Dialysis

Basic Training on
Hemodialysis Machines
Contents
Introduction
Anatomy & Physiology
History
Principle of Operation
Maintenance
Introduction on Dialysis
Dialysis is a treatment for people in the
acute or chronic renal insufficiency (kidney
failure). This treatment cleans the blood and
removes wastes and excess water from the
body . Normally, this work is done by
healthy kidneys.
Effects of Dialysis
Dialysis will not cure the Kidney
disease,but it does some of the work of
healthy Kidney.
Dialysis need to carried out for a life time
until
Kidney
transplant
is
done
successfully.
Kidney
No. of Kidneys
: Two
Shape
: Bean shape
Weight
: 120-170 grams
Size
: 11-13cm in length
Breadth
Thickness
Location
either
5 - 7cm
2.5 - 3cm
: The kidneys are located on the
side of the spine at approximately
above 6-8 cm waist level.
Kidney Functions
A quick summary of the functions of the kidney:
Removes waste products from blood.

Removes excess fluid.( Concentration & Dilution of
urine).
Regulates Acid-Base Balance.

Regulates Electrolyte Levels.
Regulates Blood Pressure.
Regulates Red Blood cell production.
Causes of Kidney failure

Diabetes.
Drugs (Heavy Dosage)
Snake bite.
Family history.
High Blood pressure.
Unknown factors.
Symptoms of Kidney Failure

Generally feeling ill
Lacking interest in everyday activities; Difficulty in
concentrating or relaxing.
Tiredness and loss of energy.
Shortness of breath.
Altered taste sensation.
Increased night-time urine production.
Loss of Appetite and nausea or vomiting.
Swelling of the legs.
High Blood pressure
Symptoms of Kidney Failure

Case studies report that in some cases, people may
not have any symptoms to report that their kidneys
are not working well.
Recommendations:
Regular physical examinations, with blood test and
urine tests can facilitate earlier identification.
Test results may show signs of kidney disease even
when a patient feels fine.
Renal Replacement Therapy
Hemodialysis
Peritoneal dialysis
Renal
Transplant
10
Renal Transplant
Transplant is the surgical implantation
of a healthy kidney from a donor to a
patient.
11
Hemodialysis
In Hemodialysis, blood is passed through
an Artificial kidney machine to clean it.
Hemo means
Filtration
Blood,
Dialysis
means
12
Peritoneal dialysis
Peritoneum, the inner lining of the
abdomen
is
a
semi-permeable
membrane, that allows the removal of
waste materials & excessive water
from the patient body.
13
History & Development of Dialysis

Therapy
The early Egyptians explored the internal body organs
& cavities of the human anatomy to understand its
Physiological functions as early as 3500BC
In 1600,Sir William Harey recorded the human
circulatory system and encouraged fellow scientists to
further investigate blood and blood related diseases
14

Therapy
Thomas Graham from London, Discovered that
vegetable parchment behaved as a Semi
permeable membrane. In 1861. Graham called
the process of selective diffusion "DIALYSIS"
derived from a Greek term meaning a
"Loosening from something else", hence
Separation or Filtration.
15

Therapy
Kolff & Berk developed the first clinically emodialyzer in
1943
There are many traditional methods of treating kidney
diseases before 1950 such as soaking the patient in
warm water ,Vena-section (Bleeding of the veins) and
many others but with out true success.
16

Therapy
In 1954, the first dialyser was introduced by Thomas
Graham and thereafter created much interest in
Kidney failure and its treatment. From the size of a
large bed then to the size of a domestic water filter
today, dialysers have been improved tremendously in
its efficiencies, compatibility and size. This in turn
has greatly changed the treatment modalities and
outcomes.
17

Therapy
In 1964 Mr. Albert babb, a Biomedical Engineer, devised a
system to Mix Dialysate solution for the Dialysis
Treatment at the request of Dr. Scribner. The principle of
this system is still being used today
The Arterio-Venous shunt was soon replaced by an
Arterio-venous Fistula by joining an artery to a vein. As the
arteial Blood rushes along in the vein ,thus changing the
characteristics of the vein to that of an artery . The
"Reinforced" Vein could then be repeatedly cannulated for
Hemodialysis Treatment.
18

Therapy
Dr Belding Scribner carried out the first HEMODIALYSIS treatment on
Mr. Clyde Shields in 1960. The first Arterio-venous shunt was
devised to function as a permanent Vascular access for the procedure
of Hemodilaysis. Mr.Wayne quinton, an Engineer assisted Dr.Scribner
by inventing the blood access for the repeated Hemodialysis
treatment
In 1970's & 80's,Hemodialysis became a widely acceptable method of
treatment for acute & end stage renal failure. Then a lot of
Hemodialysis machine manufacture are came in to the market with
different principle of techniques.
19

Therapy
Apart from HEMODIALYSIS,other special treatment are used for the Renal failure patient
due to some clinical reasons in ICU, ICCU & other critical areas, They are: Peritoneal dialysis
CAPD(Continuous Ambulatory Peritoneal Dialysis)
CRRT(Continuous Renal Replacement Therapy)

CCPD (Continuous Cycling Peritoneal Dialysis)
CAVH (Continuous arterio Venous Hemofiltration)
CVVH (Continuous Veno Venous Hemofilltration)
CAVHD (Continuous Arterial Venous Hemodialysis)
CVVHD(Continuous Veno Venous Hemodialysis.
20

Therapy
With the advancement of Bio-medical
Technology,
the
Hemodialysis
machine
Manufactures introduced new and improved
machines for Hemodialysis treatment.
Treatment time was shorten from 8hours to
2hours ( as in High flux dialysis).
21

Therapy
Advance Treatment Parameters are introduced by some of the HDU
Machine Manufacture using the technology Development in the BioMedical Field.
High Flux Dialysis.
Single needle dialysis.
Sequential therapy.
Ultra filtration profile.
Sodium Profile.
Automatic NIBP measurement during treatment
with alarm limits.
OCM
22
Treatment options for Patients with Kidney failure
Hemodialysis
At
Home
In a
HDU
centers
Peritoneal Dialysis
At
Home self
Dialysis
In Dialysis Unit
Or
ICU,ICCU,
Pediatric Dep
IPD
Self
Dialysis
Self &
Nurse
assisted
Dialysis
Living Related
Donor Kidney
IPD
CAPD
CCPD
Kidney Transplantation
CAPD
CCPD
Unrelated
Cadaver
Kidney
IPD- Intermittent Peritoneal Dialysis
CAPD- Continuous Ambulatory Peritoneal Dialysis.

CCPD- Continuous Cycling Peritoneal Dialysis
23
Hemodialysis
Hemodialysis means The cleaning of the blood.
90% of end stage renal failure patient will go for
Hemodialysis Treatment.
Hemodialysis process is based on two function
Removal of waste product by Diffusion &
Convection.
Removal of excess water by Ultra filtration.
24
Hemodialysis
Hemodialysis treatments are carried out

in the following Health Care Centers.
Hospital (Dialysis unit, ICU & CCU )
Hemodialysis centers.
Home Dialysis ( Mostly for VIP,Hepatitis
& HIV patients)
Diabetic Centers.
25
Hemodialysis
Disadvantages of Hemodialysis
Patient needs to visit the center & spend five hours
every three times a week.
Expensive.
Patient cant lead a standard life due to the frequent
visit to center
Infection during the treatment.
26
Peritoneal Dialysis
Peritoneum is a membrane that covers the Organs
in the Abdominal Cavity.
Peritoneal Dialysis Involves putting Dialyzing fluid

in to the Peritoneal cavity.
As the blood flows past the Peritoneal
Membrane,waste products are taken out of the blood
& Into the Peritoneal cavity which is called here as
Diffusion.
27
Peritoneal Dialysis
A person on PD has a Catheter (Approximately 6cm in
length) in the lower part Abdomen all the time which is fix by
a Doctor by a small operation.
Dialysis fluids are then regularly introduced into the
Abdomen & allowed to remain for a time period. Then the fluid
will be drained & again filling process will take place.
The cycle of Fill,Dwell,Drain & Treatment time will differ
from patient to patient.
Mostly 80% of Peritoneal Dialysis will be done at Home
28
Types-Peritoneal Dialysis
Two Major Peritoneal dialysis
(1) CAPD- Continuous Ambulatory Peritoneal Dialysis.
(2) CCPD- Continuous Cycling Peritoneal Dialysis
29
Types-Peritoneal Dialysis
Continuous Ambulatory Peritoneal Dialysis
CAPD is the only type of PD that is done without Machines. Patient
can do it themselves.
Dialysate bag fixed in the stomach which connected to Peritoneal
cavity through the catheter.A new bag will be changed each time after
it drain the waste from Peritoneal cavity.
CAPD Treatment is four or five times a day, dialysate (1.5-2 L)
remains in Peritoneal cavity for about four to six hours each time.
While the dialysate is in Peritoneal cavity, Patient can go to usual
activates.
30
Types Peritoneal Dialysis

Continuous Cycling Peritoneal Dialysis
CCPD done at home using a special machine called a Cycler.
CCPD is similar to CAPD except a number of cycles (exchanges)
occur.
Each Cycle usually lasts 1 Hours & exchange done throughout
night while patient in sleep.
31
Disadvantage Peritoneal Dialysis

Displacement
or Plugging
Abdominal cavity
of
the
Catheter
in
Infection as a result of contamination of the

catheter, tubing or solution.
Breathing Difficulties ( Increased fluid in the
Abdominal cavity)
Pain ( When Fluid fill& Drain)
32
Transplant is the surgical implantation of a healthy
kidney from a donor to a Patient. The procedure is
carried out after an extensive examination &
Investigation have been performed on both the donor &
Patient. To ensure the best possible outcome & to
Minimize any complication to both of them.
Only one kidney is removed surgically from the donor &
Placed in the lower part of the Patient Abdomen. After
transplant patient need to be on special life-long
medication to prevent rejection.
33
Types of Kidney Transplant
Living Related Individual :Close Family Members are Potential Donors. Potential donors are required to under
go extensive examination, Investigation & Counseling . The best matched individuals
will be considered.
Living Non-Related Individual:-
Transplant of this nature is not carried out in Malaysia but are performed in some
foreign countries. These transplant are commercial in nature. The Transplant
procedure are same as above.
Cadaver:Cadaver transplant involves the harvesting of organs from a donor who is certified as
Brain Dead. Written Family consent is further required. The Transplant procedure
are same as above.
34
Basic Anatomy& Physiology Renal

System
35
Basic Anatomy& Physiology

Renal System
Normal human being have two
Kidneys, each about 10cm (4 inch)
long.
Location:Back of the body
behind the lower ribs.
Function:A healthy kidney is
basically a filtering system. In fact,
each kidney is made up of about a
million
filtering
units
called
Nephrons.
36
Roll of kidney In Human body
1. Acts as a filter system.
2. Gets rid of waste products.

3. Balances the body's fluid content.
4. Activates vitamin D to maintain healthy bones.
5. Produces Hormones that control Blood pressure.
6. Produces the hormone Erythropotin to help make Red Blood cells.
37
Why Kidney is Required

Removes waste products from blood.
Removes excess fluid.
(Concentration & Dilution of urine)
Regulates Acid-Base Balance.
Regulates Electrolyte Levels.

Regulates Blood Pressure.
Regulates Red Blood cell production.
38
Flow of Blood to the Kidney
Work procedure of Kidney

As blood passes through the kidneys, it is "cleaned" - the bodys waste
products and excess fluid are removed.
These waste products, along with the excess fluid, are then sent through
the ureters to the Bladder.
Then they are passed out of the body as Urine.
39
Longitudinal section of the Kidney
Renal Artery
Renal Vein
Urethra
Nephrons
Cortex
Medula
Calix
Renal Pelvis
40

Renal Artery
One quarter of the total blood output
from the heart comes to the kidneys
along the Renal Artery
Two
renal arteries arise from the abdominal section of the

aorta, each artery supplies a lobe of the kidney.
The incoming artery divides into four or five branches,
eventually forming arterioles, each of which leads to the compact
ball of capillaries called the Glomerulus.
41

Renal Vein
Cell waste is discharged in the veins for excretion
through the kidneys.
The body circulates about 425 gallons of blood through
the kidneys on a daily basis, but urine conversion from the
blood is total depended on the body fluids & Waste.
The remainder goes back for circulation through the Renal Arteries.
The capillaries eventually re-converge into small venules which lead to the
larger renal veins.
There are two renal veins, one extending from each lobe of the kidney, and
opening into the vena cava.
42
Longitudinal section of Kidney

Nephrons
Each kidney contains about a million
filtering units (Nephrons).
A Nephron begins as a hollow-walled,

bowl-like structure (Bowman's capsule),
which contains a tuft of blood vessels (the
Glomerulus).
The Nephron is the functional unit of the kidney.
Each Nephron has two main parts.
Glomerulus's & Tubule
43
Longitudinal section of Kidney& Nephron
44
Glomerulus's
The Glomerulus consists of a network of thinwalled capillaries closely surrounded by a pearshaped epithelial membrane called Bowmans
Capsule.
Blood enters the capillary tuft through an afferent arteriole. Because of the blood pressure
in the capillaries & because of their thin walls, Ultra filtration occurs.
Water & Solutes of molecular weight less than 68,000 d(Albumin) pass freely into
Bowmans Space. Such solutes include Electolytes & Urea, creatine ,uricacid, glucose,
aminoacids & Low molecular weight proteins. This Fluid is the Glomerular Filtrate Rate
(GFR).
A man of Average size has about 180L of filtrate per day, or 125ml/min.
Ninety nine Percent of this filtrate is reabsorbed in the Tubules.
45
Function of Glomerulus & Tubules

Main functions:
Reabsorption
Secretion
Of the180 L of Glomerular filtrate each

day,about 2L remain as the final Urine.
Rest of the water is reabsorbed along with Glucose,amino& other electrolytes.

The remaining filtrate becomes concentrated & begins to resemble the ultimate urine as it
progresses down the tubule.
Final adjustments of water-to-solute load occur in the distal tube.
Tubules conserve water & Electrolytes by returning them to the blood.
46
How Urine is produced in the Kidney

Blood enters the glomerulus at high pressure.
Much of the fluid part of blood is filtered
through small pores in the walls of the blood
vessels in the glomerulus and the inner layer of
Bowman's capsule, leaving behind blood cells and
most large molecules, such as proteins.
The clear, filtered fluid (filtrate) enters
Bowman's space (the area between the inner and
outer layers of Bowman's capsule) and passes
into the tube leading from Bowman's capsule.
47
In the first part of the tube (proximal

convoluted tubule), most of the sodium,
water, glucose, and other filtered substances
are reabsorbed and ultimately returned to the
blood.
The kidney also uses energy to selectively

move a few large molecules, including drugs
such as penicillin but not proteins, into the
tubule.
These molecules are excreted in the urine

even though they're too big to pass through
the pores of the glomerular filter. The next
part of the nephron is the loop of Henle.
48
As the fluid passes through the loop,

sodium and several other electrolytes
are pumped out and the remaining fluid
becomes increasingly dilute.
The dilute fluid passes up the next part

of the nephron (distal convoluted
tubule), where more sodium is pumped
out in exchange for potassium.
Fluid from several Nephrons passes

into a collecting duct.
49
In the collecting ducts, the fluid can

continue through the kidney as dilute
urine, or water can be absorbed from the
urine and returned to the blood, making
the urine more concentrated.
Through hormones that affect kidney
function,
the
body
controls
the
concentration of urine according to its
need for water.
50
Types of Kidney Failure
Acute Renal Failure
Chronic Renal Failure
End-Stage Renal Failure
51
Acute Renal Failure

ARF is the rapid deterioration of renal function that is usually reversible if diagnosed &
Treated early.
Prerenal
It causes reduced
blood flow to the
Kidney sufficiently to
impair function.
Symptoms are Heart
Failure, Blockage of
Renal arteries
Intrarenal
It is caused by direct
damage to Kidney
tissue. Which Causes
75% of Renal Failure.
Postrenal
Blocks the urine flow

to the kidney.
Obstruction may be at
the Ureter,Bladder or
Urinary tract.
52
Chronic Renal Failure

This is progressive irreversible loss
occurring over many months or years.
of
function
As the number of functional nephrons decreases each

remaining unit must clear an increasing solute load.
Eventually the limit to the amount of solute that can be
cleared is reached & the concentration in body fluids
will rise.
53
End-Stage Renal Failure

Treatment for ESR failure is Kidney
transplant or Hemodialysis or Peritoneal
Dialysis
54
Cause of Kidney Failure

There are a number of known causes of kidney failure but in quite
a lot of people the cause is never found. The commonest causes
are diabetes, high blood pressure and a painless inflammation of
the kidneys called glomerulonephritis. Resulting in a progressive
loss of the filtering units (Nephrons) in the kidney.
Other common causes are the inherited condition of cysts in the

kidneys (polycystic kidney disease); repeated kidney infections or
kidney infections (pyelonephritis) in childhood; and obstruction to
the urine flow.
55
What Happen if Kidney Fails?

If the kidneys are damaged, they may carry on producing
urine but become less efficient at removing waste
products from the blood.
Instead, the waste products continue to circulate and
build up in the bloodstream.
At the same time, without the hormones that a healthy
kidney would produce, the bone marrow becomes less
efficient at producing red cells, so anaemia develops.
56
What Happen if Kidney Fails?

Once the kidney problem has been diagnosed, regular
blood tests will be required. Treatment with a variety of
drugs may be needed, for example, to control blood
pressure.
The treatment may be changed quite frequently based
on the results of your blood tests.
57
Kidney Diagnosis
Procedures to diagnosis disorders of the kidneys and urinary tract may
include urine analysis, blood tests that reflect kidney function, imaging
procedures,tissue and cell sampling.
Urine Analysis:Protein, Glucose, Ketones, Blood in the urine, Nitrites,acidity,
concentration of urine & Urine cultures.
Common blood tests that detect and measure this include the BUN (B-U-N or
blood urea nitrogen) and creatinine
Imaging Procedures:An x-ray of the abdomen can show the size and position of the kidneys, but an
ultrasound scan is usually better for this purpose.
58
Kidney Diagnosis
Ultrasound scanning uses sound waves to produce an image of
anatomic structures.
The technique is simple, painless, and safe. It can be used to study
the kidneys, ureters, and bladder, with the added advantage that
good pictures can be obtained.
Ultrasound scans provide some indirect information about kidney
function.
Ultrasound scanning is an excellent way to estimate kidney size and
to diagnose a number of kidney abnormalities, including bleeding in
the kidneys. Ultrasound scanning is used to locate the best place for
a biopsy.
59
Kidney Diagnosis
Kidney Function Tests:Kidney function can be assessed by analyzing a blood sample as well
as a urine sample. The kidney filtration rate can be estimated by
measuring serum creatinine, a waste product. The level of blood urea
nitrogen (BUN) can also indicate how well the kidneys are
functioning, although many other factors can alter this level.
Creatinine clearance a more accurate test can be approximated from
a blood sample, using a formula that relates the serum creatinine
level to a person's age, weight, and sex; determining it exactly
requires a 24-hour urine collection.
60
Kidney Diagnosis
Computed tomography (CT) is more expensive than
ultrasound scanning and intravenous urography but has
some advantages.
Because CT scans can distinguish solid structures from

those that contain liquids, they're most useful in
evaluating the type and extent of kidney tumors or other
masses distorting the normal urinary tract.
61
Kidney Diagnosis
Angiography, which involves injecting a radiopaque
substance into an artery, is the most invasive of all
kidney imaging procedures and is reserved for special
situations, such as when a doctor must evaluate the blood
supply to the kidneys.
In many hospitals, conventional Angiography is being

replaced by spiral CT techniques.
Complications of angiography may include injury to the
injected arteries and neighboring organs, reactions to the
radiopaque substance, and bleeding.
62
Kidney Diagnosis
Tissue and Cell Sampling
A kidney biopsy, in which a tissue sample is removed and examined
under a microscope, may be performed so that a doctor can establish
a diagnosis and observe the progress of treatment.
A needle biopsy, in which the needle is inserted through the skin, is
often part of the evaluation of kidney failure, and biopsies of a
transplanted kidney are performed frequently to look for signs of
rejection.
For a biopsy of a person's own (native) kidney, the person lies face
down, and a local anesthetic is injected into the skin and muscles of
the back over the kidney.
63
Kidney Diagnosis
Tissue and Cell Sampling
The biopsy needle is inserted and tissue is removed for
microscopic examination.
For a biopsy of a transplanted kidney, the needle is inserted
directly through the abdominal wall.
Ultrasound is used to help guide the needle to an abnormality.
64
Renal Replacement Therapy

Hemodialysis
Peritoneal dialysis
Kidney Transplantation.
65
Principles Of Hemodialysis
66
What is Hemodialysis?
Hemodialysis Means The cleaning of the Blood.
Hemo Means Blood & Dialysis means cleaning.
Hemodialysis is a process of
dialysis which requires the
transport of blood and a dialysate fluid on either side of a SemiPermeable membrane, to effect the diffusion of toxic metabolites
& transport of water across the membrane to waste.
The Hemodialysis process consists of two part
Removal of waste products by Diffusion & Convection known as

CLEARENCE.
Removal of excess of water,by Ultra filtration.
67
Diffusion
Higher concentration
Lower concentration
Balance concentration
Diffusion is the movement of solutes (dissolved solids ) in the blood form a

Higher to lower concentrated across a semi-permeable membrane.
The removal of waste products by diffusion occurs when there is a
concentration gradient between the blood & the dialysate; the blood contains
a high concentration of waste products where as the dialysate does not
contain any.
68
Diffusion
Apart from removing waste products,Diffusion also
assists in maintaining the bodys essential mineral salts.
The blood with higher mineral salt concentration is
removed while blood with lower concentration is
corrected with the transfer from the dialysate.
Diffusion is dependent on concentration Gradient &
Temp.
69
Convection
SemiPermeable
Membrane
Blood
Dialysate
Blood
Dialysate
Convection is the movement of solutes that is able to pass through the

Semi-permeable membrane, by the following the flow of Ultrafiltration.
The Quantity of waste products removed is depends on the molecular

size of the waste,pore size of the semi-permeable membrane & the
Negative pressure applied (TMP).
70
Semipermeable
membrane
Ultrafiltration
Flow
direction
Negative
Direction
High
Concentration
Low
concentration
- Movement of solvents (water) by pressure variance.

In the dialyser, the Blood & Dialysate flows within their compartment in opposite
direction and is separated by a thin layer of Semi-permeable membrane
Due to Negative (Sucking) pressure applied on the dialysate side of the Semipermeable membrane,water from blood compartment is drawn into the dialysate side.
This Movement of water is known as Ultrafiltration.
71
About Dialyser
72
How it Works with Artificial Kidney
During Hemodilaysis Patient blood is removed with a needle & Circulated

outside the body & cleaned by running it through an Artificial kidney
(Dialyser) using a Hemodialysis machine .
The Blood is then returned to the body through a second needle.
The Artificial Kidney contains a chamber which is divided by a thin semipermeable membrane.
On one side of the membrane is a special solution called the Dialysate.

On the other side is the blood which needs to be cleansed.
Waste products such as urea & creatinine are small in size & will pass
through the membrane and be removed.
Waste products are removed from the blood through three chemical
process: Diffusion,Convection & Ultrfiltration.
73
About Dialyser
Dialyser is the Filtering unit of the Hemodialysis treatment.
The Dialyser possess 4 ports as follows:-
1.
Arterial Blood port.
2.
Venous Blood port.
3.
Venous Dialysate port.
4.
Arterial dialysate port
74
Dialysate Solution
There are five important Compounds in Dialysate solution
1. Sodium chloride.
2. Sodium Bicarbonate or Sodium Acetate.
3. Calcium Chloride
4. Potassium chloride
5. Magnesium Chloride.
There are two types of dialysis solution commonly used
1. Acetate Dialysis
2. Bicarbonate Dialysis.
75
Acetate Dialysis
The Acetate is Physiologically compatible with blood & is
Metabolized to Bicarbonate in the liver without incident in stable
Patient.Acetate is mixed with water in a proportioning system in
ratio of 1part of acetate with 34 Part of water to form a Dialysate.
Advantage of Acetate:Many patients have been treated with this type of dialysis for
many years with few problems.
Concentrate is stable during storage & is not prone to bacterial

contamination.
The Delivery systems are simpler & Less costly compared to
Bicarbonate delivery system. Only one concentrate is used in
Acetate dialysis
76
Acetate Dialysis
Disadvantage of Acetate: Patient serum Bicarbonate may decrease early during dialysis;
usually it then corrects after a period of time.
Acetate accumulation contributes to Cardiovascular instability
& Hypo tension, as well as Nausea,vomiting & Post dialysis
Fatigue.
Not Suited for rapid,high-efficiency dialysis or High-flux
dialysis.
77
Bicarbonate Dialysis
To over come the Patient problem in Acetate Dialysis, Bicarbonate dialysis
has been introduced. Calcium & Magnesium will not remain in a solution
with bicarbonate because of the low Hydrogen ion content. To solve this
two separate concentrates are used.
A (acidified) concentrate chemical contains most of sodium,calcium,
magnesium, & Potassium, chloride & Small amount of acetic acid to maintain
low pH.
B (Bicarbonate) Contains Sodium Bicarbonate. Some system includes part
of the sodium chloride to raise the conductivity to monitor the concentrate.
Advantage of Bicarbonate:Solves the patient problems in acetate.
78
Bicarbonate Dialysis
Disadvantage of Bicarbonate: Delivery system is more complex, since it must mix & monitor
three liquids instead of only two.
B concentrate is not stable,if mixed with another container.
When Bicarbonate powder is mixed it should be keep in a tightly

closed container.
Bicarbonate is very susceptible to Bacterial contamination.
Bicarbonate precipitation will occur if machine is
well.
not cleaned
79
Principle of Hemodialysis
80
Extracorporeal circuit
Arterial Circuit.
Blood from the artery
Arterial Pressure Monitor.

Blood Pump.
Heparin Pump.
Venous Circuit
Venous Blood port.
Air detector
Venous pressure
Venous line clamp.
Blood/Saline detector.
Blood to the Venous.
81
Dialysate Circuit
Fresh Dialysate Circuit
RO treated water mixed with A& B
Concentrated solution (34:1:1.83) ratio.
Dialysate Heated to blood temp 37C.
Degassing & Flow Balancing circuit.
Dialysate Measuring & Monitoring.
Bypass circuit incase of dialysate alarm.
If No Dialysate alarm Dialysate will pass
through the Venous Dialysate port in the dilayser.
Spent Dialysate Circuit

Blood leak detector.
Negative pressure Control Circuit.
Flow Balancing & UF Control Circuit.
Spent Dialysate to Drain
82
The Tasks of Hemodialysis

Machine.
To Prepare Fresh Dialysate.
To Control & Monitor the Dialysate to the Dilayser.
To Control & Monitor the Ultra filtration rate.
To Control & Monitor the Spent dialysate (Negative pressure)
To Control & Monitor the Extracorporeal circuit.
83
The Tasks of Hemodialysis

Machine.
84
To Prepare Fresh Dialysate.
The Tasks of a Hemodialysis Machine.

Heating.
Degassing
Mixing.
85
To Control & Monitor the Dialysate to the Dilayser.
86
The Tasks of a Hemodialysis Machine

To Control & Monitor the Ultra filtration rate.
Ultra filtration is removal of waste from the patient blood.
UF :- Appling a Negative pressure across the membrane
with reference to the UF Goal (Target of water removal
from the patient).
Most of the Hemodialysis Machine Manufacture will
design the below types of UF system:Open Systems
Closed System.
87

Pre-Pump 500 ml/min
Flow meter (A)
Ultra-filtration (OPEN SYSTEM)
To Patient
Flow
controller
Post-Pump 500ml/min
Dialyser
From Patient
Flow meter (B)
In open system, Pre-pump will run with the feed back from the flow
meter(A) which was controlled by Flow controller circuit. Post-pump
will run with the feed back from the flow meter (B) which was
controlled by Flow controller circuit, but post-pump may run faster
than Pre-pump based on the UF Goal set by the Patient.
88

Pre-Pump 500ml/min

Flow meter (A)
To Patient
Flow
controller
Post-Pump
510ml/min
Dialyser
From Patient
Flow meter
(B)
10ml
In open system, Pre-pump will run with the feed back from the flow
meter(A) which was controlled by Flow controller circuit. Post-pump
will run with the feed back from the flow meter (B) which was
controlled by Flow controller circuit, but post-pump will run faster
than Pre-pump to get the 10ml from the patient.
89

Pre-Pump 510ml/min
Flow meter (A)

10ml
To Patient
Flow
controller
Post-Pump 500ml/min
Dialyser
From Patient
Flow meter (B)
In open system, if the Pre-pump faster than post pump due some
failure. Then there is a risk of reverse ultra-filtration.
So the open system will have high Failure rate in UF accuracy. UF
REMOVAL INACCURATE IN OPEN SYSTEM.
90
Ultra filtration (Closed SYSTEM)

500ml/min
Spend Dialysate to Drain

To Patient
Balancing
Chamber
Fresh Dialysate to BC
Dialyser
From Patient
500ml/min
In closed loop system, Dialysate Inflow & Outflow to the dialyser is

Maintained by a Balancing Chamber system which is more accurate system
in flow balancing. So there is no possible of Reverse Ultra-Filtration.
There is very less possibility of UF Inaccuracy.
91
Ultra filtration (Closed SYSTEM)

500ml/min
Spend Dialysate to
Drain
To Patient
Balancing
Chamber
Fresh Dialysate to
BC
Dialyse
500ml/min
r
From Patient
(10ml/min)
To Drain
UF Pump
In closed system, UF goal is achieved by a UF pump. For example if UF rate is

10ml/min then UF pump will pump out 10ml/min waste from the patient blood. Closed
system is a problem less system in Achieving the UF Goal. Most of the Manufactures
follow the close loop design only.
92

How Balancing chamber works?
Spend Dialysate to Drain
To Patient
Balancing
Chamber
Fresh Dialysate to BC
Dialyser
From Patient
93
To Control & Monitor the Spent dialysate (Negative pressure)
Negative pressure pump is used to remove the Spent Dialysate from the dilayser.
Negative pump is controlled & monitored by the flow control circuit considering the
calculation of UF target .
Finally before Draining, Spent dialysate fluid will be passed through the Blood Leak
sensor to check for any blood leakage from the dialyser.
94
How Important is Blood leak Detector

Blood leak detector is very important in the Hemodialysis treatment to detect the
ruptures of any dialyser fiber.
If Dialyser fiber ruptures blood will mix with the spent dialysate & it will passes into
the machine.
Once the Blood leaks, the Blood leak detector will detect the blood in the Dialysate
and Blood leak alarm will be triggered.
Once Blood is triggered, following will happen in the machine:1) Blood pump stopped, 2) Venous line clamped, 3) Dialysate flow will bypass the
dialyser to avoid further blood leak into the machine.
95
Arterial Circuit.

Blood Pump.
Heparin Pump.
Blood flows from the artery needle
from the patient through the arterial
blood circuit to the Dialyser.
Arterial chamber is used to measure
the pressure in it & to adjust the level
of the blood in the chamber.
Machine has the alarm limit for
High/low Arterial pressure, based on
the actual arterial pressure.
96
Arterial Circuit.

Blood Pump.
Heparin Pump.
Blood pumps used to

pump the blood from
artey & to venous.
Blood pump stops for
the following alarms.
Arterial Pressure,venous
pressure, Air detector,
Blood leak detector.
97
Arterial Circuit.

Blood Pump.
Heparin Pump.
Heparin Pump is used to

pump the Heparin into the
blood to prevent coagulation
(Blood clots) in the Blood
circuits.
Finally blood enters into the
Dialyser in the Arterial blood
circuit.
98
Venous Circuit
Venous Blood port.
Air detector
Venous pressure
Venous line clamp.
Air detector is based on

Ultrasound principle.
If Air is in the blood, then

venous line is clamped &
Blood pump stopped.
99
Venous Circuit
Venous Blood port.
Air detector
Venous pressure
Venous line clamp.
Venous
pressure
depend on the venous
line of the Patient.
Monitor
High/low
alarm limit.
100
Venous Circuit
Venous Blood port.
Air detector
Venous pressure
Venous line clamp.
Venous line clamp is used

to clamp the blood flow to
the patient for the
following alarm condition
Arterial Pressure, Venous
pressure, Blood leak, Air
detector.
101
Venous Circuit
Venous Blood port.
Air detector
Venous pressure
Venous line clamp.
Finally blood pass through

the Blood/Saline detector.
Then Blood return back to
the Patient via the Venous
needle.
102
Introduction to Hemodialysis Machine.

Hemodialysis Machine plays an important roll in Hemodialysis treatment.
Main Function of the Hemodialysis machine:To Regulate the Blood flow from patient to Dialyser & Return back the
cleaned blood from the dialyser to Patient.(Extracorporeal circuit)
To Prepare the Fresh Dialysate as per the Patient requirement & feed into
Dialyser with proper flow.
To remove the Target Volume of fluid from the patient by determining the
necessary pressure to be applied onto the semipermeable membrane.
Drain the Spend dialysate from the Dialyzer & Blood leak in the spend
Dialysate is Monitor
General Machine Description

Hemodialysis Machine Front View
1. Monitor.
2. Modules - Level 1
2a Modules - Level 2
3. Hydraulics.
4. Castors.
5. Bicarbonate suction Tube (Blue)
6. Concentrate suction Tube (Red)
7. Rinse chamber.
8. Interlock Shunt for Dialyzer.
9. IV Pole.
Hemodialysis Machine Rear View

1. Monitor (Rear)
2. Sample collection Valve.
3. Filter.
4. Dialyzer supply line.
5. Dialyzer return line.
6. Disinfections Connector.
7. Water inlet filter.
8. Bicarbonate Connector (CDS)
9. Concentrate Connector (CDS)
10. Drain.
11. Water supply.
12. Diasafe.
13. Vent
14. Power supply Unit.

15. Dialyzer Holder.
Monitor
Monitor rear & Power supply unit.

1. Fan.
2. Service switch.
3. Audible Alarm.
4. Traffic Light.
5. RS232.
6. I/P & O/P Port.(For Ext equipment)
7. Screen Socket.
8. Hour meter.
9. Alarm In
10. Alarm Out
11. Symbols.
12. Power supply.
13. Power switch.
14. Power cord.
15. Loud Speaker.

16. Remote control.
17. Optional.
Blood pump
1.Display.
2. Alarm LED.
3. Operation LED.
4. Pressure connector.
5. Clamping piece.
6. Blood pump cover.
7. Rotor.
8. Sensor.
9. Start/Stop.
10 & 11 Key.
Heparin pump
1. Slide Carriage.
2. Bolus.
3. Rate.
4. Time Key.
5. Syringe Holder.
6. Stop-watch time Indicator
7. Start/Stop key.
8 & 9 Key.
10. Power.
11. Display.
12. Alarm.
Air detector
1. Key
2. Venous Pressure connector.
3. Holder( Venous chamber)
4. Venous line clamp.

5. Optical Detector.
Concentratesis.
Mixing Ratio
Vascular Access for Hemodialysis
Common Methods:
Fistula
Internal Graft
Subclavian

Internal fistula: This involves having an artery and a
vein connected surgically. When they are joined, the
stronger blood flow from the artery causes the vein to
become larger. Needles can be inserted in the
enlarged vein to connect you to the dialysis machine.
Internal graft An artery is surgically connected to a
vein with a short piece of special tubing placed under
the skin. Needles can be inserted in this graft.

Sometimes, when it is necessary to gain access to the
bloodstream quickly, or when the veins in the arms are
too small to provide enough blood for hemodialysis, a
central venous catheter is used.
A soft tube(double lumen catheter) is surgically inserted
into a large vein in the neck. This Procedure is called a
Subclavian.
This method is usually temporary until a permanent
access site is ready.
Forms of Hemodialysis Treatments.

Volume controlled Ultrafiltration.
Sequential Ultrafiltration.
Acetate Hemodialysis.
Bicarbonate Hemodialysis.
Single Needle Hemodialysis.
High Flux Hemodialysis.
Minimum Ultrafiltration.
UF Profile.
Sodium Profile.
Ultra filtration & Sodium Profiling.
Patient Preparation.
Check Blood pressure.
Check Pre-weight.
Treatment Parameters.(Refer to the Doctor recommendation)
UF Target Calculation (Based on the Dry Weight)
Clean Dialyzer & Blood Tubing's using Dialyser reprocessing unit.
Check AV Fistula of Patient.
Pre-Blood sample (Frequency of sampling are various from center to

center).
Disposables required to start Treatment.
(AV Fistula Needle, Saline solution, Transducer protector,Test

Strips,Concentrate,Syringe Heparin Solution..)
Disposables
Dialyser, Blood line set(Arterial & Venous Blood lines)
Arterio- Venous Fistula (AVF) needles.
Dialysate concentrate.
Transducer Protector.
Syringe.
Intravenous set (IV set).
Normal Saline Solution.
Heparin Solution.
Alcohol Swab.
Disinfections & Test Strip.
Factors influencing Hemodialysis
Temperature.
Conductivity.
Negative pressure (TMP)
UF Target.
Arterial Pressure.
Venous Pressure.
Blood pump rate.
Air detector.
Blood Leak Detector.
Heparin Infusion
Negative pressure (TMP) & UF Target

Dry Weight:- Dry Weight of a Patient is only an estimation & may change from time
to time. A Regular review by the Doctor is important to ensure that the patient dry
weight.
UF Target:- UF Target is based on the Dry Weight & Pre weight. UF Target = (Pre
weight -Dry Weight) + Food & Fluids during treatment + Saline + If any additional
fluid added.
Trans Membrane Pressure(TMP):TMP = __________UF Target_________

KUF X Time
KUF is amount of water removed per hour per mmhg pressure being exerted on the
semi-permeable membrane.
Machine Preparation for treatment
Before switch on the machine.

Check Water supply,Power supply & Drain.
Switch on the Machine.
Rinse machine for 15 minutes.
Connect the concentrate selected for treatment.
Start Self test to ensure the proper functioning of the machine, during
self test all the parameters are tested.
Self Test Passed. Prime the blood line & Dialyzer.
Machine ready for the Treatment.
Treatment Sequence
After Self test passed machine will enter to Prime Mode.
During Prime Mode Patient Blood lines & Dialyser are primed with
saline solution until the Patient circuit is clean & free from the
Disinfectant & Air.
Check the Pre-weight of the Patient. Based on the dry weight, UF Goal
will be calculated.
Ensure all parameters such as UF Goal, Treatment Time,UF/Na

Profiling & Heparin dosage are fed into the machine.
Now stop the blood pump & Clamp both the Arterial & Venous blood
line.
Remember to clamp the IV set.
Treatment Sequence
Patient will be connected to Hemodialysis machine using the Artery &

Venous Fistula needle inserted in the patient arm.
Once both the Artery & Venous Blood lines are connected to the
patient, open the clamps in the blood line.
Patient blood is passed from Artery Fistula to artery blood line.
Arterial pressure is monitored before the Blood pump, connected to

the Machine using the Transducer protector.
Transducer Protector is used to protect the blood entering into the

machine.
Level of the Blood in the chamber is adjusted if required.
Treatment Sequence
Blood is pumped at a set flow rate of 100-150 Ml/Min to the

Dialyser via Heparin Pump which is used to mix the Heparin
solution.
Heparin solution is slowly added (2ml/hr) in to the Arterial blood

tube as an anti-coagulant to avoid the blood clot in the Extracorporeal Circuit during dialysis & Bolus of 5ml will be given
before blood enters the arterial Tube.
Heparin pump will be stopped 30 minutes before closing the

dialysis treatment, to clot the blood once patient disconnected.
Blood enters in to Arterial Blood port of Dialyser Via Arterial

Blood line.
Treatment Sequence
Blood from the Dialyser pass through the Venous Blood port Via
Venous blood line to the Patient Venous Fistula needle.
Venous chamber :- To Check the Air in the blood tubing & To

Monitor the venous pressure of the patient.
Transducer protector is connected in the venous chamber tube to

protect Blood entering into the machine.
Finally venous blood tube is inserted into the venous clamp &
Optical detector will detects the colour change. (Saline-BloodSaline).
Patient blood enters in to the Venous fistula needle.
Blood is circulated from & to the body for four hours to do the
Hemodialysis.
Treatment Sequence
Once Blood reaches the Optical detector of the venous clamp
Dialysis Starts led will flash.
Check all the Treatment Parameters Settings & Alarm Windows
for all the alarms.
Switch UF function.
Treatment time start counting down.
Alarms during treatment Sequence

Arterial Pressure.
Venous Pressure.
TMP
Blood leak.
Conductivity.
Temperature.
Air Detector.
Flow Alarm.
Water Alarm.
Power Failure.
Clinical Problems during treatment

High Blood Pressure.(Salt & Fluid High)
Difficulty in Breathing. (Salt & Fluid High)
Coughing. (Salt & Fluid High)
Low Blood Pressure (Excessive Fluid Removal)
Crams. (Excessive Fluid Removal)
Sudden Dizziness.
Sudden Chills.
Chest Pain.
Test & Measurement during treatment

Weight :- Before & After treatment.
Blood Pressure & Plus :- Every one hour or even more frequently.
Temperature:- Before & After treatment.
Following will be conducted at regular intervals.
Liver function test.
Blood count.
Serum, Urea, Electrolytes, Calcium & Phosphate levels.
ECG.
Blood Iron.
Hepatitis Status.
HIV Test.
End of the Treatment

Once the treatment completed machine will display Treatment completed.
Clamp Artery Fistula line, Disconnect Artery blood line & run the blood pump
slowly return the blood back to the venous fistula.
Once air reached the air detector, blood pump will be stopped.
Remove Venous chamber from the Air detector.
Bypass Air detector alarm & run the blood pump to pump the blood until end of
venous blood line.
Ensure there is no Air when blood is return back to the patient.
Disconnect the Blood tubes & Dialyzer from the Machine.
Check Patient Post weight.
Rinse & Disinfect the blood tube & Dialyzer using Dialyzer reprocessing unit.
Cleaning program
Machine need to be Rinsed as per manufacture
recommendation after each Hemodialysis treatment.
Ensure the Dwell time of the chemicals used for
disinfections are as per Manufacture recommendation.
Check the machine drain free from the disinfectant
used before connecting to the Patient.
Cleaning program
Cleaning program
Cleaning program
Associated Equipments in Hemodialysis Unit

Water treatment plant (Reverse osmosis system)
Dialyser reprocessor
Defibrillator
Weighing scale
NIBP
Stethoscope
Oxygen cylinder
Maintenance
Hemodilaysis Training
Maintenance
Block Diagram.
Daily Maintenance.
Test Equipment.
Schedule Maintenance (PPM)

Trouble shooting.
Safety.
Block Diagram
Electronic Circuits
Power supply Unit
Hydraulic Circuit
Block Diagram
Power Circuits Block Diagram
Block Diagram of General Hydraulics
Flow Diagram of Hydraulics
Operation of Balancing Chamber
Filling Program
Hydraulic Flow Diagram
Daily Maintenance
Start of operation.
Rinsing
Self test.
Visual Inspection.
End of Operation.
Disinfection & Cleaning.
Test Equipment
Test Equipment required to test HDU Machine.
Analyzer like HDM 90/99( To test Temperature, Conductivity,

pressure,pH,Flow,Voltage,Frequency& etc.)
Special Pressure Gauge (If required)
Measuring Jar (1000Ml)
Measuring Jar (100Ml)
Syringe (50CC)
Safety Analyzer.
Scheduled Maintenance (PPM)

Perform Disinfections Before & After PPM.
Check Machine performance.
Check with user for any malfunction of the machine
before start PPM.
Perform PPM as per the check list.
Replace Recommended PPM Kit as per Manufacture
Guideline.
Finally do the Safety Test.
Trouble Shooting
Inlet Water Flow
Display
Conductivity
Indicators
Temperature
Blood leak
Pressure
Air detector
Flow
Power fail
Blood pump
UF
Safety
Electrical safety:Type of Protection:- Safety class 1
Degree of protection against electrical shock:- Type B.
Safety test need to carry out after Maintenance.
Ensure that machine is installed as per the Manufacture
Operating conditions.
Water Quality to the machine
Electrical supply.
Drain height.
Water inflow pressure.
Water inflow temperature.
Water inflow rate.
Operating Temperature.
Safety
Ensure Hepatitis & HIV patients are treated in a
Isolated area & a separate machine is used with a
caution Label. Take a special precaution before using
the machine.
Hemodialysis Machine should be used only by a well
trained personnel.
Machine should not be tested when Patient is
connected.
Use only treated water which complies to the
Standards.
Safety
Label the Patient name in the Dialyzer& Blood
tubing.
After each Hemodialysis treatment rinse the
machine.
The Content of opened bicarbonate concentrate
container cannot be store.
Dont Mix the Bicarbonate concentrate from one
container to another.
Pass the Self test before connecting to the patient.
At the end of the day Chemical disinfections need to
be done as per Manufacture recommendation.
Safety
In case power failure for long time & no power back
up return the blood back to Patient.
Do not remove the blood line from the venous line
clamp during treatment.
Check for the machine Drain & the Patient circuit is
free from the Disinfectant before connecting to the
patient.
Check the Blood segment size in the blood module.
Safety
Connect the correct concentrate container to the
correct concentrate tubes (A & B).
Check the Mixing ratio is as per your concentrate
manufacture specification.
Dont switch off the machine immediately after
dialysis.
Before start dialysis conform your conductivity
reading using your external Meter.
Send the dialysate sample to the lab for Bacteria
growth every month.
Every Six month do the RO water sampling for the
recommended standards.
Q&A
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Basic Training on

Removes waste products from blood.

Regulates Acid-Base Balance.

Regulates Red Blood cell production.

Causes of Kidney failure

Symptoms of Kidney Failure

Symptoms of Kidney Failure

Renal Replacement Therapy

History & Development of Dialysis

History & Development of Dialysis

History & Development of Dialysis

History & Development of Dialysis

History & Development of Dialysis

History & Development of Dialysis

History & Development of Dialysis

CRRT(Continuous Renal Replacement Therapy)

History & Development of Dialysis

History & Development of Dialysis

with alarm limits.

Treatment options for Patients with Kidney failure

IPD- Intermittent Peritoneal Dialysis

CAPD- Continuous Ambulatory Peritoneal Dialysis.

Hemodialysis treatments are carried out

Peritoneal Dialysis Involves putting Dialyzing fluid

Mostly 80% of Peritoneal Dialysis will be done at Home

(2) CCPD- Continuous Cycling Peritoneal Dialysis

Types Peritoneal Dialysis

Disadvantage Peritoneal Dialysis

Infection as a result of contamination of the

Pain ( When Fluid fill& Drain)

Basic Anatomy& Physiology Renal

Basic Anatomy& Physiology

Roll of kidney In Human body

1. Acts as a filter system.

2. Gets rid of waste products.

6. Produces the hormone Erythropotin to help make Red Blood cells.

Why Kidney is Required

Regulates Electrolyte Levels.

Flow of Blood to the Kidney

Work procedure of Kidney

Longitudinal section of the Kidney

Longitudinal section of the Kidney

renal arteries arise from the abdominal section of the

Longitudinal section of the Kidney

Longitudinal section of Kidney

A Nephron begins as a hollow-walled,

Longitudinal section of Kidney& Nephron

Function of Glomerulus & Tubules

Of the180 L of Glomerular filtrate each

Rest of the water is reabsorbed along with Glucose,amino& other electrolytes.

How Urine is produced in the Kidney

How Urine is produced in the Kidney

In the first part of the tube (proximal

The kidney also uses energy to selectively

These molecules are excreted in the urine

How Urine is produced in the Kidney

As the fluid passes through the loop,

The dilute fluid passes up the next part

Fluid from several Nephrons passes

How Urine is produced in the Kidney

In the collecting ducts, the fluid can

Types of Kidney Failure

Acute Renal Failure

Chronic Renal Failure