Lilavati Hospital and Research Centre has a largest dialysis unit in the city of Mumbai which can accommodate

100-120 patients for dialysis from 7.00AM to 11.00PM. The AKD department has provision for 16 latest technology (computerized volumetric) single patienthaemodialysis machines with 12 beds and 4 dialysis chairs. Each bed is provided with a television set. More than one thousand dialysis procedures done each month backed by an efficient Bio-medical engineering team, which helps in servicing the dialysis machines. A call bell system is arranged for in the department whereby a call switch pressed by the patient is indicated on the panel at the main nursing station and immediate attention is given to. Separate washing areas for infected and non-infected patients are provided for reprocessing of dialyses and blood tubing after which they are stored in the respective wash rooms. Infected patients (i.e. Hbs Ag and HIV antibody-positive) are dialyzed on isolated machines.

Provision for dialysing critically ill patients in the 6th floor ICU and 1st floor SICU & ICCU has also been made with 2 haemodialysis machines each placed on the respective floors. Three extra machines are kept as standby machines in case of machine are kept as standby machines in case of machine failure or breakdown. Reverse osmosis (R.O) water is provided for all the haemodialysis machines in AKD as well as in ICUs. The R.O water provided in the AKD department is kept in constant circulation by using a variable frequency booster pump which continuously pumps R.O water through the stainless steel plumbing lines maintaining the circulation of R.O water even if no dialysis machine in functioning. A CRRT ( Continuous Renal Replacement therapy) machine is provided for doing CVVH ( Continuous Veno-Venus Hemo filteration, CVVHD ( Continuous Veno- Venous Hemodiafiltration, SLED ( Slow Continuous Ultra- efficiency Dialysis), SLUF ( Slow continuous ultra-filtration, plasmopherosis etc) procedures in the ICUs. Backed by an excellent team of Urologist and Transplant Surgeons. Well known consultant nephrologist are attached to Lilavati Hospital and Research Centre. 2) The Artificial Kidney unit of intensive care and extracorporeal methods of detoxification was founded in 1988. Department provides emergency assistance of extracorporeal methods of detoxification and other efferent methods of treatment for patients with severe disease (therapeutic, surgical), accompanied by the development of endotoxemia, in patients with acute poisoning and chronic intoxication (alcohol and drug abuse). The department has two candidates of medical sciences. Doctors and nurses have the experience of modern medical care Department offers the following health care treatment in hospital and outpatient: hemodialysis; hemodiafiltration; fractional separation, adsorption, and dialysis of the plasma; discrete plasmapheresis; filtration plasmapheresis; hemosorbtion; ultraviolet irradiation of autologous blood.

3) The Dialysis unit at Bishop Benziger Hospital has 7 modern state-of-the art hemodialysis machines with provision to include a total of 8 more dialysis machines. The unit is fully equipped to deal with all the needs of kidney patients, including ventilator, defibrillator and specially trained dialysis staff. Within a short span the unit has turned into a fully functional round the clock unit, with three shifts per day. In addition, there are facilities for kidney biopsy , CAPD Cather insertion and training for peritoneal dialysis patients. The department of Nephrology and Dialysis unit is headed by Dr. Praveen Namboodiri, M. D.(Medicine), DM.(Nephrology).

Major Equipments
Lithotripter "The state of art Lithotripter for the non operative treatment of all kind of kidney and upper ureteric stones. This procedure is mainly intended for treating stones in the urinary system, stones which are mainly found in the kidney, ureter and the bladder. This medical procedure which is being installed in the department of Urology here is known as Extra Corporal Short Wave Lithotripsy. The most modern sophisticated Lithotripter is an effective and proven treatment modality. Procedure involves no surgery or incision. Procedure involves no General Anaesthesia. Hospital stay for the procedure is only one day. Procedure is painless with absolutely no loss of blood. Success rate for the procedure is more than 90%. Patient will resume normal routine in just three days. Level of Anaesthesia given is minimum.

According to the procedures performed here and the credentials and track record of our Urologist, success rate of the procedure is 90% and if the size of stone is less than 1cm, we can assure a success rate of 100%. Certain cases may need more than one sitting for total breakage of stones. After the procedure is completed and the urologist discharges the patient, he/she is free to make their follow-up with their local physician.

4) The hospital has a well-equipped intensive care unit including:

Defibrillators. Ventilators. Central oxygen and suction equipments. Consultants and specialists of very high standard with well trained nursing staff to manage cases of : o Acute Mt acute pulmonary embolism Arrhythmias. o Acute respirator, liver, and renal failure. o Septicaemia. o Post operative care of major operations.

o o

Multiple trauma patients. Shock.

HIGHLIGHTS

5)

The Nephrology unit deals with the diagnosis and treatment of kidney diseases, electrolyte disturbances and hypertension, and the care of patients requiring renal replacement therapy, including dialysis and renal transplants. We specialize in all aspects of Nephrology, critical care and transplant Nephrology. We provide personalized health care services in all aspects of Nephrology including: haemodialysis, peritoneal dialysis, Critical Care and kidney transplant. The Haemodialysis unit of SUT Hospital is the first in Trivandrum and currently the largest. It has the longest living patient on haemodialysis in Kerala. Patients are referred to the nephrology department for various reasons, such as:

Acute renal failure, a sudden loss of renal function Chronic kidney disease, declining renal function, usually with an inexorable rise in creatinine Hematuria, blood loss in the urine Proteinuria, the loss of protein especially albumin in the urine Kidney stones, usually only recurrent stone formers Chronic or recurrent urinary tract infections Hypertension that has failed to respond to multiple forms of anti-hypertensive medication or could have a secondary cause Electrolyte disorders or acid/base imbalance

Tumors & bleeding from kidneys

FACILITIES
Dialysis Center The unit has six state of the art AK 95 S dialysis machines and performs both Hemodialysis and Peritoneal dialysis. PROCEDURE

Hemodialysis- For hemodialysis, the patient has to undergo a minor surgery by which an AV (arterio-venous) fistula or a shunt will be made. It is via this shunt that the dialysis machine is connected during dialysis. The machine will make the blood free of waste products, excess fluid, and excess body chemicals in addition

to supplying essential hormones. Most people undergo three dialysis sessions each week, for about four hours each time. Peritoneal Dialysis (CAPD) - Peritoneal dialysis, another way of filtering wastes from the body, utilizes the peritoneal membrane lining the abdominal cavity which has a rich blood supply. In people with kidney failure, the peritoneal blood supply contains excessive waste products and fluids. When clean fluid comes into contact with that blood supply, the wastes travel into the cleaner fluid. Kidney Transplant - Kidney transplantation is the best way to treat kidney failure or end-stage renal disease (ESRD). A new Kidney transplant unit is being set up in the super speciality wing. Renal Biopsy Renal Angiogram Hermo Perfusion for detoxification in poisoning

Artificial Kidney Dialysis

When Kidneys Do Not Work When the kidneys do not function properly, dialysis must be performed artificially. Without this artificial kidney dialysis, toxic wastes build up in the blood and tissues, and cannot be filtered out by the ailing kidneys. This condition is known as uremia, which means literally "urine in the blood." Eventually this waste build-up leads to death. Artificial Membranes The artificial kidney uses cellulose membranes in place of the phospholipidbilayer membranes used by real kidneys to separate the components of blood. This cellulose membrane is the same type of membrane that you used in this experiment. Cellulose is a polymer of glucose molecules that form long, straight chains (Figure 8). Parallel chains form linkages with one another by hydrogen bonding to make strong fibers. These fibers in turn interact to form the strong, sheet-like structure of the membrane.

Figure 8
This is a twodimensional ChemDraw representation of a cellulose chain (polymer strand). One of the glucose units is shown in blue.

Note: To view the molecule interactively, please use Chime, and click on the button to the left.

The arrangement of the cellulose fibers may contain gaps, creating tunnels through the membrane (Figure 9). These form the pores through which particles may pass from one side of the membrane to the other. The size of the gaps determines the size of the particles that will be able to pass through the membrane (i.e., the molecular weight cut-off, as described in the Introduction to the experiment in the lab manual). Figure 9
This is a CPK representation of a cellulose membrane. Each cellulose fiber is colored to show the interactions of the fibers to form a sheetlike structure. Note the gaps between fibers that form pores in the membrane. Note: The coordinates for this model were determined using molecular-mechanics calculations, and the image was rendered using the Insight II molecular-modeling system from Molecular Simulations, Inc. (see References).

Types of Artificial Kidney Dialysis

Two types of artificial kidney dialysis are used clinically. Hemodialysis uses a cellulose-membrane tube that is immersed in a large volume of fluid. The blood is pumped through this tubing, and then back into the patient's vein. The membrane has a molecular-weight cut-off that will allow most solutes in the blood to pass out of the tubing but retain the proteins and cells. The external solution in which the tubing is immersed is a salt solution with ionic concentrations near or slightly lower than the desired concentrations in the blood. Recall that if the external concentration of a particular species is lower than the internal concentration, then that species will pass through the cellulose membrane by diffusion into the external solution. In this manner, excess substances in the blood are removed from the body. To maintain the blood's concentration of a species, the external solution is made to have the same concentration of that species as the blood. In such a case, the two solutions are in dynamic equilibrium, and so the blood's concentration does not change. Peritoneal dialysis does not use an artificial membrane, but rather uses the lining of the patient's abdominal cavity, known as the peritoneum, as a dialysis membrane. Fluid is injected into the abdominal cavity, and solutions diffuse from the blood into this fluid. After several hours, the fluid is removed with a needle and replaced with new fluid. The patient is free to perform normal activities between fluid changings. Thus, artificial kidney dialysis uses the same chemical principles that are used naturally in the kidneys to maintain the chemical composition of the blood. Diffusion across semipermeable membranes, polarity, and concentration gradients are central to the dialysis process for both natural and artificial kidneys.

6) Abstract
Twenty-four patients with high microvascular permeability pulmonary edema were initially treated by means of conventional supportive therapy for 112 days. Continued deterioration was treated by predilutional hemofiltration and induced a dramatic improvement in patients.

Survival was 92%. Sieving coefficients for autacoids and middle molecular weight vasoactive peptides involved in the development of high microvascular permeability pulmonary edema were higher than 0.88 indicating that clearing from blood of these peptides during one pass

through the hemofilter is similar to that obtained during one pass through the pulmonary normal microvasculature. Hemofiltration seems to be a significant breakthrough in the treatment of ARDS secondary to severe sepsis.

7)
The Nephrology department looks after patients with kidney problems. It gives them the treatment they need through medicines, tablets, dialysis or kidney transplantation.

What They Do
Everybody normally has 2 kidneys. The kidneys remove waste, like urea, from the blood. They also control the amount of water in our bodies. If the kidneys do not work properly these things are not removed and people get sick. The urea levels go up and making people feel sick. Water also builds up in the body and causes more problems. People with kidneys that do not work come to Nephrology department for treatment.

Diagnosis finding out what the problem is

Diagnostic tests are tests used to give a diagnosis. These tests find out what the problem is. The nephrologists will ask for various diagnostic tests. Different problems need different tests. These diagnostic tests are done in the labs (biochemistry, microbiology, Clinical Pathology etc). After a kidney transplant they look for certain viral infections. This test is done in the molecular diagnostic and research lab of Nephrology. CMV is Cytomegalovirus that can infect the kidney and so cause problems. This monitoring looks for problems eg after the transplants. The levels of immunosuppressive medicines in the blood of transplant patients are looked at. For this, the Nephrology department works with the department of Clinical Pharmacology. These immunosuppressive drugs are used after transplants to keep the kidney working. The tablets suppress bodys immune system. Too much drug makes the patient sick. Not enough tablets and the kidney may stop working. Clinical Pharmacology department tests the amount of medicine in the blood. Depending on the concentration of medicine in the blood the dosage of the tablets is changed.

Biopsies
The Nephrology Department has good equipment to do kidney biopsies. On an average about 1200 biopsies are done every year. The biopsies are done on both native, ie the patient's own kidney, and transplanted kidney.

Dialysis
Some problems are controlled by medicines, diet and life style changes. Life style includes exercising, resting, type of work etc. But, if the kidney is working very poorly, the patient has to have kidney dialysis or a transplant. In dialysis, the patient is connected to a machine. His blood flows through the machine (like flowing through the kidney). The machine removes the wastes and returns the cleaner blood back to the patient. So, these machines, called dialysers, are like artificial kidneys. The Nephrology Department has a dialysis lab called the Artificial Kidney lab or AK lab. The dialysis of the blood (Haemodialysis) is done in the AK lab. Another form of dialysis uses the space inside our abdomen. This peritoneal cavity is where the stomach, liver, gut, colon, kidneys are. This space is used for dialysis and so it is called peritoneal dialysis. Both forms of dialysis are done in the AK Lab.

There are about 26 haemodialysis machines. Dialysis is done by trained haemodialysis technologists. There are also nurses and all are supervised by nephrologists. Minor surgical procedures (small operations) are also done in the AK lab.

CAPD
Patients whose kidneys do not function are said to be in End Stage Renal Disease (ESRD). The only treatment for them is to have a kidney transplant. Until they find the right kidney for transplant, they are kept on dialysis.

Renal Transplantation
Patients who cannot keep coming to the hospital for hemodialysis can have Continuous Ambulatory Peritoneal Dialysis (CAPD). They can come to the AK lab to learn how to do CAPD. Then they do the CAPD themselves at home. One staff nurse and one dialysis technologist do the training and see patients CAPD patients when they come back to CMC. Transplant can only be done when: The patient comes with a suitable donor. The donor is someone who will give one of his or her kidneys to the patient The donor must be medically fit to donate. The donor has to undergo an operation to remove their kidney and must be fit enough for this The tissue matches. There are special markers on our cells and these are tested in the HLA lab. If the donor and the patient have some of the same markers then the tissues match&rdquo When all three are OK then transplantation is done. The transplant surgery is done by the transplant surgeons. After the surgery they will be in the care of the nephrologists again. After the transplant surgery patients go to the renal transplant outpatient services which is three mornings a week.

Patient Education
The patients with chronic renal problems are also taught about life style changes. They are taught ways to look after themselves when they are at home and how to look at their medical problems. E.g., transplant patients and their relatives are trained to measure their blood pressure (BP). This can easily be done at home. They can also keep a record of the BP.

Equipment, Buildings and Facilities

AK Lab: The AK lab has about 26 dialysers (kidney dialysis machines) as there are so many patients that need dialysis. It is also needed at night and weekends for emergency dialysis. The lab has four rooms, three for haemodialysis and one for peritoneal dialysis. Molecular Diagnostic & Research Lab: The department also has a molecular diagnostic & research laboratory. Third floor of O Block. This has microscopes for general kidney pathology tests. Also a fluorescence microscopy for immunofluorescence assays. Immunofluorescence assays are tests to look at cells. Cells will glow in the dark if they have special molecules on them. The laboratory can also do tests using Polymerase Chase Reaction (PCR). PCR is a way to measure very small amounts of DNA, our genes. The PCR makes lots of copies of the DNA. This new larger amount can then be used to do more tests.