use.
Management:
1. Concomitant occurrence of hypotension and cramps may respond to treatment with  100 ml  of
0.9 % saline
2. Hypertonic saline or dextrose >>>>>dilatation of the  muscle bed blood vessels and restore blood
volume.
 *Hypertonic dextrose( 50 ml of  10 % dextrose.) is preferred for treating non diabetic patient to avoid  
thirst  produced by saline.

Skin disorders in dialysis patient

a- Related to uremia
pruritus
xerosis
uremic frost
hyperkeratosis penetrans
uremic pigmentation
purpura
calciiphylaxis
bulbous dermatosis
nail changes
b. Drug related    
hypertrichosis
acne
 hypersensitivity
c. Related to renal disease
cutaneous vasculitis
Pruritus (Itching)

Pruritis is present at some time in 80-90% of dialyzed patients. It may appear as a symptom of early
uremia, but is also troublesome and  persistent in some  patients  on long-term dialysis therapy. Overall,
itching was often most severe during or after hemodialysis session but was also increased during periods
of inactivity or bed rest.
ETIOLOGY:   
1. Circulating uremic toxins.
2. Elevated calcium-phosphorous product.
3. High para thyroid hormone
4. Dry skin aggravate the pruritus.
5. Allergic patients to:  
Heparin
Plasticizers used to soften hemodialysis tubing.
Ethylene Oxide gas used  to sterilize hemodialyzers &blood line
DIAGNOSIS:
Pruritis may involve the entire skin surface, predominantly on the face, back, trunk & extremities
Telltale signs of scratching include:
Excoriation , Heemorrhgic crusts , Pustule , Lichenification , Nodule formation
TREATMENT: 
A. General measures.
1. Relieve the dry skin with topical emollients e.g. Lubricating solutions, Camphor and Menthol
containing creams
2. Switch from ethylene oxide to gamma ray-sterilized dialyzer.
B. Phototherapy: Ultraviolet light-B delivered in a conventional light box giving 2 treatments per week
for 4 weeks..
C. Control of calcium and phosphorous metabolism:
Treat hyperphosphtemia, Control hyperparathyroidism, including vitamin D therapy and partial
parathyroidectomy.
D. Drug therapy :  
Antihistamines,e.g. Diphenhydramine ,Hydroxyzine
 Parenteral lidocaine infusion
Oral activated charcoal
E. Renal transplantation
    
Causes of Chest pain in ESRD  patients
Cardiovascular
Angina pectoris
Pericarditis   
Valvular heart disease Aortic dissection
Pleuropulmonary
Pneumonia
Pleuritis
Hemothorax
Pulmonary embolism/infarction
Gastrointestinal
Esophageal spasm/reflux
Acid peptic disease
Pancreatitis
Cholecystitis/Cholelithiasis
Musculoskeletal
Rib fracture
Renal osteodystrophy
Muscle cramps
Neurologic
Spinal disease with nerve root compression
Herpes zoster
Miscellaneous
Anaphylactic reaction
Air Embolism
 
Hemodialysis associated angina
a)Causes:
 Hemodynamic stress caused by hemodialysis
  Reduction of blood Po2 Particularly with acetate dialysate bath and or complement activating
cuprophane dialyzers that can cause; pulmonary leukocyte sequestration , change hemoglobin-
oxygen affinity, arrhythmia and hypotension (First use syndrome). It occurs in ~5% of dialysis
treatment given with fresh unused dialyzers
 Thus hemodialysis reduce coronary artery filling time ,perfusion pressure , and myocardial
oxygenation.
 Potential causes of chest pain (e.g. hemolysis ,air embolism) must be considered
 These events coupled with anemia and the possible loss of coronary vasodilator reserve may be
responsible for hemodialysis associated angina in patients with or without significant coronary
stenosis.
 b)Hemodialysis as  a risk factors for angina :
1. Hypotension and Hypertension during dialysis
2. Anemia
3. Hypoxemia during dialysis
4. Chronic volume overload
5. Hyperlipdaemia
6. Acetate intolerance
7. Atherosclerosis
The use of glucose in dialysis fluid may cause hyprlipidemia and thereby atherosclerosis. Acetate dialysis
solutions can facilitate synthesis of cholesterol and triglyceride.
C. Management of angina during hemodialysis:
1. Nasal oxygen should be initiated.
2. Reduce blood flow rate and stop ultrafiltration.
3. Sublingual nitroglycerin if blood pressure is maintained.
4. Sedation.
5. Treat the possible cause.
6. 6.Dialysis with bicarbonate dialysate bath.
7. 7.In severe cases discontinue the procedure .
8. 8.ECG and Further investigation may be required to exclude myocardial infarction.
Predialysis administration of nitroglycerin 1houre prior to hemodialysis session may be of benefit
d) Dialysis after acute myocardial infarction:
1. Postpone dialysis for 24 hours when possible.
2. Such patients are best dialysed peritonealy (if possible) to avoid the attendant     hemodynamic     
instability
 3. If peritoneal dialysis is impossible -Hemofiltration or Bicarbonate dialysate bath with close
monitoring ,oxygen therapy .,blood transfusion if Hct is less than 30% , along with all measures
to avoid hypotension (review the previous tips)
Air Embolism
Air embolism is a serious complication of the dialysis procedure. Air can be introduced via the
segment  of the blood circuit that operates in the negative pressure range-the portion between the arterial
fistula needle and the blood pump.
Routes of air introduction:
a. Air leaks around tubing joints (saline and heparin infusion sites placed before the pump)
b. Excessive undetected or unmonitored negative pressure, related to inadequate fistula flow rate for
the pump demand ,or malposition of the arterial needle.
c. Unattended intravenous solution administration.
d. The use of prepump arterial drip chamber
e. The use of air to return blood to the patient at the completion of dialysis.
To avoid that venous  air trap and air detector are located just distal to the venous pressure monitor. The
air detector is attached to a relay switch which automatically clamps the venous blood line and shuts off
the blood pump if air is detected.
Manifestations
a. In seated patient: Air migrates to cerebral venous system (not to the heart) causing obstruction to
cerebral venous return with loss of consciousness , convulsion , even death.
b. In recumbent position: The air tends to enter the heart and generate foam in the right ventricle and
pass into the lungs manifested by dyspnea, cough, chest tightness. Further passage of air across
the capillary bed into the left ventricle can result in air immobilization to the arteries of the brain
and the heart with acute neurological and cardiac dysfunction.
c. Foam will often seen in the venous blood line.
d. A peculiar churning sound may be heard on auscultation ,if the air gone into the heart.
Management
a. Clamp the venous line and stop the blood pump.
b. Place the patient in Trendelenberg position on the left side with the chest and head tilted
downward to trap the air at the apex of right ventricle away from the outflow tract.
c. Cardiorespiratory support, Oxygen 100%.
d. Occasionally percutaneous aspiration of the air foam from the heart may be necessary.
e. Other measures include IV Dexamthsone to reduce brain edema ,Heparin /Dextran to improve the
microcirculation.
 Ruptured  Dialyzer
Causes of dialyzer rupture
1. Improper priming
2. Improper or inadequate heparinization.
3. Damaged dialyzer.
4. Accidental tubing kink; causing high venous pressure
5. Clotting
Management:
 Dialyzer rupture is uncommon, if it occurs , an immediate decision must be made to
1. Reinfuse the blood (or not)
2. Change the ruptured dialyzer as quickly as possible.
3. Cleaning the dialysate circuit or reset up.
4. Resume dialysis if safe to do so .
When the rupture is extensive and the pressure in the dialysate compartment is greater than the pressure
inside the blood compartment, dialysate can rapidly enter the blood compartment and the patient. To
avoid that, the machine should always be set to at least 25-50 mm Hg negative pressure.
[Usually less than 1% of blood present in dialysate trigger the blood leak alarm
 
Clotted dialyzer
Causes
a. High venous Pressure
b. Slow blood flow
c. Turbulence of air that may have been infused during priming
d. Turbulence of air and blood while using single needle machine
e. Blood transfusion during dialysis
Mechanism:
Platelet activation upon contact with the dialyzer membrane is the primary mechanism responsible for
clotting during dialysis.
Management:
When a dialyzer clots , the dialyzer, the arterial line, the venous line may need to be replaced. In clotted
dialyzer without rupture, the entire dialysate circuit does not need to be set up again or recleaned
Dialyzers need not to clot even if no heparin is used during dialysis.The procedure consisted of clamping
the arterial line every 20-30 minutes, and rinsing the blood circuit with normal saline to clear the dialyzer
and blood lines. Negative pressure  to be adjusted to compensate  for the excess fluid  administered.
Saline rinsing interferes with platelet aggregation and prevents overproduction of active coagulation
factors. Thus the formation of stable fibrin network is prevented.

Needle-Site Bleeding
 Needle-site bleeding may occur after venipuncture as a result of:
1. capillary trauma or trauma occurring when rotating the needle or manipulating the needle side to
side during insertion.
2. Multiple puncture at the same site
3. Overheparinization
 Management:
1. Direct pressure is the simplest and effective measure. It should be aseptically and with extreme
care to avoid AV access occlusion.
2. Apply gel foam to the puncture site
3. Adjust heparin dose
4. Change the puncture site every dialysis
 
High Venous Pressure
High venous pressure is seen on almost daily basis. The purpose of monitoring venous pressure is to
identify any pressure changes within venous return line during dialysis. Venous pressure of +50 to +100
mmHg above the atmospheric pressure is acceptable during dialysis(preset pressure -100 to +100 ). If
venous pressure moves out of limits an audible alarm is heard and the blood pump stopped until the
problem is corrected.
Causes of high venous pressure:
1. Needle related
Needle may have infiltrated the access wall
Needle hole may be resting against the side wall of the access
Needle may have been inserted into scar tissue inside the access
Needle may be to short and the hole is not completely inside the access
Needle with small gouge (16) when blood flow rate is high.
2. Clotting
Clotting of venous needle
Clotting of venous side of AV shunt
Clotting of venous blood line
Clotting of the filter
 3. Access related
Stenosis or spasm at the venous limb of the access
Clotting at the venous limb of the access
AV graft have naturally high venous pressure(150-200mmHg)
4. Lines related
Kinked venous line
Management  ( See also alarm problem solving)
1. Manipulate the needle and or the line. If the access is small, a tourniquet must be used, being
certain the blood pump is off.. Recannulation with new needle if needed ,the original one should
be left in place until the end of dialysis. to avoid undue bleeding as the patient is heparinized
2. Adjust the blood flow rate, Proper heparnization, Treat access problem, and Proper needle and
needling
3. Extreme care must be exercised when dialyzing a patient with high venous pressure
4. This increases the baseline TMP and obligatory ultrafiltration will occur
5. Single-needle device is occasionally impossible to use, because with high venouspressure ,venous
return will be impaired and blood recirculation will be high.
Abnormal Arterial Pressure
The arterial pressure monitor reads in negative pressure because it measures the partial vacuum resulting
from the roller pump withdrawal of the whole blood at a relatively high rate through the small bore needle
inserted into the arterial end of the access. It identifies how much suction is being placed on the arterial
wall. When the pressure becomes very negative (-150 &-200mmHg) the access will collapse and the
blood flow will be discontinued to the machine. Furthermore very high negative pressure may cause air
bubbles to enter around the needle causing air embolism and or clotting of the dialyzer.
 Causes of an increase  in negative pressure:
1. Needle related –
Needle may have infiltrated the access wall
Needle hole may be resting against the side wall of the access
Needle may have been inserted into scar tissue or flap inside the access
2. Clotting
Clotted arterial needle
Clotted arterial side of AV shunt
3. Access related 
Stenosis within the access
Spasm of the access.
 Positional in acute access
4. Patient related   -Low blood pressure
 Management:   ( See also alarm problem solving)
1. Manipulation of the arterial needle is similar to that of venous needle. In most cases the needle may
have to be replaced with the same precaution as with venous needle
2. Treat the cause.
3. Proper needling
4. Asses the access
 
Hemolysis
Acute hemolysis during hemodialysis is rare  but must be immediately identified and emergency
management initiated to minimize the patient morbidity.
Technical causes:
1. Hypotonic dialysate
2. Overheated dialysate
3. Formaldehyde in the dialysate
4. Hypochlorite in dialysate
5. Copper or Nitrates in the dialysate
6. Overoccluded blood pump
7. Severe foaming in the roller clamp segment
Manifestations
1. Port-wine appearance of blood in the venous return line
2. Presence of pink plasma in centrifuged blood sample.
3. Patient Manifestations :Headache , Arm pain , Chest pain, Drowsiness Dyspnea , Back pain,
Diaphoresis  ,  Pallor, Arrhythmia ,Cardiac arrest
4. Laboratory studies, Drop in Hemoglobin and Hematocrit ,Hyperkalemia, Arrhythmias ,Cardiac arrest
Management
1. Clamp the blood lines
2. Turn the blood pump off
3. Do not reunifies  the blood
4. Leave the needle in place
5. Draw blood for: Type and crossmatch    CBC    Electrolyte  Trace metal
6. Save dialysate and blood samples for further evaluation
7. Discard the dialyzer lines
 8. Evaluate the problem by reviewing the following
a. Check conductivity
b. Check the dialysate temperature
c. Look for kinks in the blood line in the pump
d. Check dialysate for ;Electrolyte Formaldehyde-Chlorine-Trace metal
9. Check the IV priming solution
10. Resume dialysis to prevent hyperkalemia and blood transfusion  if necessary
 
Conductivity
Conductivity is a property of electrolyte solutions to conduct an electric current. It is measured in units
called mhos or milli mohos (1mhos =1000 milli mhos). A mho is the conductivity of body through which
1 A of current flows when potential difference is 1 V. It is important to be aware that the display meter of
clinical dialysis machines does not read in milli mhos, but displays an entirely arbitrary scale intended to
present a clinically understandable reading approximately equal to mEq/L chloride ions  in the dialysate
solution. Because dialysate chloride  concentration is usually 105 mEq/L, the scale deviation from the
ideal set line are, therefore, approximately % deviation from the desired reading. All recent dialysis
machine have factory-set conductivity meters with alarm system. When conductivity meter detects high
or low conductivity  the machine automatically sounds an alarm and puts the dialysate into bypass mode
so that  no dialysate flow to the dialyzer.
Usually conductivity is adjusted between 13-14 in single bath system. In Redy Sorbent hemodialysis the
initial dialysis solution conductivity adjusted according to patient natremic status (it will be discussed in
later tips). The newer computerized dialysis machine display the actual sodium and electrolyte
concentration in dialysate (profiling)
 
High-Conductivity Alarm:
Causes : High-conductivity is a dialysate production complication caused by too much concentrate and
not enough treated water
Management :   (See also alarm problem solving)
Evaluate the incoming water and check for kink the line.
The water pressure and filters should be also checked
Recheck the conductivity:
If normal, there is malfunction in the machine itself (change it)
If high again concentrate should be changed
Check the conductivity before resuming dialysis   
Low-Conductivity Alarm:
Causes : Low conductivity is a dialysate machine mixing complication that occurs when the machine
receives insufficient dialysate concentrate within the mixing chamber. The result is a hypotonic dialysate
that cause hemolysis. The usual reasons are :
1. The concentrate container runs dry
2. Leakage at the concentrate pump .
3. Malfunction in the concentrate pump feedback circuit
Management : (See also alarm problem solving)
 Change the concentrate container if it is dry
 If the concentrate container has not run dry, a sample of dialysate should sent to the      laboratory
for sodium and chloride
 Recheck the conductivity with second conductivity meter:
 If low conductivity is confirmed  ; change the concentrate bottle (recheck again)
 If the conductivity still low after changing the concentrate , a different machine should be  tried
Hemodialysis related therapies
Contents:
High flux dialysis
Chronic hemofiltration
Continuous arteriovenous hemofiltration
CRRT
Therapeutic plasma exchange
High-Flux Dialysis
 
H igh-flux dialysis is a form of dialysis therapy where both diffusive and convective solute removal take
place. A dialyzer described as high flux has a permeable membrane that allows small and large molecular
weight solute to be diffused across the membrane.
Requirement of high-flux dialysis:

1. Dialyzer:
                                                                          
High flux membrane (Synthetic membranes) include: Polysulfone , Polyacrylonitrile (PAN),
Polymethy lmethacrylate (PMMA), Polycarbonate,  polymide, Ethylene-vinylalcohol copolymer and
Cellulose triacetate]

                                                           High Flux Dialyzer

Nature of high flux membrane:
a. They are a thin , smooth luminal surface, supported by a sponge-like wall structure.
b. They have solute removal clearance of substance in  the molecular weight range of 5000(insulin)
to 12000(B2-microglobulins).
c. The surface area ranges from 0.6-2 msq 
b. All have ultrafiltration coefficients (KUF) of 20 to 80 ml/hr/mmHg or more.
Preparation of the dialyzer: according to the instruction of manufacturer  
2.Dialysis machine with :
a. Ultrafiltration control device is required is essential  to control fluid loss
b. Bicarbonate dialysate delivery system for better cardiovascular stability.
c. Dialysate flow rate: 1000 ml/minute .
3.Blood flow rate : High blood flow rates (300-500 ml/minute) are needed (a) to maximize the
permeability and achieve higher clearance.(b)to increase the pressure at dialyzer outlet. Blood flow rate
influenced by:
a. Blood pump design in terms of rotor speed and torque. It should be capable of higher speed with
adequate occlusion.
 b. Tubing segment design in terms of diameter and thickness which determine the ability to deliver
a constant stroke volume. It should be designed to prevent pump segment from softening and
losing elastic recoil.. It was found that the actual blood flow reduced by 10% due to softening of
the tubing segment as treatment progresses.
c. Fistula needle design with 15-14 gauge and ultrathin wall is required. The resistance of the fistula
needle is inversely related to the fourth power of the inside diameter. The difference between a 16
and a 14 gauge needle is significant.
d. Vascular access
4. Water: Good quality of water is required
5. Disinfection: The equipment and dialysate bicarbonate containers must be disinfected on regular basis
to avoid bacterial growth.
Advantages of high flux dialysis:
1. It allows reduction of time on dialysis ,up to 6-9 hours per week.
2. Prescribed for patient with amyloidosis in dialysis patients to
remove B2 microglobulin. B2 microglobulin is removed by adsorption to the membrane 100 mg
/treatment.
3. Membrane used in high flux dialysis have better biocompatibility with blood than cellulose
membrane.
4. NB. Amyloid deposits are polymerized forms of the protein B2 microglobulin.
Backfiltration (Reverse filtration)
·   The ultrafiltration controller generates a dialysate pressure profile that creates reverse filtration from
the dialysate to blood in distal portion of the dialyzer. It depends on the pressure distribution along the
length of the dialyzer in both the blood and dialysate compartment. At the blood inlet there is a region of
filtration, as the blood pressure exceeds the dialysate pressure. Backfiltration occurs when the dialysate
pressure is greater than that of the blood. 
 

              
                  High UF rate              Critical UF rate          Low UF rate-BF
                 No Backfiltration         No backfiltration        Backfiltration
·      Contamination of blood by pyrogenic material and
endotoxin fragments is created. It depends on the phenomenon
of backfiltration occurring with high flux membranes [Highly
permeable membrane]. As much as 180-480 ng of endotoxin
could transferred to the patient during a single high flux dialysis compared to the minimum pyrogenic
dose for man about1-2 ng/kg body weight.  Addition of a molecular filter or ultrafilter to dialysate path
immediately ahead of the dialyzer is necessary to reject the intact or fragmented endotoxins.
Negative features related to high flux membrane:
1.Very expensive.
2.Automated ultrafiltration control is required because of very high water permeability 3.Significant loss
of protein by adsorption.
4.Backfiltration from the dialysate and risk of bacterial or endotoxin contamination, due to high hydraulic
permeability
Complications related to high-flux dialysis:
1.Pyrogen reactions caused by passage of endotoxin into the blood
2.Osmotic disequilibrium syndrome.
3.Transient hypokalaemia
4.Cardiovascular instability because of rapid fluid removal and the accompanying hypotension.
5.Access problem ;rebound and cardiopulmonary circulation
6.Other complications ; as in conventional dialysis
Limitation of high flux dialysis:
1.Fluid removal:
Shortening of the dialysis time by high flux dialysis may be ultimately limited by the ability to correct the
intradialytic weight gain while maintaining cardiovascular stability. As a general rule, it has been noted
that when patients intradialytic weight gain more than 5 kg and the dialysis time shortened to less than 3
hours, a significant increase in hypotension may occur.
2.Cardiovascular instability:
Cardiovascular instability , unrelated to excessive weight gain could be a limiting factor in application of
high flux dialysis. It account 2-3% of all patients failing this type of dialysis. Patients who have poor
cardiovascular reserve and high incidence of intradialytic hypotension on standard dialysis are not a good
candidate for high flux dialysis.
3.Extracoprporeal blood flow:
Inability to achieve higher blood flow rate has been noted to be a limitation to deliver higher clearance.
Access with recirculation rate more than 20% or in patients whose arterial line collapses when blood flow
rates exceed 300 ml/min , the ability to deliver higher clearance needed for shorter treatments may be
compromised.

Chronic Hemofiltration
 
Contents:   
Difference between Hemodialysis and Hemofiltration:
Technical Aspects
Advantages
 
 
Hemofitration is an alternative treatment method of patients suffering from  ESRF.
Difference between Hemodialysis and Hemofiltration:
-The basic difference between both modes of therapy is in the principle of solute transport. In
hemodialysis the solutes are removed by diffusion , while in hemofiltration it is removed by convection
(solvent drag).
-During hemofiltration fluid removal taken place by ultrafiltration in a large amount. Fluid replacement,
therefore , is essential with the composition of the substitution fluid similar to plasma water.
The Membranes used for hemofiltration are coarse fine membranes made of Polymide , Cellulose
acetate , Polysulfone or Polacrylantrile.It allow for efficient removal of solutes up to molecular weight of
~25000 D. 
Technical Aspects:
Hemofiltration requires continuous administration of a substitute fluid. .At present it is principally carried
out by fully automatic machines.Basicaly the blood access is linked to a typical hemodialysis monitor and
the fluid balancing system is connected to electronic scale with a computer controlled infusion pump.
Treatment schedule is calculated automatically from desired exchange volume by subtracting the desired
weight loss from the filtration rate.
Hemofiltration prescription can be calculated using the following formula:-
Ultrafiltrate L/week=
Protein intake X0.12 X7
0,70  g/L
Where
Daily protein intake ( g ) based on dietary interview
0.12 =grams of nitrogen recovered per gram of ingested protein
7= No of days
0,70 =Mean urea nitrogen concentration in the ultrafiltrate.
The infusion rate  is determined by filtration capacity of the filter. This ensures a linear weight loss during
the treatment. Hemofilters with various membranes are available with filtration rate of more than 180 ml /
minute (in the presence of vascular access allows for blood flow rate of more than 500 ml / min.)TMP can
be changed at any time during treatment.
Advantages
1- Cardiovascular stability:  Hemofiltration has beneficial effects on the cardiovascular system in both
hypotensive and hypertensive patients .It was shown that the peripheral resistance increased during
hemofiltration .Dialysate sodium, prostaglandin (PGE2) , interleukins are contributory factors which
enhance the vascular stability during hemofiltration.
2- Hemofiltration considered to be preferable for hypertnsive patient.BP could often normalized within
months of hemofiltration commencement.
3-It ameliorate the acid base disturbance ,remove larger molecule and has no impact on the ionized
calcium(i.e. no effect on parathyroid gland).Removal of B2 microgloulin prevent amyloid associated
dialysis.
4-Higher  survival rate was observed in elderly patient treated by hmofiltration than in hemodialysis.
Continuous Arteriovenous Hemofiltration (CAVH)
 
Contents:
Introduction
Mechanism of hemofiltration
Difference between hemodialysis and hemofiltration
Clinical indication of CAVH
Technical aspect
Prescription of CAVH
Nursing care in CAVH
Positives and Negatives of CAVH
Conclusion
 
Introducion
C ontinuous arteriovenous hemofiltration is an extracorporeal treatment in which fluid , electrolyte ,and
low and middle molecular weight solute are removed from the body by convective transport. The cellular
elements and protein contents are conserved. The blood enters the exteacorporeal circuit by an arterial
access, flows through a hemofilter, and returns to the patient via venous access. The technique utilizes the
patient's own cardiac output and arterial pressure to move the blood in the circuit and a large volume of
ultrafiltrate with the same characteristics of plasma is generated. Typically 10-15 liters fluid and solute
are removed per day. Therefore concomitant administration of balanced replacement solution is required.
The substitution  of the amount of fluid lost by ultrafiltration with sterile replacement solution permit  
correction of  electrolyte, acid base abnormalities and lower the patient’s BUN concentration. The credit
of this technique goes to Peter Kramer when he observed that the arterial  blood pressure is sufficient to
produce ultrfiltration [1,2].
Top
Mechanism of hemofiltration
The mechanism underlying hemofiltration involves the use of a transmembrane pressure gradient. This
pressure gradient is achieved by the net difference between hydrostatic and osmotic pressures. The
hydrostatic pressure consists of  a-The arterial blood pressure(systolic blood pressure more than 80
mmHg), which drives the fluid across the membrane into the ultrafiltrate compartment. b-The pressure
exerted by the fluid within the ultrafiltrate system, which drives fluid from the fibers into the ultrafiltrate.
The pressure opposing the hydrostatic pressure is the colloidal osmotic pressure exerted by plasma
proteins.
Top
Difference between hemodialysis and hemofiltration
The basic difference between hemodialysis and hemofiltration is in the principle of solute transport.
During hemodialysis the solutes are removed by diffusion and the fluid by ultrafiltration. During
hemofiltration the solute removal is accomplished by convection  that is solvent drag. The fluid removal
here likewise takes place by ultrafiltration but in large amount, therefore fluid replacement is essential.
Top
Clinical indication of CAVH: [3,4]
1-Acute renal failure with  cardiovascular instability
2-Acute renal failure in critically ill overhydrated patients who are resistant to diuretics.
e.g. with
a. Chronic heart disease
b. Non cardiogenic pulmonary overhydration
c. Oligoanuric status
 d. Needs for total parenteral nutrition
e. Cerebral edema.
f. Burns.
3-Acute renal failure patients who are critically ill with multiorgan failure.
4-Acute renal failure patients who are critically ill with electrolyte abnormalities
5-Seriously ill chronic renal failure patients with any of the previous indications
6-Drug overdosage.
7-Management diuretic-resistant cardiac failure in non-renal failure patients.
Top
Technical aspect
CAVH does not require complicated equipment [fig 1]. Principally IV infusion pump to regulate the fluid
replacement and heparin infusion pump are required. A third pump used to control the ultrafiltration rate
is required in the two pump method. The CAVH set contents includes catheters, hemofilter, blood lines,
guide wires, introducing needles, ultrafiltrate line and graduated drainage bag.
a-Vascular access
Vascular access should guarantee adequate arteriovenous pressure gradient, low resistance, flexible ,
biocompatible and clinically well tolerated.
1-Percutanuous cannulation of femoral artery and vein are usually used.
2-Scribner A-V shunt
3-Arteriovenous fistulae or grafts are used as arterial line while peripheral or central vein are used for
blood return.
b-Blood lines
The length and the diameter of blood lines are critical in conducting the blood at a given arteriovenous
pressure gradient. Reduction of the arterial line(50 cm) and longer venous line(75 cm) permit high
hydrostatic pressure inside the hemofilter.
c-Hemofilter
Several small hollow fiber highly permeable membranes are used for CAVH. The membranes are made
of polyacrylonitrile or polysulphone with a surface area of 0.2 - 0.5 m 2.
d-The ultrafiltration line and drainage bag
The ultrafiltrate flow from the ultrafiltrate port into the drainage bag through the ultrfiltration line. The
difference in altitude between the hemofilter and the drainage bag must be 40 to 60 cm to allow the
generation of negative pressure inside the hemofilter's ultrafiltrate compartment thus enhancing the
ultrafiltration. In some cases suction may be applied at the ultrafiltrate port to increase the negative
pressure[5]
e-Fluid replacement
Commercially available replacement solution is typically have the following composition: sodium 140
mmol/L, potassium 0-2 mmol/L, calcium 1.75 mmol/L, magnesium 0.75 mmol/L, chloride 106 mmol/L
and lactate 45 mmol/L or acetate 41 mmol/L. If ready made replacement solution is not available several
formulae can be used depending on patients requirements.
1.Ringer's lactate + calcium and magnesium as required
2.For hypotensive, acidotic patients or with liver disease infuse bicarbonate -buffered solution by
alternating the following two solutions:
a.0.9 saline + calcium and magnesium as required
b.5% dextrose/0.45% saline + 66 mmol sodium bicarbonate ( with 23% sodium chloride if needed to
attain the desired sodium level 130-140 mEq/L)
3.For patients with lactic acidosis acetate containing Ringer's solution can be used.
 
Replacement solution  can be infused into the arterial line [predilution] or into the venous line
[postdilution]
In postdilution blood in the hemofilter can become very concentrated which lead to poor blood flow and
clotting specially at high fluid removal rate.
In predilution the blood is diluted with the replacement solution before it reaches the hemofilter.
Predilution is recommended when fluid removal of more than 10 liters/day are required.
The ultrafiltrate contains a lower concentration of waste product in postdilution than in prediluation fluid
replacement.
The fluid removal and replacement rates are controlled by a- Gravity method which is suitable for
ultrfiltration rate of up to 10 liters/day. b- Two pump method in which the ultrafiltrate and fluid
replacement are dialed by IV infusion pumps. It is suitable for ultrafiltration rates up to 10-20 liters /day
f-Anticoagulation
Prolonged anticoagulation is required in CAVH to prevent clotting in extracorporeal circuit and to extend
hemofilter span life and performance with minimal side effects to the patient. A loading dose of 500 -
2000 heparin is usually injected into the arterial line followed by maintenance dose of 10 units/kg/hour
[6]. PTT to be measured every 6-12 hours  keeping the systemic PTT about 150% of the baseline.
Heparin-free, regional heparinization, and regional citrate anticoagulation are also applicable to patients
with liver disease, active or recent bleeding, heparin induced thrombocytopenia or in postoperative
patients.
Top
Prescription of CAVH [7]
The rate  of urea production by the body is directly dependent on the rate at which the protein (ingested
and endogenous ) and amino acids are broken down. Urea nitrogen generation rate ranges from 5 to 10
gm / day. The higher the urea nitrogen generation rate  the great the need to increase urea clearance per
day.
Plasma urea clearance in postdilution CAVH urea concentration of the ultrafiltrate is approximately equal
to the plasma. Urea clearance is simply equal to ultrafiltrate volume. In predilution however urea
clearance can be calculated by the following formula:
 Urea clearance = Ultrfiltrate volume X  Ultrafiltrate urea concentration    X 0.85
Plasma urea concentration
 
Table 1 shows CAVH schedule according to the patient catabolic state
 
Patient category Desired plasma urea clearance /day*
Not hypercatabolic and has residual renal function 5-10 liters
Not hypercatabolic and has  no residual renal function 8-15 liters
Hypercatabolic with minimal or no residual renal 15-25 liters
function
* multiplied by 1 on post dilution and by 1.2 on prediluation
Top
Nursing care in CAVH
·        Patient and or family education about the purpose and function of CAVH
·        A baseline assessment , including clinical history, the patient's weight and physical examination,.
·        Hamodynamic profile is essential. It includes vital signs, central venous pressure, pulmonary artery
pressure. pulmonary capillary wedge pressures and arterial pressures
 
·        Baseline laboratory data; hemogram, coagulation profile, and chemistry .
·        Establish the vascular access aseptically.
·        The hemofilter and lines are primed, heparinised and attached to the patient (according to
manufacture's instruction)
·        The hemofilter must be secured carefully to the patient to avoid accidental disconnection.
·        Continuous care; Hemodynamic profile, patients fluid status,  pulses distal to the access, blood
flow, blood lines, hemofilter, ultrafiltration rate, laboratory values.
·        Hourly record of ultrafiltrate.
Top
Positives and Negatives of CAVH
Positives of CAVH: [8,9,10]
·        The main advantage of CAVH over intermittent conventional hemodialysis is the patient's
cardiovascular stability during the procedure.
·        CAVH provides an alternative option to peritoneal dialysis for patients with intra-abdominal sepsis
or recent abdominal surgery
·        Continuous and smooth blood purification with clearance rate of about 9.5  ml/minute are achieved .
·        Precise control of body fluid,  electrolyte and acid base abnormalities in oligoanuric patients are
easier. CAVH has been shown to be beneficial when parenteral nutrition is indicated.
·        CAVH is a simple and safe procedure to treat critically ill patient - ease of initiation and technically
less demanding.
Negatives of CAVH [7,9,10]
·        Access related:
      Thrombosis of femoral artery                     Emolization of atherosclerotic plaque
      Retroperitoneal  or local hematoma              False aneurysm
      Femoral arteriovenous fistula
·        Require strict fluid and electrolyte monitoring to avoid fluid and electrolyte imbalance.
·        Bleeding ; local - overhepranization. In patient with systemic bleeding the advantages and the risk
must be weighted.
·        Hemofilter malfunction ;
     Clotting should be suspected when blood lines becomes dark and or reduction of
     ultrfiltrate volume. Hemofilter leak and rupture also may occur.
     Decreased blood flow may indicate vascular access problem and or low blood pressure.
·         Inadequate solute clearance in severely hypercatabolic and hyperkalaemic patients.
·         Access site infection
Conclusion
Acute renal failure and the associated water overload are common problems in critically ill patients and
contribute significantly to mortality. Such patients are often hemodynamically unstable and can not
tolerate conventional hemodialysis. Continuous arteriovenous hemofiltration provides a simple and safe
renal replacement therapy for such critically ill patients in Intensive Care Units.  It is possible  that
patients who develop acute renal failure could be managed using Continuous Arteriovenous
Hemofiltration in hospitals which do not have an associated dialysis unit.
Top
Peritoneal Dialysis
Contents:
The peritoneum and mechanism of peritoneal dialysis
Peritoneal dialysis catheter
Definitions
Continuous ambulatory peritoneal dialysis
Automated peritoneal dialysis
Assessment of peritoneal function and anatomy
Complications of peritoneal dialysis
Peritoneal Dialysis Catheters
Contents:
Chronic Peritoneal Dialysis Catheters
Break In Procedure for New Chronic PD catheter
Care of Peritoneal Dialysis Catheter
 
 
Chronic Peritoneal Dialysis Catheters
Catheters for peritoneal dialysis must transport the fluid into and out of the peritoneal cavity as rapidly as
possible and maintain normal structure and function of the tissues near the catheter tract [i.e.
biocompatible]. Tenchkoff catheters are generally used for chronic peritoneal dialysis. A more recent
modifications of Tenckhoff catheter are described to improve the performance and decreases the catheter
complications.
 
 
 
Peritoneal dialysis in situ
 
 
 
Important features of Tenckhoff catheters:
Material of the catheters: Tenckhoff catheters are made of silicone or polyurethane with radiopaque
stripe for x-ray visualization.
Shape: It may be straight or coiled; coiled catheters are believed to minimize catheter migration out of the
pelvis and have fewer outflow problems.
Cuffs: Catheters have one or two dacron cuffs made of Dacron polyester or velour and provide for tissue
ingrowths to stabilize the catheter. The standard distance between the two cuffs is 5 cm.When double
cuffs catheters are placed the internal cuff is placed the rectus muscle and the external cuff is placed in the
subcutaneous tissue proximal to the exit site.  Cuffs intended to prevent migration of bacteria along the
subcutaneous tunnel into the peritoneum.
Parts: It consists of, Intraperitoneal segment containing side holes and open tip for fluid flow ,
Subcutaneous segment that passes through the peritoneal membrane, muscles, and subcutaneous tissues ;
External segment that extends from the external cuff out to exit site.
Sizes are different to accommodate neonate to adults. For obese patients with pendulous abdomen the
distance between the two cuffs is more than 5 cm. Standard adult catheter size; Intraperitoneal segment
15-20 cm , Subcutaneous segment 5-7cm; External segment 10 cm
Placement procedure Details of catheter placement is beyond the scope of the Tips.
-Chronic catheters are placed, surgically, using Tenckhoff trocar, using guide wire, using a Pull-Apart
introducer and by peritonescopy.The usual site of implantation is about 3 cm below the umbilicus.
-The exit site should be in the right [or left] midquadrant area avoiding the belt line and skin folds. The
direction of the exit site is directed upwards or downwards depending on the catheter used. The
superficial cuff should be 2 cm distance from the skin exit site It is useful to consider the patient
preferences and whether he or she is right or left handed. Furthermore the intestinal peristalses movement
push the catheter to the pelvis when the exit site in the right midquadrant.
-As a rule the required intra-abdominal length for adults corresponds closely to the distance between the
upper rim of symphysis pubis and the umbilicus when the patient in recumbent position except in obese
patients. If the catheter is to long ; up to 5 cm may be pared off the distal intra-abdominal segment
-Drainage problem, sepsis, exit and tunnel infection, peritoneal bleed, subcutaneous hematoma, bowel
perforation, ileus, pericatheter leak, pain, and catheter kink are potential complications for catheter
insertion.
-Partial omentectomy may be necessary in some if it is prominent [3-4 inches are removed]
-The proper location of the catheter tip with the standard Tenckhoff catheter should be just beneath the
left inguinal ligament, between the anterior abdominal wall, mass of omentum and bowel loops, [or cul-
de-sac of the pelvis if it is feasible]
-Tight closure of the peritoneum using running lockstitch is mandatory.
 
        There are several other versions of chronic catheters including modifications features intended to
improve dialysate flow and decrease catheter complications
 a-To minimize outflow obstruction
-Curled Tenckhoff Catheter to separate visceral and parietal layers of the peritoneum by increasing the
bulk of the tubing.
-The Toronto Western Catheter [Oreoulous-Zellerman] with two perpendicular disks to hold the
momentum and bowel away from the exit holes    
-The lifecath catheter has performed 90 bend in the subcutaneous portion which terminates in two discs
separated by numerous columns , this large area of disc  decreases the attraction of the omentum towards
the catheter
b- To minimize leakage and fix the catheter in position
-Modifications includes the deep cuff by adding a silicone bead posterior to the deep cuff.
c- To lower the rate of cuff extrusion and exit site infection.
-The swan neck catheter with a V-shaped  arc between the deep and superficial cuffs with exit site facing
towards the pelvis.
-Moncerief-popvich catheter with longer external cuff to allow tissue ingrowth into the external cuff.
Break In Procedure for New Chronic PD catheter
The break in period is that period which immediately follows catheter insertion. During that period the
risk of pericatheter leak is high. The leak of fluid around the catheter delays the growth of fibrous tissue
into the cuff of the catheter. Furthermore the risk of exit site, tunnel infection and peritonitis increases.
Basis of break in:
1-Flushing the peritoneal cavity with heparinised dialysate is helpful to clear intrapertoneal blood clots,
fibrin and minimize omental adhesion.
2-Intraperitoneal pressure is minimized by restriction of the exchange volume and patient activity. Patient
should be instructed to avoid excessive strain (e.g. constipation and cough)
3- Prophylactic antibiotics.
Break In Procedure:
A-First 24 hours:
1-Start flushing of peritoneal cavity immediately after insertion of the catheter with low volume
exchange; 500 ml of dialysate without dwelling time.
2-Add 500 U of heparin to dialysate.
3- Continue flushing till the effluent becomes clear (not bloody) then shift to dialysis with dwelling time.
3-Observe for       Excessive bleeding                     Pericathter leak
                            Outflow failure                             Excessive urine
                            Unusual drained fluid
4-Prophylactic antibiotic; 80 mg Gentamicin IV to be given at the start (if not given before surgery)
5-Discontinue dialysis after 24 hours unless long dialysis is indicated.
B-Second day -2 weeks: 
1- Organize dialysis with interdialytic phases according to patient needs.
2-Increase the exchange volume to 750 ml for 6 hours then to 1000 ml reaching the desired exchange
volume within two weeks.
3-Continue heparin 500 units /2L bag.
4- Observe for    Late pericatheter leak                Exit site and tunnel infection
                          Evidence of peritonitis              Outflow failure
                         Catheter related complications    
Break in for Patients with Pericatheter Leak:
1-Temporarily discontinue dialysis for at least 2 weeks.Hemodialysis supports during that
Period. 
2-Keep the catheter patent by flushing the peritoneal cavity three times per week. Perform in-out
exchange (zero dwell) using less than 500 ml of 1.5% dialysate containing 1000 U heparin /2 L bag.
3-Refractory leak necessitate catheter replacement.
4-Reinstitution of dialysis with smaller volume after leak resolving.
5-Avoid hypertonic solution and treat the precipitating causes.
  (Review the tip of pericatheter leak page)
 
Care of Peritoneal Dialysis Catheter
        Aseptic technique is mandatory
        Avoid trauma or traction on the catheter.
        During the first 3 days after catheter implantation, dressing need not to be changed, unless there
catheter leak or bleeding. The dressing should immobilize the catheter against the skin.
        Occlusive, air-impermeable coverings should never be used, nor should ointments
        The patient and nurses should avoid catheter movement at the exit site (it delays healing and can
lead to exit site infection).
        Subsequently gentle cleaning with antimicrobial solution (e, g. Povidone-iodine solution and
Hydrogen peroxide) using sterile applicators followed by a dry gauze dressing.
        Exit site dressing should be kept dry all the time:
     Moisture causes; Irritation, Maceration & Invites Infection.
        Crusts around the exit site my persist for several weeks.It should be removed carefully (not
forcefully) by help of hydrogen peroxide soaks.
        Reddening and tenderness about the subcutaneous cuff is frequent during the first few days .Its
normal or represent exaggerated tissue reaction to foreign body.
        Complete healing of incision & exit site is suspected within 4 weeks. After complete healing the
catheter exit site may be left unprotected (optional).
        Shower with liquid soap and water is allowed when the catheter site is well sealed (bath only if the
water below the exit site) - dry with clean towel - paint with betadine or povidone-iodine
solutionfollowed by 2x2 gauze dressing. Swimming is not permitted.
        All taping to the abdomen should be done with paper tape or similar products of low irritation
potential.
        Clothing should be comfortable to avoid mechanical irritation. The catheter exit site should not be
located under the belt or tight clothing.
Examination of exit site and tunnel

Clean exit site

Inspection of PD Catheter
1. Cracks 2.Tears 3.Debris in the adaptor
Inspection of Exit site and Tunnel   Focuses on
1. Redness, 2.Unusual swelling, 3.Bulging of exit or tunnel, 4.Bleeding, 5.Crusting, 6.Discharge,
7.Erythema
Palpation of exit sit and tunnel
1. Tenderness, 2.Induration, 3.Irregularity, 4. Discharge on gentle squeezing, 5.Skin folds for infection,
6.Abscess or sinus tract
  WHAT TO DO?    
 1- Notify the physician to confirm the finding
2-A culture should be taken before the area is painted with the antimicrobial agent.
3-The sooner antibiotic therapy initiated the better the prognosis.
 
Infected exit site
Continuous ambulatory peritoneal dialysis
Contents:
CAPD schedule:
Indications and contraindications:
Clearances of CAPD in comparison to other dialysis forms:
Sterile technique
Transfer sets
Connectors for CAPD
Dialysis solutions
Advantages and disadvantages
 
 
T he basic principle of continuous ambulatory peritoneal dialysis (CAPD) is a continuous presence of
dialysate in the peritoneal cavity. The dialysis fluid is left in place for 6-8 hours and slowly equilibrates
with plasma solutes in the peritoneal cavity. The fluid is then discharged in a plastic bag ,connected to the
catheter, and the contents of new bag are introduced through the catheter. Increasing the osmolality of
dialysis fluid by adding concentrated glucose (hypertonic) will increase the fluid loss.. It has a lower cost
than HD and with better hemodynamic stability.
CAPD schedule:
The basic technique of CAPD is extremely simple. Three or four exchanges are required every day [every
4-8 hours]. The patient can undertake this treatment alone without machine. Usually 2 L of dialysate are
used by most of the patients i.e.56 liters per week. The total outflow ~ 10 L including ultrafiltrate. Some
of the patients can tolerate 2.5-3 L of dialysate per exchange
Indications and contraindications:
  Review the previous Tips-Principles
Top
Clearances [liters/week] of CAPD in comparison to other dialysis forms:
 
 Substance CAPD CCPD NIPD HD
Urea 57 57 58 126
Creatinine 47 47 36 100
Vit B12 34 30 17 30
 
CAPD provides a continuous urea clearance of about 57 L/week. The weekly plasma urea clearance for
the forms of chronic peritoneal dialysis are comparable but less than that achieved by hemodialysis.
Top
Sterile technique:
 Rigid adherence to aseptic technique is required when performing bag exchanges in order to prevent
peritonitis. The following guidelines to be considered:
1- Follow specified techniques carefully without deviation.
    -Perform bag exchanges in  a clean area and wear a mask.
    -Exclude animals from the working area.
    -Restrict any activities during a bag exchange
    -Close off the area if possible.
2- Good personal hygiene is obligatory.
    -Wash the hands scrupulously for 3-5 minutes with soap or bacteriostatic agents (see the
        training module)
    -shower (see the training module)
3- Observe and inspect supplies and dialysate outflow regularly.
    -Examine the new bag, ports, line etc., for possible defects or leaks.
    -Examine the outflow bag for cloudy appearance, fibrin, or blood.
    -Examine the catheter exit site and palpate the tunnel tract for signs if infection.
4-Accidental contamination of the spike during the procedure must be reported to dialysis
     staff.
 Top
Transfer sets
1-Straight transfer set
 It is a simple plastic tube ; one end connected to the peritoneal catheter and the other to the dialysate
bag.. Bag exchanges are performed by breaking the connection between the transfer set and the dialysate
bag. The dialysate is instilled by gravity and the empty bag with the transfer  set are rolled and stored in a
pouch carried by the patient. The bag is used as drainage bag for the following exchange after 4-8 hours
dwell time. The bag is then disconnected from the transfer set and discarded then a new bag is attached
and fresh solution is instilled.
2-The Y transfer set
This set is a Y-shaped tube ; the stem is connected to the peritoneal catheter via a short adapter. The two
limbs of the Y are attached to dialysis solution bags , one empty and one  filled with fresh solution. The
used dialysate is drained into the empty bag and the peritoneum is filed with from the containing fresh
solution. The Y set is disconnected when not performing a solution exchanges. The use of Y set permit
flushing the tubing with 15-30 ml of fresh solution before draining the spent dialysate and refilling. The
bacteria that may be introduced during connection and washed out rather than washed into the patient.
The Y sets are designed in two forms [1] Reusable: Disinfectant is injected into the set and kept safely
with the two limbs connected to each other. The two limbs are rinsed free antiseptic at the time of next
exchange using fresh dialysis solution. [2] Disposable: The set is preattached to the dialysis solution bag
and empty bag. It is discarded after each use.
Positives of the Y set: [1]Unlike straight set the patient is free from the set and the bag between exchanges
with less mechanical stress to the exit and the tunnel. [2]Low peritonitis rate than that of straight set due
to less mechanical stress to the exit and the tunnel and to the flush before fill.
 Top
Connectors for CAPD
1-Catheter-to-transfer set connectors
A luer-lok made of titanium or durable plastic are designed to reduce the possibility of bacterial
contamination. A sterile connections at the catheter-to-transfer set joint are also available for the
removable Y sets.
2-Transfer set- to- container connectors
Over several years a number of transfer set-to-container connections have been developed. The spike and
port design is the standard. It is operated by pushing a spike located at the end of transfer set into a port
on diaysate container. Other transfer set-to-container connections includes; Inpersol system, Easy lock,
and Delflex system.. Recently some systems have eliminated the transfer set-to-container connection, and
are known as double bag systems.
3-Special connectors:
It is more complex and sophisticated devices such as ; in-line filters , ultraviolet light sterilization device ;
heat sterilization ,thermic splicing of transfer line ,tube cutter and mechanical aids
 Top
Dialysis solutions (Dialysate):
 
Dialysate is available in premixed clear flexible bags. Dialysate volumes ranging from 250 to 750 for
pediatric and 1 to 3 L for adult patients. The standard volume is 2 L.
The composition of dialysate varies somewhat by manufacturers but the standard dialysate as follows:
 
  Dialysate component Composition Remarks
 Osmotic Dextrose monohydrate 1.5% ,2.5% ,  
agents 4.25%
Icodextrin (Extraneal) UF as 3.86%  
glucose
Amino acids   malnourished patients

Electrolyt Sodium 130-134 mmo/l Low sodium is available for

e hypertensive and hypernaremia
Potassium 0-1.5 mmo/l  
Calcium :standard 1.75-2.5 mmo/l  
                reduced 1.25 mmo/l
                low 1.0   mmo/l
Magnesium 1.5 mmo/l  
Chloride 102 mmo/l  
Lactate 35 - 40mmo/l  
Bicarbonate  
pH 5.2-5.5  
Others Amino acids Commercially available for malnourished patients
 
      Dextrose chemically signifies the D-isomer of glucose. The molecular weight of D-glucose
monohydrate is 10% greater than that of anhydrous glucose. For this reason the dextrose solution bottle
are 10% greater than the true glucose concentrations.(e.g. 1.36% glucose is listed as 1.5% dextrose and
3.86% glucose is listed as 4.25% dextrose.
      Icodextrin (Extraneal), glucose polymer, has recently been introduced. This is a very large (20 –
≥500 glucose molecule) polymeric gluco-pyranose molecule produced by hydrolysis of starch. It allows
ultrfiltration to occur over log period of time by dragging water molecule through the membrane. It
provides ultrafiltation similar to 3.86% after 8-12 hours. It is used once daily.
      Lactate is used as bicarbonate generating base. Metabolism of lactate in the liver will result in
generation of bicarbonate. Hence the bicarbonate loss during peritoneal dialysis is compensated.
      Preparations with low calcium and magnesium concentration are used for patients with
hypercalcaemia or hypermagnesemia.
      Preparations with amino acids are also used for malnourished patients.
      Additives like heparin, insulin, potassium and antibiotics are added to dialysate according to the
patient requirements.
      Heparin (500/L) is added in the following situations:
          Fibrin in the dialysate outflow
          Peritonitis to maintain the patency
          After placement of a dialysis catheter to maintain the patency
          Hemoperitonium
 
NB:Heparin is not absorbed in amount sufficient to result in anticoagulation of the patient
Top
Advantages and disadvantages
Advantages:
1-Ease of performance
2-Safe - fewer dialysis related symptoms and with better hemodynamic stability.
3-It has a lower cost than HD.
3-Portability
4-Hemoglobin concentration generally increase during the first few months and remain stable thereafter.
The proposed reasons include the possibility of extrarenal erythropoietin by peritoneal macrophages and
the better removal of uremic inhibitors of erythropoietin.
5-Excellent blood pressure control.
6-Adequate control of electrolyte and acid base balance.
7-Stable control of nitrogenous waste products.
8-No routine anticoagulation
9-Control of parathyroid hormone
10-Libral diet
Disadvantages: "review the tip of complication of peritoneal dialysis"
1-Potential for infection [peritonitis-exit site and tunnel infection]
2-Low efficiency than hemodialysis
3-Weight gain and hyperlipidaemia particularly during the first year.
4-Body image problem
5-Potential protein loss ; nutritional supplementation is recommended when serum albumin tend to
decrease.
6-Patient dropout is higher than with hemodialysis[ peritonitis-malnutrition-inadequate dialysis]
7-Potential pulmonary compromise
 
             

 
 
 

            
Automated peritoneal dialysis (APD)
 
 
Cyclers:
Cyclers are an automated device capable of delivering a measured volume of dialysate into the peritoneal
cavity and providing automated drainage of spent dialysate after specific dwell time.
Functions:
1.Measurs the volume of dialysate to be infused.
2.Warm the dialysate to body temperature before infusion.
3.Time the frequency and numbers of exchanges
4.Measure ultrafiltration.
5.Mix dextrose concentrations to achieve the desired ultrafiltration.
Modern electronic and computerized programs are used to improve the functions of the traditional
mechanical cyclers. The new cyclers generation are reliable , efficient , simple and capable to perform
many functions.
The early cyclers used the gravity for infusion and drainage of dialysate into and out of the peritoneal
cavity. Further improvement in some designs a pump is used to force the dialysate up to a raised
containers , from which it is allowed to enter the peritoneal cavity. Timers and clamps of the cyclers
regulate the time of inflow , dwell, and outflow of dialysate. Advanced cyclers measure the total amount
of dialysate infused and drained and display the net difference between the two i.e. e volume of
ultrafiltration. Most of the cyclers have alarms that will sounds or light and shut off the cyclers if failure
to achieve the exact inflow or outflow volume occurs. In some cyclers pneumatic pressure pumps to
regulate the inflow -after warming -, dwell, and outflow of dialysate. Sensitive pressure monitoring
devices are required to avoid accidental infusion of large volumes of dialysate  and to avoid suction of the
mesentery or tissues during draining.
Tubing sets:
Disposable one step set up cassettes, including all the necessary tubing for the cyclers has simplified the
procedure of setting up the equipment. Multiple use of tubing sets and the utilization of empty solution
bags as the next day's drain has been tried to reduce the cost and patient effort in setting up their
equipment. Large dialysate containers are used to reduce the number of connections.
Connectors:
APD has shared the same connectors developed for CAPD of the same system. The use of external
occlusion for the disconnection procedure during APD has markedly simplified the procedure and reduces
peritonitis rate.
 
 
Solute clearance with some PD modalities:
 
  Clearance L/day Schedule
Modality Urea Creatinine Exchanges Volume Duration
Acute PD 24 16 24 2 24
CAPD 8.1 6.2 4 2 24
CCPD 8 6 4 N+1 D 2 10
NPD 7.7 5.3 12 2 8
TPD 10.4 6.3 - TV    =1.5 8
RV    =1.5
Total =27
 N, Nocturnal -  D, Diurnal  -   TV, Tidal volume  -  RV, Residual volume
 
Intermittent Peritoneal Dialysis (IPD)
This mode of peritoneal dialysis ,alternate dialysis of various duration (10-48 hours) with interdialytic
phases lasts for one or more days according to the patient needs. The exchange volume can be adjusted 
according to patient’s size , volume of peritoneal cavity , and cardiopulmonary tolerance. Introduction of
automated techniques (Cyclers and reverse osmoses machines) increased the safety by reducing risk of
infection and also the effectiveness of PD by insuring the regularity of the exchanges.
Initially patients with residual renal function do well on 40 hours per week of IPD, but as the endogenous
renal function decreases the effectiveness of IPD fails.
Nocturnal Peritoneal Dialysis (NPD).
Nocturnal Peritoneal Dialysis (NPD) is Intermittent Peritoneal Dialysis (I'D) performed nightly. The total
exchange time in this mode of therapy is 8-10 hours using the cycle times up to 60 minutes. No. dialysis
fluid in the abdomen during the daytime
Prescription (sample)
Dialysate volume: 2-liter exchange [16-20 liter/night]
Session length: Over 8-10 hours
Exchange time: On 10 p.m.            -----      Off  8 p.m.
                        One exchange every hour or more
                        Abdomen left dry in the morning.
Ultrafiltration: Use.....liters 1.5% and......liters 4.25%
Additives: Heparin , potassium , insulin ................etc
Indication
1. in patients with increased membrane permeability (high peritoneal transfer rates) . The use of short
frequent peritoneal exchanges will results in adequate ultrafiltration and improved solute removal.
2.in patient suffering from complications associated with increased intraabdominal pressure. Patients
suffering from ;  hernias , bladder and uterine prolapse , low backache , restrictive lung disease , severe
cardiovascular instability , gastrointestinal reflux and abdominal pain associated with dialysate infusion
may benefit from NPD.
Disadvantages:
1.NPD has the disadvantages of not providing  a steady physiological state.
2.Expensive due to the relatively high dialysate flows and the need of cycle.
 
 
Continuous Cyclic Peritoneal Dialysis (CCPD)
Continuous Cyclic Peritoneal dialysis is a form of automated peritoneal dialysis. Cyclers with timers that
allow dwell times of several hours is necessary.CCPD users must carry out 3-5 nightly exchanges over
10-12 hours, plus a daytime exchange remain in the peritoneal cavity to control uremia. 10-18 % of urea
cleared by the daytime exchange It avoid  interrupting daytime activities and may also reduce the
incidence of PD complications.
Prescription (sample)
Dialysate volume: 2-liter exchange [10 liter/day]
                            4 exchanges at night and 1 at day time
Session length: Over 10 hours
Exchange time: On 10 p.m.            -----      Off  8 p.m.
                        One exchange every 2.5 hour at night
                        The fifth exchange left in the peritoneal cavity in the morning morning.
Ultrafiltration: Use.....liters 1.5% and......liters 4.25% at nighttime and ......% at daytime.
Additives: Heparin , potassium , insulin ................etc
The use of hypertonic solution [4,25]during daytime is recommended because of prolonged dwell time
and significant absorption of dextrose after4-6 hour dwell.
Indications:
1.Patients who needs partner assistance
2.In patient suffering from complications associated with increased intraabdominal pressure. See TAD
3.Inadequate dialysis with other modalities,
Advantages:
1.The efficiency of  COD in removing small and middle molecule is comparable to CAPD. Adequate BP
control is also achieved.
2.It provide a relatively continuous therapy without necessity for on and off procedure during the active
hours
3.The risk of hernias and pericatheter leak are lower in COD than CAPD.
4.Less peritonitis rate.
5.CCPD is the treatment of choice in children.
Disadvantages:
1.The need of cycle
2.Expensive , related to the cycle and its disposable tubing.
3.Protein loss and hyperlipidaemia
 
Tidal Peritoneal Dialysis (TPD)
Tidal peritoneal dialysis is a therapy in which the patient abdomen is filled with dialysate, and a portion
of the dialysate is drained and replaced by fresh dialysate. The rationale behind this technique is that a
sufficient residual volume always in contact with peritoneal membrane while partial exchanges are
carried out throughout the night. It is one form of automated peritoneal dialysis which permits a reduction
in dialysis time and improves the efficiency of dialysis by keeping the abdomen full while drain and fill
times. The peritoneal cavity is drained completely only at the end of dialysis session.
This technique uses  a modified cycle regulated by volume rather than time and high dialysate flows ,
unlike COD and NYPD in which the cycle regulated by time rather than volume..
Example ; Exchange volume = 3 liters , (Reserve volume =1.5 liter , Tidal volume 1.5 liter) , for a total of
30 liters over 8-10 hour. Cycles are short; usually less than 20 minutes.
Advantages:
1.The high dialysate flow rate provides increased diffusion and minimizes the formation of unstirred
layers of dialysate next to the peritoneum.
2.The presence of reserve volume provides continuous contact between the dialysate and the peritoneal
membrane , i.e. continuous excellent  clearance and ultrafiltration.
Disadvantages:
1.The peritoneal dialysis catheter must have excellent inflow and outflow
2.The need of special volume controlled cycle.
3.Very high dialysate flows.
4.The ultrafiltration volume must be calculated and added to the drain volume with each exchange.
5.Clearance of larger molecule is high.
6.Expensive
 
Complications of peritoneal dialysis
Contents:
List of complications
Mechanical PD Catheter  Dysfunction
Other Common Complications of Peritoneal Dialysis
 
List of complications
   Peritonitis
 Catheter related
           [see other common complications]
             Infection :      -Exit site
                                   -Tunnel
             Cuff extrusion
             Malposition
             Pain
             Bleeding
             Catheter obstruction
             Visceral Perforation
Mechanical
             Dialysate leak:-Pericathter
                                   -Pleural
                                   -Abdominal wall
                                   -Genitalia
                                   -Vaginal
             Hernias         :-Incisional
                                   -Ventral
                                   -Periumblical
                                   -Catheter tract
                                   -Inguinal
            Back pain
Medical
          Hypotension
          Peripheral vascular insufficiency 
          Nutritional
                                 - Hypoalbuminemia 
                                 -Obesity
                                 -Hyperlipidemia
          Peritoneal dialysate eosinophilia
          Loss of peritoneal ultrafiltration or transport capacity
Top
 
 Peritonitis
 Peritonitis is the most aggressive complication of chronic peritoneal dialysis, which becomes the limiting
factor in the success of this technique for many patients
POTENTIAL SOURCES OF PERITONITIS
EXOGENOUS
Primary connection site
Injection site for medication 
The transfer set-catheter connection contamination
Poor hand washing
Defective tubing
Disconnection of dialysate circuit.
Exit and tunnel infection.
Frequent use of antibiotic predispose to fugal peritonitis
Others e.g. diarrhea, URTI, Contaminated hands       
ENDOGENOUS
1-Acute visceral inflammation e.g. Appendicitis, Diverticulitis, Cholecystitis, or Perforated bowel  
.2-Septicemia
3-Bacteria residing female genital tract.
   
DIAGNOSTIC FEATURES OF PERITONITIS
Abdominal pain and bowel symptoms in 80% of cases
Cloudy outflow
Fever   (50%
Nausea (30%)
Diarrhea (7-10%)
Poor  drainage   
Loss of ultrafiafiltration                                         
Peritoneal fluid white blood cells count > 100/ml with >50 % polymorphonuclear      leukocytes.
Gram stain positive for organism ~50% of time.
Culture positive in 95 % of cases.
 
ORGANISMS CAUSING PERITONITIS
·      Gram-positive pathogens:     65--75 %
                  Staphylococcus epidermidis
                  Staphylococcus aurous
                  Streptococcus species
·      Gram-negative pathogens:     25--30 %
                Enterobacteriaceae ( proteus, E Coli, Klebsiella Enterobacter sp.)
                 Acinetobacter sp.
                 Pseudomonas sp.
·      Other pathogens                       <5 %
                Fungal    ----Nocardia -------Asppergillus----Actinomycosis
                 TB & nonTB mycobacterium
·      Culture negative :                        5 %
 
Complications of peritonitis:
Catheter removal
Loss of ultrafiltration
Deterioration of nutritional status
Ileus
Adhesions of peritoneal membrane.
Fungal peritonitis
Death
 
Prevention of peritonitis
Careful selection of patients
Adequate patient education and training
Treatment of constipation
Avoid exogenous sources of peritonitis
 Treatment of staphylococcus aurous nasal carriers.
Avoid unnecessary use of antibiotic.
Initial Clinical Evaluation of Patient with Suspected Peritoneal Dialysis-Related Peritonitis
Symptoms: cloudy fluid and abdominal pain
Do cell count and differential
Gram stain and culture on initial drainage
Initiate empiric therapy
Choice of final therapy should always be guided by antibiotic sensitivities
Antibiotic therapy
ISPD Guidelines/Recommendations
ADULT PERITONEAL DIALYSIS-RELATED PERITONITIS TREATMENT
RECOMMENDATIONS: 2000 Update
Empiric Initial Therapy, for Peritoneal Dialysis-Related Peritonitis, Stratified for Residual Urine
Volume
Antibiotic Dosing Recommendations for CAPD (Only) Patients With and Without Residual Renal Function a

Treatment Strategies After Identification of Gram-Positive Organism on Culture

Treatment Recommendations if a Gram-Negative Organism Is Identified on Culture at 24 to 48
hours
Treatment Strategies if Peritoneal Dialysis Fluid Cultures Are Negative at 24 to 48 Hours or Not
Performed
Treatment Recommendations if Yeast or Other Fungus Identified on Gram Stain or Culture
 
 
Empiric Initial Therapy, for Peritoneal Dialysis-Related Peritonitis, Stratified for Residual Urine Volume

Residual urine output

< 100 mL/day > 100 mL/day
in 1 g/bag, q.d. 20 mg/kg BW/bag, q.d.
or  
15 mg/kg BW/bag, q.d.  
1 g/bag, q.d. 20 mg/kg BW/bag, q.d.

n, netilmycin 0.6 mg/kg BW/bag, q.d. Not recommended

2 mg/kg BW/bag, q.d. Not recommended

body weight

Top
Antibiotic Dosing Recommendations for CAPD (Only) Patients With and Without Residual Renal
Function a
 
CAPD intermittent dosing CAPD continuous dosing (per
 
(once/day) liter exchange)
Drug Anuric Non anuric Anuric Nonanuric
Aminoglycosides        
Increase
Amikacin 2 mg/kg MD 24 mg Increase all
all
doses by MD by 25%
Gentamicin 0.6 mg/kg MD 8 mg
25%  
Netilmicin 0.6 mg/kg   MD 8 mg  
Tobramycin 0.6 mg/kg   MD 8 mg
All LD same
Cephalosporins      
as anuric
LD 500 mg, MD increase
Cefazolin 15 mg/kg 20 mg/kg
MD 125 mg by 25%
LD 500 mg,
Cephalothin 15 mg/kg ND MD, ND
MD 125 mg
LD 500 mg,
Cephradine 15 mg/kg ND MD, ND
MD 125 mg
500 mg p.o.,
Cephalexin ND As intermittent MD, ND
q.i.d.
LD 200 mg,
400 mg p.o./IV,
Cefuroxime ND MD 100_200 MD, ND
q.d.
mg
LD 250 mg,
Ceftazidime 1000_1500 mg ND MD, ND
MD 125 mg
LD 250 mg,
Ceftizoxime 1000 mg ND MD, ND
MD 125 mg
All LD same
Penicillins      
as anuric
4000 mg IV, LD 4 g IV, MD
Piperacillin ND MD, ND
b.i.d. 250 mg
 MD 125 or
250_500 mg p.o.,
Ampicillin ND 250_500 mg MD, ND
b.i.d.
p.o., b.i.d.
250_500 mg p.o., 250_500 mg
Dicloxacillin ND MD, ND
q.i.d. p.o., q.i.d.
Oxacillin ND ND MD 125 mg MD, ND
MD, no
Nafcillin ND No change MD 125 mg
change
LD 250_500
Amoxicillin ND ND MD, ND
mg, MD 50 mg
LD 50 000 U,
Penicillin G ND ND MD, ND
MD 25 000 U
Quinolones        
500 mg p.o., LD 50 mg, MD
Ciprofloxacin ND ND
b.i.d. 25 mg
400 mg p.o., then
Ofloxacin ND As intermittent ND
200 mg p.o., q.d.
Others        
Increase
15_30 mg/kg MD 30_50 Increase MD
Vancomycin doses by
q.5_7 d mg/L by 25%
25%
LD 400 mg,
Teicoplanin 400 mg IP, b.i.d. ND ND
MD 40 mgb
LD 1000 mg,
Aztreonam ND ND ND
MD 250 mg
LD 300 mg,
Clindamycin ND ND ND
MD 150 mg
250 mg p.o.,
Metronidazole ND As intermittent ND
b.i.d.
300 mg p.o.,
Rifampin ND As intermittent ND
b.i.d.
All LD same
Antifungals      
as anuric
Amphotericin NA NA MD 1.5 mg NA
2 g LD, then 1 g
Flucytosine ND As intermittent ND
q.d., p.o.
Fluconazole 200 mg q.d. ND As intermittent ND
 100 mg 100 mg q.12
Itraconazole 100 mg q.12 hr 100 mg q.12 hr
q.12 hr hr
Isoniazid 300 mg
Antituberculus ND As intermittent ND
p.o., q.d.
+ rifampin 600
       
mg p.o., q.d.
+ pyrazinamide
       
1.5 g p.o., q.d.
+ pyridoxine 100
       
mg/d
All LD same
Combinations      
as anuric
LD 1000 mg,
Ampicillin/sulbactam 2 g q.12 hr ND ND
MD 100 mg
LD 320/1600
320/1600 mg
Trimeth/sulfamethox ND mg p.o., MD ND
p.o., q.1_2 days
80/400 mg p.o.
MD = maintenance dose; LD = loading dose; ND = no data; p.o. = oral; q.i.d. = four
times per day; IV = intravenous; q.d. = once per day; b.i.d. = twice per day; IP =
intraperitoneally; NA = not applicable.
CAPD patients with residual renal function may require increased doses or more
frequent dosing, especially when using intermittent regimens. For penicillins: "No
change" is for those predominantly hepatically metabolized, or hepatically
metabolized and renally excreted; "ND" means no data, but these are predominantly
renally excreted, therefore probably an increase in dose by 25% is warranted;
"NA" = not applicable, that is, drug is extensively metabolized and therefore there
should be no difference in dosing between anuric and nonanuric patients. Anuric =
<100 mL urine/24 hours; nonanuric = >100 mL/24 hours. These data for CAPD
only.
a
 The route of administration is IP unless otherwise specified. The pharmacokinetic
data and proposed dosage regimens presented here are based on published literature
reviewed through January 2000, or established clinical practice. There is no
evidence that mixing different antibiotics in dialysis fluid (except for
aminoglycosides and penicillins) is deleterious to the drugs or patients. Do not use
the same syringe to mix antibiotics.
b
 This is in each bag × 7 days, then in 2 bags/day × 7 days, and then in 1 bag/day × 7
 days.
Top
Treatment Strategies After Identification of Gram-Positive Organism on Culture
 
    Other gram-positive
Enterococcus Staphylococcus aureus organism
(Coagulase-negative
staphylococcus)
At 24 to 48 hours
Stop cephalosporins Stop ceftazidime or Stop ceftazidime or
aminoglycoside aminoglycoside
Start ampicillin 125 mg/L/bag Continue cephalosporin Continue cephalosporin
Consider adding Add rifampin 600  
aminoglycoside mg/day, oral
If ampicillin-resistant, start If MRSA, start If MRSE and clinically
vancomycin not
vancomycin or clindamycin or clindamycin responding, start
vancomycin
If VRE, consider   or clindamycin
quinupristin/dalfopristin
Duration of therapy
14 days 21 days 14 days
At 96 hours
If no improvement, reculture and evaluate for exit-site or tunnel infection, catheter
colonization, etc.
Choice of final therapy should always be guided by antibiotic sensitivities.
VRE = vancomycin-resistant enterococcus; MRSA = methicillin-resistant S. aureus;
MRSE = methicillin-resistant enterococcus.
Top
Treatment Recommendations if a Gram-Negative Organism Is Identified on Culture at 24 to 48 hours
 
Adjust antibiotics to sensitivity 14
Single gram-negative organism
< 100 mL urine, aminoglycoside days
 
 
  > 100 mL urine, ceftazidime
 
Pseudomonas/stenotrophomonas Continue ceftazidime and add 21
< 100 mL urine, aminoglycoside (see
 Empiric Therapy, Table 2)
> 100 mL urine, ciprofloxacin 500 mg,
p.o. b.i.d.
or piperacillin 4 g IV q.12 hours
  or sulfamethoxazole/trimethoprim 1_2 days
  DS/day  
  or aztreonam load 1 g/L; maintenance  

  dose 250 mg/L IP/bag  

Continue cefazolin and ceftazidime and
Multiple gram-negatives and/or add 21
anaerobes metronidazole, 500 mg q.8 hours, p.o., days
  IV, or rectally  
  If no change in clinical status, consider  
surgical intervention
IV = intravenously; DS = double strength; IP = intraperitoneally.
Top
Treatment Strategies if Peritoneal Dialysis Fluid Cultures Are Negative at 24 to 48 Hours or Not
Performed
 
Duration of
 
         Continue initial therapy therapy
If clinical improvement Discontinue ceftazidime or
 
  aminoglycoside
14 days
Continue cephalosporin
If no clinical improvement at Repeat cell count, Gram stain, and
 
96 hours culture
If culture positive, adjust therapy accordingly 14 days
If culture negative, continue antibiotics, consider infrequent
14 days
pathogens and/or catheter removal
Top
Treatment Recommendations if Yeast or Other Fungus Identified on Gram Stain or Culture
At 24 to 48 hours
Flucytosine Loading dose 2 g p.o.; maintenance dose 1 g p.o.
             and  
200 mg, p.o., or intraperitoneally, daily
Fluconazole
If organism is resistant, consider itraconozole
At 4 to 7 days
 If clinical improvement, duration of therapy 4_6 weeks
If no clinical improvement, remove catheter and continue therapy for 7 days after
catheter removal
 
 
 
 Relapsing peritonitis
ISPD Guidelines/Recommendations
ADULT PERITONEAL DIALYSIS-RELATED PERITONITIS TREATMENT
RECOMMENDATIONS: 2000 Update
    Definition
Relapsing peritonitis is defined arbitrarily as another episode of peritonitis caused by the same
genus/species that caused the immediately preceding episode and occurs within 4 weeks of completion of
the antibiotic course.
   Presentation
 Clinically, these patients will have signs and symptoms similar to those described in patients with
sporadic peritonitis.
 
  Treatment
In the presence of coagulase-positive staphylococcus infection, a search for an occult tunnel infection
should  be made.
 Coagulase-positive or -negative staphylococci should be treated with cephalosporins and rifampin for
approximately 4 weeks.
MRSA or S. epidermidis, clindamycin or vancomycin should be considered for therapy
If enterococci are recultured, ampicillin and an aminoglycoside should be used in the recommended
doses. Consideration should also be given to the possibility of an intra-abdominal abscess.
If no clinical response is noted after 96 hours of therapy for relapsing peritonitis, catheter removal is
indicated. If the patient responds clinically, but subsequently relapses an additional time, catheter removal
and replacement are recommended.
In relapsing peritonitis caused by gram-negative organisms, one should evaluate clinically for an intra-
abdominal abscess. Catheter removal and surgical exploration should be strongly considered in these
patients. Treatment with ceftazidime or an aminoglycoside alone can be used once culture results are
known. If pseudomonas or stenotrophomonas organisms are identified again on culture, the catheter
should be removed. Finally, in those patients with relapsing peritonitis, short-term interruption of PD may
be of value; however, the availability of supportive hemodialysis will dictate whether this option can be
considered.
 
 
 
Reference:
ISPD Guidelines/Recommendations
ADULT PERITONEAL DIALYSIS-RELATED PERITONITIS TREATMENT
RECOMMENDATIONS: 2000 Update
William F. Keane,1 George R. Bailie,2 Elizabeth Boeschoten,3 Ram Gokal,4 Thomas A.
5 6 7 8 9 10
Golper,  Clifford J. Holmes,  Yoshindo Kawaguchi,  Beth Piraino,  Miguel Riella,  Stephen Vas
Department of Medicine,1 Hennepin County Medical Center, University of Minnesota Medical School,
Minneapolis, Minnesota; Albany College of Pharmacy,2 Albany, New York, U.S.A.; Department of
Peritoneal Dialysis,3 Academic Medical Center, Amsterdam, The Netherlands; Manchester
Royal Infirmary,  Manchester, United Kingdom; Vanderbilt University Medical Center,5 Nashville,
4

Tennessee; Baxter Healthcare Corporation,6 McGaw Park, Illinois, U.S.A.; Renal

Division,7 Jikeikai University, School of Medicine, Tokyo, Japan; University of Pittsburgh Medical
Center,8Pittsburgh, Pennsylvania, U.S.A.; Renal Division,9 Department of Medicine, Evangelic School of
Medicine, Curitiba Parana, Brazil; University of Toronto,10 Toronto Hospital, Toronto, Ontario, Canada
Top
Indications of catheter removal
Tunnel infection
    Peritonitis that fails to response to appropriate antibiotic therapy
    Mycobacterium peritonitis
    Fungal peritonitis
    Fecal peritonitis
 
Top
 
Flow chart for diagnosis and management of exit-site infections is shown
 
ABDOMINAL PAIN DURING PERITONEAL DIALYSIS
 
Symptom       Possible Cause                 Treatment
Pain  on inflow      Low dialysate pH Add bicarbonate to dialysate
Catheter tip irritation Observation
Pain during dwell    Over distention of the abdomen Longer drain time
Decrease exchange volume
Pain following  dialysis   Peritonitis Antibiotic
Free abdominal air Recumbent position
None
Constant pain    
Diffuse Peritonitis Antibiotic
Abdominal pathology Diagnosis and treatment
Pelvic area Perineal, rectal, bladder irritation Observation; consider catheter
by catheter tip replacement
Shoulder pain Air under diaphragm Recumbent position
None
 
PERITONEAL IRRITATION:
When, catheters are newly placed, some patient experience pain in the perineum, rectum, or genitalia,
which is probably due to irritation by the catheters tip. Such pain is usually self-limited and disappears
within 1 week. In some patient, this persists continuously and intensified when the peritoneal cavity is
drained of fluid. In such cases the catheter may be too long for the patient, causing continuous irritation
by pressing against pelvic structures.   Late development of transvisceral erosion may occur,
necessitating at least a temporary interruption of chronic peritoneal dialysis and catheters removal.
Top
 
Dialysate Leaks
Sites of dialysate leakage:
1-Pericatheter                         
2-Pleural
3-Abdominal wall                 
4-Genitalia                                       
5-Vaginal
 
Pericatheter Leak
Pericatheter is the most frequent site of dialysate leak.Usualy occurs within the first two weeks of catheter
placement. Occasionally leakage will occur along catheter tract after months suggesting:
                      1-Delayed adherence of the catheter cuffs.
                      2-Traumatic injury to the catheter, resulting in patency around the cuffs
·      Pericatheter dialysate leak, frequently associated with :
                      1-Overdistension of the peritoneal cavity with fluid.
                      2-Increased intraperitoneal pressure, e.g. in chronic cough and constipation
·      Leakage around a patent internal catheter cuff will lead to dissection of the fluid into the
subcutaneous tissue. Patients are presenting as a bulge over the anterior or lateral abdominal wall, edema,
weight gain, and diminished outflow volume.
·      In general, it is frequent in CAPD than in IPD or CCPD because of diminished intraperitoneal
pressure during recumbence. The risk is increased, if CAPD schedule is begun soon after catheter
insertion.
Management of Pericatheter leak:   
1-Prophylactic measures:
    a-Use small exchange volume for several days to a week after Catheter placement to allow healing of
the tunnel
    b-The use of hypertonic dialysate should be minimized with new catheters to reduce the volume of
ultafiltrate
    c-Instruct the patient (in CAPD) to drain all the fluid completely at each exchange.
 2-Temporarily discontinue peritoneal dialysis for 2-3 weeks and then cautiously resume peritoneal
dialysis.
 3-Treat the predisposing factors; constipation, cough, and avoids hypertonic dialysate on resuming
dialysis
 4-Catheter replacement.
 5-Discontinue peritoneal dialysis and transfer the patient to hemodialysis on permanent basis
 
Top
Mechanical PD Catheter  Dysfunction
Mechanical dysfunction of peritoneal catheter is most frequently a one-way outflow obstruction. It is
detected when the drainage volume is less than the inflow volume .It caused by catheter malposition ,
partial occlusion by fibrin , catheter encasement by omentum ,-bowel- fibrous tissue and loculation of
peritoneal cavity ...etc.Patient with recurrent peritonitis, particularly  when it is not promptly diagnosed
and treated ,may develop gradual fibrosis around the catheter, which limits  mechanical exchange of
dialysate. Typical causes  and approaches to treatment are shown in the following table:
 
Problem Possible Causes Treatment
Poor Fibrin / Clot obstruction Flush the catheter
Dialysate Add Heparin (500/l)
Inflow Urokinase/streptokinase
Poor Catheter Position Laxatives, Reposition or Replace the
Catheter
Kinked External Tubing Examine the tubing system                                                  
.and Correct
Poor Kinked External Tubing Examine the tubing
Dialysate system                                                  .
Outflow and Correct
Malposition of the Catheter Laxatives-
Reposition or Replace the    
Catheter
Air in line Flush line
Fibrin Obstruction Heparinized Saline
Urokinase-streptokinase
 Catheter Encasement by: Bowel- Replace the Catheter Catheter
Omentum, fibrous tissue Stripping, Omentectomy
Peritonitis                              Treat Peritonitis
                                         
Use of Thrombolytic Agents:
 Urokinase:           1-Dilute 5000 IU in 40-50 ml of 0.9 % saline.
                                  2-Inject the total volume into the peritoneal catheter.
                                  3-Clamp the catheter ,and wait for 2 hours, then asses the drainage.
                                  4-Repeat once if needed.  
 Streptokinase    
1-Test for Allergy ;
a-Scratch the skin with needle then place a drop o a 100 IU/ml over the scratch , and observe for 15
minutes.
b- If no wheal and flare inject 0.1 ml of the same solution intradermally, if  no wheal and flare appear,
then allergy is unlikely . 
 2--Dilute 750,000 IU in 40-50 ml of 0.9 % saline
3-Inject the total volume into the peritoneal catheter.
4-Clamp the catheter ,and wait for 2 hours, then asses the drainage.
5-Repeat once if needed
 
Top
Other Common Complications of Peritoneal Dialysis
 
Complication Cause Diagnosis Intervention
Fibrin Formation Formed in response to Whitish strands /clots  seen Heparin added to
inflammation due to in effluent or catheter .It dialysate to prevent
decreased fibrinolysis of may lead to obstruction if fibrin production and
fibrinogen e.g. in not treated. adhesion formation. 
peritonitis Urokinase or
Streptokinase is used in
severe cases
Hemoperitonium Trauma, Menstruating Blood effluent, 2 ml /L will In-and-out flushes with
women, Ovulation, result in blood-tinged room temperature
Ovarian cysts, effluent,  Hematocrit of dialysate
Peritonitis, Post 5%,indicative of major (vasoconstriction);
colonoscopy or enema,  ? bleeding. Addition of heparin to
endometriosis. prevent obstruction.
Air in Peritoneum Loose connections. Air Shoulder pain; peritoneal Tighten the connections
in the system eosinophilia Drain the peritoneal
cavity in knee-chest
position or
trendelenburge.  May
need to resolve over
time.
Hernias [in 5% of Increased intraabdominal Swelling in inguinal, IPD,CCPD with minimal
patients on CAPD] pressure due to the ventral incisional, umbilical or no dwell; Decreased
presence of dialysate in area, non painful, reducible. exchange volume;
peritoneum, specially in Some cause intestinal Surgical repair
patients with congenital obstruction.
or acquired defects;
previous  abdominal
surgeries.
Scrotal or [labial] Inguinal hernia(66%) Scrotal swelling usually Treat the cause.
edema [not Dialysate leak from bilateral] ,penile edema,
uncommon] catheter tracts(17%), weight gain, palpable
Fluid retention due to hernia, poor dialysate
high peritoneal outflow.
membrane permeability Exclude ultrafiltration
and UF failure (24%), failure PET]
Combined causes (7%) CT with contrast, peritoneal
scintigraphy
Pleural leak Congenital defect in the Shortness of breath, Avoid hypertonic
[Hydrothorax] diaphragm Decreased dialysate dialysate
Excessive use of outflow volume. Signs of Stop peritoneal dialysis
hypertonic dialysate right sided pleural effusion. temporarily.
Develop within hours or Pleural fluid have high Change the patient to
days [may be delayed up glucose and low protein. It CCPD NIPD,or HD
to several months] after can be documented by schedule
initiating PD utilizing radionuclide
imaging.
Backache Alteration of body Low back pain , Common Using low volume
posture resulting from in CAPD exchange for day time,--
the presence of dialysate Change to CCPD
in the abdomen schedule,
Obesity Results from absorption Significant weight gain , Restriction of the usage
of calories from dialysate 20% increase of body of hypertonic dialysate.
glucose [~ weight after 5 years on Diet education to reduce
600calories/day in CAPD calories intake.
CAPD]. Use of dialysate
containing nonglucose
osmotic agents
Hyperlipidemia Absorption of glucose Hypertriglycridmia, Diet education, Exercise,
from dialysate. Hypercholesterolemia; Use of nonglucose
HDL osmotic agents dialysate,
Coronary artery disease Drugs (e.g. Lovastatin).
Protein loss Proteins are lost through Protein loss =9-10 g/d with Diet : 1.5 g/kg/day +
the dialysate. CAPD total 35 kcal/kg/day
                     12-15 g/d with
IPD
 Hypoproteinemia
Hypoalbuminemia -
Compromised immunity
Orthostatic Extracellular volume Symptomatic postural  Increase salt and water
hypotension depletion due to hypotension intake.
excessive ultrafiltration Salt tablets 50-150
with inadequate dietary mEq/day.
and volume intake Dialysis instruction.
Hypoproteinemia
Autonomic insufficiency
       
       
Peritoneal Unknown, Occurs in Cloudy effluent, Elevated Self limited
Dialysate patient shortly after leukocyte containing 40- Careful monitoring to
Eosinophilia dialysis 95% eosinophils, low IgE, exclude bacterial
normal protein without peritonitis
evidence of peritonitis
Peritoneal Loss of Increase the need for Resting the membrane
Dialysis Failure : ultrafiltration due to hypertonic sol     Fluid Eliminating long dwell
  Acute and Recurrent  retention       exchange
Peritonitis  Solute removal is intact [in   CAPD -do frequent
Extensive adhesion due type 1] exchanges
abdominal surgery or  Solute removal is reduced   CCPD -additional
inflammatory process [in type 2] exchanges at day time
Idiopathic (over several Reducing cycle time
years)           Switch CAPD to
CCPD
                      CCPD to
NIPD
  Loculation of peritoneal Sensation of distension. Hemodialysis
cavity Due to  Fibrosis Inability to tolerate
            Adhesions previously used
                From       dialysate volume.
inflammation Poor dialysate outflow
Poor catheter function
   Peritoneal sclerosis Nausea, vomiting [Uremia] Laxatives
Unknown Malabsorption [weight loss] Avoid  barium
Recurrent peritonitis in Abdominal pain administration [prevent
many cases Abdominal mass or ascites bowel obstruction]
Chemical irritation Bowel obstruction Hemodialysis
   Disinfectant:   Patient has thick firm
e.g.chlorohexidine grayish-white fibrous tissue
   Tubes and connections: covering the viscera.
         e.g.plasticizers
Catheter cuff Positioning of the distal Gradual extrusion of the Removal of the cuff to
Extrusion and cuff too superficially or distal cuff through the prevent retraction with
Erosion the tunnel is to short.  catheter exit site the catheter in place
Erosion is frequent in provided infection does
individuals who are thin not develop.
and lack of adequate fat Catheter replacement.
tissue.
 Top
Other Topics
 
Contents:
Adequacy of dialysis
Renal bone disease
Management of anemia in dialysis patients
 
Minitips
 
Hemodialysis
Solutes with smaller molecular weight are dialyzable.
Diffusion is the net directional movement of molecules occurring from a solution of higher concentration
to a solution of low concentration.
Ultrafiltration is the movement of solvent across a semipermeable membrane in response to a pressure
difference applied across the membrane
If the solutes dissolved in the solvent is small enough to permeate the membrane, they are dragged along
with the solvent and cross over to the other side, and this called Convection.
Removal of urea from the patient is primarily due to existence of concentration gradients.
High dialysate flow rates during hemodialysis maintain wide concentration gradient.
Bicarbonate of dialysate bath correct the patients’ metabolic acidosis.
If air embolism is suspected, turn the patient on his left side and place the patient in trendelenberg
position
To prevent disequilibrium syndrome for a patient with extremely elevated BUN, the first two
hemodialysis treatment should be less efficient.
Hemolysis is the major complication due to the use of hypotonic dialysate.
TMP consists of positive pressure on the blood side and negative pressure on the dialysate side.
Counter-current flow is used to maintain optimum gradient between blood and dialysate cross the dialyzer
membrane.
Factors influence the effectiveness of diffusion during hemodialysis are: 1.Solute size     2.Permeability
of the membrane    3.Dialysate flow rate   4.Dialysate temperature    5.Blood flow rate  
6.Concentration gradient   7.Fluid removal   8.Clotting
Water solubility and small volume distribution are characteristic of a drug allow it to be substantially
removed by dialysis.
Access recirculation, decreased performance of reused dialyzers, and presence of red blood cells and
other plasma proteins are possible factors for in vivo clearance being lower than in vitro
Dry weight, hours of dialysis, and KUF are needed to calculate TMP
  Ultrafiltration rate(ml/hr) = KUF X TMP
Dialysis machine assures the dialysate entering the dialyzer is safe for the patient treatment by:
1. Regulate temperature  
2. Regulate conductivity  
3. Regulate PH  
4. measure pressure and flow
5. Detect a blood leak 6.Alerts the user if something wrong.
7. Bypass the dialyzer if dialysate is not safe 
The movement of water from an area of lower solute concentration to an area of  higher solute
concentration is called osmosis.
Potting soil, casing, fibers, and headers are parts of a dialyzer
The volume of plasma cleared of a given substance per unit of time is the definition of clearance.
Polysulfone, polyacrylonitrile and polymtholmethacrylate are considered to be biocompatible dialyzers.
Dialyzer compliance is the increase in dialyzer blood volume with increase in TMP.
Hollow fiber dialyzer has the least compliance.
Needle size, needle position, stenosis, and swelling are factors affect blood flow
Types of dialysate delivery systems are 1. Batch system, 2. Proportioning system  3. Regenerative system.
Patients with acute renal failure, cardiovascular problems and impaired liver function would tolerate
hemodialysis better if placed on bicarbonate dialysate bath.
Blood pressure, patient well being, and evidence of dehydration or overload are the factors to consider
when establishing a dry weight for the patient. 
The process by which a large amount of fluid is removed at a rapid rate , with a little or no solute removal
except by convection is called isolated or pure ultrafiltration
Charcoal hemoperfusion is utilized to treat drug overdose the amount of solute leaving the blood entering
the dialysate / unit of time called Net flux.
Factors affect the clearance of the dialyzer are blood flow, dialysate flow, temperature, effective surface
area, and concentration gradient.
The primary purpose of the proportioning pump in a dialysate delivery system is to prepare the dialysate
in proper water to concentrate ratio.
Cherry pop appearance of the blood occurs in the presence of hemolysis.
Headache is an early symptom of disequilibrium syndrome
Nausea, vomiting, headache and chest pain are adverse effects of acetate dialysis.
A high venous pressure alarm may be caused by needle placement, infiltration of the venous site, and
clotting of the venous return line.
 Heavy meal during hemodialysis is discouraged Factors affect the clearance of the dialyzer are blood
flow, dialysate flow, temperature, effective surface area, and concentration gradient.
The primary purpose of the proportioning pump in a dialysate delivery system is to prepare the dialysate
in proper water to concentrate ratio.
Cherry pop appearance of the blood occurs in the presence of hemolysis.
Nausea, vomiting, headache and chest pain are adverse effects of acetate dialysis.
A high venous pressure alarm may be caused by needle placement, infiltration of the venous site, and
clotting of the venous return line. 
Factors affect the clearance of the dialyzer are blood flow, dialysate flow, temperature, effective surface
area, and concentration gradient.
The primary purpose of the proportioning pump in a dialysate delivery system is to prepare the dialysate
in proper water to concentrate ratio.
Cherry pop appearance of the blood occurs in the presence of hemolysis.
Heavy meal during hemodialysis is discouraged before or during dialysis to avoid, post dialysis
hyperkalemia, postdialysis hypernatremia, vomiting during dialysis, and hypotension during dialysis.
B12 is the marker for middle molecule clearance.
Urea clearance is enhanced by high blood flow rate and dialysate.
Nausea, vomiting, pericarditis, neuritis and increase in urea and creatinine. Are symtopms and sighs of
inadequate dialysis. 
KT/V more than 1.2 is the standard for hemodialysis prescription to reduce the morbidity and mortality
rate.
Movement of fluid from interstitial spaces to vascular compartment occure as a result of hypertonic
infusion therefore should be avoided during the last hour of dialysis.
Regular use of high sodium dialysate ma predispose to thirst, hypertension, and fluid overload.
Formula for Urea Reduction Ratio (URR) is:  
            Pre Urea - Post Urea   /    Pre Urea  X 100 = URR percent
[65% or more is the standard URR]
 
Molecular weight, blood flow rate, and dialyzer are factors affect solute clearance.
The capability of a dialyzer to remove fluid expressed as ml/hr/mmHg is called coefficient.
Pre-pump arterial pressure reading is reflective of the resistance of the access to the blood flow out of
access.
Hemolysis and vessel wall damages is great if pre-pump arterial pressure is allowed to exceed >-250
mmHg.
A more negative arterial pressure reading is suspected in an access with arterial stenosis.
Chest pain, shortness of breathing and confusion during hemodialysis might indicate air embolism.
 Appearance of cherry red blood, drop in Hct, hypotension and chest pain are sighns of hemolysis.
 Hemolysis can be avoided by checking conductivity, pH, and temperature.
 Number of hollow fibers in dialyzer determines the its surface area.
Graft is a synthetic type of material placed subcutaneously to join artery and a vein.
The correct angle to cannulate the fistula is 25-35 degree
The ideal time for maturation o AV fistula to occur is 6-12 weeks.
Proper maturation of AVF is necessary to avoid infiltration on cannulation and will enhance the life of the
fistula.
Distance between venous and arterial needle tips, presence of stenosis, and direction of the needle tips are
factors affect access circulation.
Access recirculation =
Peripheral BUN – Arterial BUN / Peripheral BUN- Venous BUN x 100
                    <10% is acceptable
Compressing midpoint of AVF/AVG then palpate for continued pulsation is the method to determine the
blood flow withen the access.
The purpose of chest x-ray after insertion of dual lumen catheter into subclavian or internal jugular
catheter is to confirm the position and absence of pneunothorax.
Thrombosis of AVF/AVG is attributable to frequent hypotension, infection, and stenosis.
Venous hypertension, recirculation more than 10%, high intradialytic venous pressure, and increase
midweek urea and creatinine are signs of venous stenosis.
Poor rotation of the site of the needles is the major cause of aneurysms and pseudo aneurysms.
Cannulation of an AVG best accomplished using a 45 degree angle of the needle to avoid destruction
along the surface of the graft.