DIALYSIS

Dr. Frank Edwin

CAUSES OF RENAL
FAILURE
Diabetes
Untreated high blood pressure
Inflammation
Heredity
Chronic infection
Obstruction
Accidents
1.Renal Failure Diagnosis
Symptoms: Anorexia, Nausea, Vomiting, Oliguria
? Precipitating factors
Signs: Anaemia, Hypertension, Fluid Overload etc
Biochemistry:
Blood
Urea >7mmol/l
Creatinine >120umol/l
Electrolytes: Rising K
+
Creatinine Clearance (GFR <<120ml/l)
Urine: Proteinuria

May be Acute or Chronic
Acute Reversible or Irreversible
2. Treatment Options
No Treatment
Monitoring & Predialysis
Control symptoms
Preserve Residual Renal Function
Control rising BP (Antihypertensives)
Control Renal Bone Disease (Ca
2+
, Vit D)
Prevent/Treat Anaemias (Erythropoietin, Blood)
Dialysis
Renal Transplantation
Dialysis
Definition
Artificial process that partially replaces renal
function
Removes waste products from blood by
diffusion (toxin clearance)
Removes excess water by ultrafiltration
(maintenance of fluid balance)
Wastes and water pass into a special liquid
dialysis fluid or dialysate

Types
Haemodialysis (HD)
Peritoneal Dialysis (PD)
They work on similar principles: Movement
of solute or water across a semipermeable
membrane (dialysis membrane)
Diffusion
Movement of solute
Across semipermeable membrane
From region of high concentration to one of
low concentration
Ultrafiltration
Made possible by osmosis
Movement of water
Across semipermeable membrane
From low osmolality to high osmolality
Osmolality number of osmotically active
particles in a unit (litre) of solvent
Selection for HD/PD
Clinical condition
Lifestyle
Patient competence/hygiene (PD - high risk
of infection)
Affordability / Availability
The process of diffusion


1.



2.

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


3.

Diffusion is complete. Body wastes have diffused through the membrane,
and now there are equal amounts of waste in both the blood and the
dialysis solution.




The process of ultrafiltration in PD
11.


2
2.

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

3.

Ultrafiltration is complete. Water has been drawn through the peritoneum
by the glucose in the dialysis fluid by the glucose in the dialysis fluid. There is
now extra water in the dialysis
fluid which need to be changed.
Haemodialysis
Dialysis process occurs outside the body in a
machine
The dialysis membrane is an artificial one:
Dialyser
The dialyser removes the excess fluid and
wastes from the blood and returns the filtered
blood to the body
Haemodialysis needs to be performed three
times a week
Each session lasts 3-6 hrs
Requirements for HD
Good access to patients circulation
Good cardiovascular status (dramatic
changes in BP may occur)
Performing HD
HD may be carried out:
In a HD Unit
At a Minimal Care / Self-Care Centre
At Home
HD Unit
Specially designed Renal Unit within a hospital
Patients must travel to the Unit 3x a week
Patients are unable to move around while on
dialysis; may chat, read, watch TV or eat
Nursing staff prepare equipment, insert the
needles and supervise the sessions
Minimal / Self-Care Dialysis
Patients take a more active role
Patients prepare the dialysis machine, insert
the needles, adjust pump speeds and
machine settings and chart their progress
under the supervision of dialysis staff
Patients must travel to the unit 3x / week
Patients need to be on a fixed schedule
Home Haemodialysis
Use of machines set up at home
Machines have many safety devices inbuilt
Thorough patient training
Requires the help of a partner at home every time
Suitability is assessed by the haemodialysis team
Ideal for patients who value their independence
and need to fit in their treatment around a busy
schedule
HD Access
2 types of access for HD:
Must provide good flow
Reliable access
A fistula: arterio-venous (AV)
Vascular Access Catheter
AV Fistula
AV Fistula
Vascular Access Catheter
AV Fistula Access
Matures in about 6 weeks
Ensure good working order
Avoid tight clothing or wrist watch on fistula arm
Assess fistula daily; notify immediately if not working
Avoid BP cuff on fistula arm
Avoid blood sampling on fistula arm (except daily
HD Rx)
Avoid sleeping on fistula arm
Grafts (synthetic) may be used to create an AV fistula



Vascular Access Catheter
Double lumen plastic tube
May be placed in Jugular, Subclavian or Femoral
vein
May be temporary or permanent
Temporary awaiting fistula or maturation
Permanent poor vessels for fistula creation e.g.
children and diabetics
Catheters must be kept clean, dry and dressed to
prevent infection
Effects of HD on Lifestyle
Flexibility:
Difficult to fit in with school, work esp if unit is far from home.
Home HD offers more flexibility
Travel:
Necessity to book in advance with HD unit of places of travel
Responsibility & Independence:
Home HD allows the greatest degree of independence
Sexual Activity:
Anxiety of living with renal failure affects relationship with
partner
Sport & Exercise:
Can exercise and participate in most sports
Body Image:
Esp with fistula; patient can be very self conscious about it

Problems with HD
Rapid changes in BP
fainting, vomiting, cramps, chest pain, irritability, fatigue, temporary loss of
vision
Fluid overload
esp in between sessions
Fluid restrictions
more stringent with HD than PD
Hyperkalaemia
esp in between sessions
Loss of independence
Problems with access
poor quality, blockage etc. Infection (vascular access catheters)
Pain with needles
Bleeding
from the fistula during or after dialysis
Infections
during sessions; exit site infections; blood-borne viruses e.g. Hepatitis, HIV
Peritoneal Dialysis (PD)
Uses natural membrane (peritoneum) for dialysis
Access is by PD catheter, a soft plastic tube
Catheter and dialysis fluid may be hidden under
clothing
Suitability
Excludes patients with prior peritoneal scarring e.g.
peritonitis, laparotomy
Excludes patients unable to care for self
Addendum to Principles (PD)
Fluid across the membrane faster than solutes;
therefore longer dwell times are needed for solute
transfer
Protein loss in PD fluid is significant ~ 8-9g/day
Protein loss
s
during peritonitis
PD patients require adequate daily protein
averaging 1.2 1.5g/kg/day
Other substances lost in the dialysate
Amino acids, water soluble vitamins, some
medications and hormones
Calcium and dextrose are absorbed from the
dialysate fluid into the circulation


Addendum to Principles (PD)
Standard dialysis solution contains:
Na
+
132 mEq/l
Cl
-
96 -102 mEq/l
Ca
2+
2.5 3.5 mEq/l

Mg
2+
0.5 -1.5 mEq/l
Dialysis solution buffer:
Sodium lactate
Pure HCo
3
-
HCo
3
-
/Lactate combinations
Lactate is absorbed and converted to HCo
3
-
by
the liver
Dextrose solution strengths: 1.5%, 2.5%, 4.25%
Types
Continuous Ambulatory Peritoneal Dialysis
(CAPD)
Automated peritoneal Dialysis (APD)
CAPD
Dialysis takes place 24hrs a day, 7 days a week
Patient is not attached to a machine for treatment
Exchanges are usually carried out by patient after
training by a CAPD nurse
Most patients need 3-5 exchanges a day i.e.
4-6 hour intervals (Dwell time) 30 mins per exchange
May use 2-3 litres of fluid in abdomen
No needles are used
Less dietary and fluid restriction
CAPD Exchange
APD
Uses a home based machine to perform exchanges
Overnight treatment whilst patient sleeps
The APD machine controls the timing of
exchanges, drains the used solution and fills the
peritoneal cavity with new solution
Simple procedure for the patient to perform
Requires about 8-10 hrs
Machines are portable, with in-built safety features
and requires electricity to operate
PD Access
Done under
LA or GA
DIET
Why is diet important?

Managing the diet can slow renal disease

The need for dialysis can be delayed

The diet affects how patients feel
CONTROLLING YOUR
DIET

Foods to control are those containing:
Protein

Potassium

Sodium

Phosphorous

Fluid
PROTEINS

Animal protein
Dairy (milk, cheese)
Meat (steak, pork)
Poultry (chicken, turkey)
Eggs

Plant protein
Vegetables
Breads
Cereals
MAJOR SOURCES
OF POTASSIUM

Milk
Potatoes
Bananas
Oranges
Dried Fruit

Legumes
Nuts
Salt substitute
Chocolate
SODIUM
Regulates blood volume and pressure


Avoid salt


Use Alternate food seasonings: lemon and limes,
spices, seafood seasoning, Italian seasoning,
vinegars, peppers
FLUIDS
Healthy kidneys remove fluids as urine

Check for fluid and sodium retention


Need to restrict fluid intake
PHOSPHOROUS
Phosphorus is a mineral which combines with
calcium to keep bones and teeth strong

Too little calcium and too much phosphorus

Need to control the phosphorus in the diet

Need to take a phosphate binder or a calcium
supplement
VITAMINS
Folic acid

Iron supplements

Do not take OTCs without consulting the
doctor.
MANAGING YOUR DIET
INDICATORS OF GOOD CONTROL:

Weight loss or gain

Blood pressure

Swelling of hands and feet

Blood samples
LAB MONITORING
Haemoglobin
Albumin
Calcium
Phosphorus
GFR
(24 hour urine)

Sodium
Potassium
Urea
Creatinine

Lifestyle Changes with PD
Flexibility
Can be performed almost anywhere
Least impact on work / school life (esp APD)
Travel
Dialysis supplies can be delivered to most parts of the
world; travel more flexible. APD machines are portable;
will fit into a car boot, can be carried by train/air
Responsibility
Requires more responsibility from patient but more
independence
Lifestyle Changes with PD
Sports/Exercise
Most are possible
Advice on swimming, lifting, contact sports
Sexual Activity
May affect relations based on patient anxiety
Delivery & Storage of Supplies
Home delivery and storage
A months supplies 40 boxes; space to store
Specially recruited and trained delivery staff

Problems with Treatment
Monotomy of treatment
The treatment never goes away against days off with HD
Body Image Problems
Esp with a permanent catheter
Abdominal stretching
Fluid Overload
Much less a problem than with HD
Dehydration
Less common than fluid overload
Abdominal Discomfort
Bloated feeling
Problems with Treatment
Poor drainage
Common problem esp with new patients
Fibrin plug
Catheter displacement
Leakage
Fluid may leak around catheter exit site. (May leak
into scrotum)
Stop PD temporarily
Resite catheter (use new one)
Infections
Exit site infections
Tunnel infection
peritonitis
Problems with Treatment
Hernia
Aggravation of pre-existing herniae (repair)
Evolution of new herniae
Declining effectiveness of the peritoneum
e.g. repeated infection
Effect of glucose in the dialysis fluid
Comparison of Dialysis Treatment Options
PD Unit HD Home HD
Home Dialysis

Convenient Sessions

Socializn with other CRF pats

Home Equipment/Supplies

Special diet/fluid allowance

Sports/exercises participation Most Most Most
Full day activity -work/school

Not alwys

Direct assistpartner/family

Travel
Delivery of
supplies to most
destins easy.
Some notice req
Prior
arrangements
must be made
well in advance
Prior
arrangements must
be made well in
advance