Fundamentals of

DIALYSIS
Knowing Your Kidneys
• Healthy Kidneys are the body’s
cleaning crew
• These are twin bean shaped
organs, of the size of fist
• They make up a filter system for
the blood & reabsorb almost
99% of the fluid into the blood
• They allow blood to retain
glucose, salts and minerals and
remove toxic materials like urea,
drugs etc
Knowing Your Kidneys

• Urine forms in kidneys,

drains in ureter, gets stored
in bladder and excretes
through urethra
• Each day kidneys secrete
1.5 - 2.5 liters of urine
 Functions of The Kidney
• Removes toxic and waste products & excess water
• Maintains body’s balance of salts
• Sodium
• Calcium
• Phosphate and other acid substances
• Releases several hormones
Renin helps to regulate Blood Pressure
Erythropoietin helps in RBC production
Activated Vitamin D helps maintain normal bones
 Kidney Diseases

• Kidney diseases alter the structure and function of Kidneys

• Leading causes are diseases like Diabetes and High BP
• Certain drugs also injure kidneys e.g. antibiotics, pain killers
and antipsychotic drugs
 Kidney Failure

• Kidney diseases lead to malfunctioning of kidneys

• In kidney failure, kidneys do not perform their normal
function
• As a result toxic substances like urea & creatinine accumulate
in body and vital components like albumin leak out in the
urine
Chronic Kidney Disease

Dailysis Zone
Signs and Symptoms of Kidney failure

Pale and sallow complexion

Fatigue
Shortness of Breath
Body itch
Poor appetite, sometimes with nausea/
vomiting
Swelling of the face and legs
Frequent urination specially during nights
Decrease in urine volume
 Treatment of Kidney Failure

1. Dialysis

2. Kidney Transplantation

Kidney Transplantation is best and most comprehensive

solution for kidney failure but many patients may not be
suitable for the same
Goals of Dialysis

• Solute clearance
• Diffusive transport (based on countercurrent flow of blood and
dialysate)
• Convective transport (solvent drag with ultrafiltration)
• Fluid removal
 Understanding Dialysis
• It’s a process of removing waste products and excess fluid
when kidneys stop working
• Dialysis uses a membrane as a filter called dialyzer and a
solution called dialysate to accomplish this
 Dialysis is of two main types
• Hemodialysis • Peritoneal Dialysis
• Uses an actual artificial • Uses Peritoneum, the lining of
kidney-Dialyser to clean the the abdomen, as a filter to
blood clean the blood
 What is Hemodialysis (HD)?
• The blood to be treated is pumped outside the body to a
machine (Dialyzer) that acts like artificial kidney
• Tiny pores in filter membrane filter out toxins while vital
components such as proteins, are left in the blood
• Excess water is also removed during the process of cleaning
• After cleaning, the machine returns the clean blood back to
body
• HD is usually carried out three times a week and average
session lasts for 4- hours
• During the cleaning process, patients usually watch TV,
read or talk to each other
What is Hemodialysis (HD)?
 Solute transport in different dialysis
modalities
 Haemodialysis
 Diffusive transport of solutes Diffusion Membrane
Relevant: - cut-off of membrane
- weight of solutes

 Haemofiltration
 Convective transport of solutes
Relevant: - cut-off of membrane Convection Membrane
- flow across membrane

 Haemodiafiltration Pressure

 Diffusive transport of small solutes

 Convective transport of large solutes
Solute transport in different dialysis
modalities
Hemodialysis
 Getting Ready for HD
• Before HD treatment, patient would need a dialysis access
to allow blood to flow between body and dialyzer
• There are various types of accesses used for HD
- Arterio-Venous Fistula the joining of vein and artery
just under the skin
 Getting Ready for HD
- Arterio Venous Graft used when the patients blood vessels
are too small for fistula connection

- Subclavian Cannula/ internal jugular

cannula is a soft plastic tube
inserted into a vein under the collar
bone or neck. It’s usually a
temporary access for urgent dialysis
 Dialysis Fluid in HD

• Also known as dialysate

• Fluid in the dialyzer that helps remove wastes and extra fluid
• Contains various chemicals depending on the status of the
patient
• Dialysate is prepared according to the specific requirements
of a patient
Possible Problems during HD

Low BP

Nausea (feeling sick)

Cramps

Headaches

Fatigue

Infections

Clotting

Fluid Overload
Peritoneal Dialysis
 Possible Problems in PD
• Fluid overload

• Fluids leak in the groin or around the catheter

• Infections are the major risk, mainly of two types

• Exit site infections
• Peritonitis infection of the peritoneal membrane
 Fluid Management in Dialysis

• People with renal failure make little or no urine and depend

on Dialysis for excess water’s removal
• It is essential to control the volume of fluid intake to prevent
the body from fluid overload, which might cause
complications like increase in BP, shortness of breath,
swollen eyelids and ankles or feet and distended abdomen
Fluid Management in Dialysis- Few Tips
• Count all fluids, all ice cubes, gravies, soups in your fluid
allowance
• Measure a jug of water to restrict to the
allowed amount
• Reduce salt intake
• Instead of few large drinks divide daily fluid into smaller and
frequent drinks
• When mouth feels dry rinse with water
• Weigh yourself daily and check for any unusual weight gains
Dialysis Process
• Once the patient is diagnosed for acute/chronic or
ESRD will be referred for Dialysis by Nephrologist Dr.
• Patient will be send for catheterization.
• Will do dialysis with the Double lumen catheter till
his/her Arterial-Venous Fistula is surgically created &
matured.
• It takes about a month for this.
 Patient at Dialysis unit
• Patient will come for dialysis with Catheter/AVF
• Pre dialysis parameters like BP, pulse, body temperature
& weight is checked recorded.
• Blood access site is observed for patency, cleaned with
antiseptic & prepared for dialysis.
• Machine is Rinsed/disinfected/surface cleaned.
• Dialyser (artificial kidney/filter) and blood tubing set is
rinsed with normal saline to remove air & disinfectant.
• Machine and kit is tested for traces of disinfectant to
avoid chemical reaction.
Patient during dialysis
• Dialysis is started, all the machine parameters &
safety alarm limits are set.
• BP, pulse are checked again after starting treatment,
monitored & recorded every hourly.
• Patient is monitored for 4 hours during the dialysis for
any discomforts.
• During the dialysis patient can read books, watch TV,
eat food.
Ending dialysis
• Patients blood is returned using normal saline.
• The kit is send for washing/cleaning & disinfection to
reprocessing room.
• Any post dialysis injections like vitamins, antibiotics
are given.
• AVF needle removed & dressing done.
• For catheter patient heparin/antibiotic lock is given
and dressing done.
• All vital signs post dialysis weight & parameters are
recorded with clinical episodes if any.
Patient leaving dialysis unit
• Patient well being is confirmed by RMO DR on duty.
• Send back home with next dialysis schedule.
• Any special instructions communications are given at
this time eg. Blood test due on next dialysis etc.
Acute Complications of Dialysis
• Hypotension (25-55%)
• Cramps (5-20%)
• Nausea and vomiting (5-15%)
• Headache (5%)
• Chest pain (2-5%)
• Back pain (2-5%)
• Itching (5%)
• Fever and chills (<1%)
Acute Complications of Dialysis
• Chest pain
• Can be associated with hypotension and dialysis
disequilibrium syndrome
• Always consider angina, hemolysis, and (rarely) air
embolism
• Consider pulmonary embolism if recent
manipulation of thrombus and/or occlusion of the
dialysis access
Acute Complications of Dialysis
• Hemolysis
• Suggestive findings include port wine appearance of the blood in the
venous line, a falling hematocrit, or complaints of chest pain, SOB,
and/or back pain
• Usually due to dialysis solution problems, including overheating,
hypotonicity, and contamination with formaldehyde, bleach,
chloramine, or nitrates in the water, or copper in the dialysis tubing
• Treatment includes discontinuation of dialysis without blood return to
the patient, and evaluation for hyperkalemia with medical treatment
as necessary
Acute Complications of Dialysis
• Arrhythmias
• Common during, and between, dialysis treatments
• Controversial whether due to disturbances in plasma
potassium
• Treatment is similar to the non-dialysis population,
except for medication dosing adjustments
Critical quality area in Dialysis
• Reverse osmosis plant/ water availability.
• Dialyser and blood tubing reprocessing
• Customer care services
• Infection control /Bio hazard handling
• Emergency trolley check
• All Resources/ facility in working condition round the clock.
• Staff competency to handle medical emergency
• Dialysis unit ambience/structure standardization.
• Machine/RO & all equipments routine maintenance.
Other Complications of Kidney Failure
Renal Osteodystrophy
ESRD causes increased bone breakdown and abnormal
metabolism of Calcium, Phosphorus, Vitamin D and PTH,
leading to Renal Osteodystrophy
Affects most of the ESRD patients and causes bones to
become thin, weak or malformed
Itching (Pruritus)
Many patients complain of itchy skin
Phosphate binders such as calcium carbonate and aluminium
hydroxide help
Some patients also improve with EPO shots
Sleep Disorders
Quite common in ESRD patients when on dialysis
Other Complications of Kidney Failure

Amyloidosis

• Dialysis related amyloidosis is common problem for

older (more than 5 years) dialysis patients

• Proteins deposit in joints and tendons, causing pain,

stiffness and fluid in the joints
Thank You