By

Dr. Iheme, C.P.

M.B.B.Ch
Outline
 Introduction
 Epidemiology
 Haemodialysis apparatus
 Mechanisms of solute transport
 Indications for dialysis
 Components of dialysis prescription
 Dialysis Adequacy
 Complications of Haemodialysis
 Conclusion
Introduction
 Definition: Dialysis is a process whereby the solute
composition of blood is altered by exposing it to a
dialysate through a semipermeable membrane.
Introduction ctd
 Functions of the kidney
• Remove excess salt, water, and acid.
• Remove or regulate other electrolytes (e.g. K , Ca , Mg ,
+ 2+ 2+

PO ).
4

• Remove waste products of metabolism (Ur and Cr

routinely measured, but there are many others).
• Make erythropoietin.
• 1 ά -hydroxylates and activates vitamin D.
Epidemiology
 US: 490,000 ESRD patients, 300,000 currently on HD

 UK: 23,500 HD patients, 74000 PD patients

 White population predominant

 Diabetes is the most common underlying diagnosis,

followed by hypertension in the US.

 Nigeria:17ooo new cases yearly. Prevalence of 79,050

 Renal Replacement Therapies
offered to the patients

9, 1% Haemodialysis

7, 1%
CAPD

556, 73% 188, 25%

Renal
Transplant
Conservative
Arogundade et al, WCN 2009
Epidemiology
 Mortality rate in RRT patients age 30–34 is 25x higher

 age >85,mortality is 73x higher

 Median survival
 age 45–54 is currently 10.5 years
 age 55–64 it is 5.6 years
 age 65–74, 3 years
Haemodialysis apparatus
Mechanisms of solute transport
1. Diffusion: movement of substances from an area of
higher concentration to an area of lower
concentration of solutes.

2. Ultrafiltration (convective Transport): water driven

by a hydrostatic is pushed through the membrane .
 Solutes that can pass easily through the membrane
pores are swept along with the water ( “solvent drag”).
Mechanisms of solute transport
 Hemodiafiltration: hemodialysis and hemofiltration
are combined. Seen in newer models of machines

 “Countercurrent” flow : Maximize the concentration

difference of waste products between blood and
dialysate in all parts of the dialyzer.
Indications for dialysis in AKI

AEIOU
 Acidosis: pH<7.2
 Electrolyte abnormalities:
 life-threatening hyperkalemia associated with ECG
changes
 symptomatic hypermagnesemia and hypercalcemia
Indications for dialysis
 Intoxications: Xtics of dialysable substances
 Low molecular weight (<500 Da)
 High water solubility
 Low degree of protein binding
 Small volumes of distribution (<1 L/kg)
 High dialysis clearance relative to endogenous clearance

 E.g. barbiturates, bromides, chloral hydrate,

alcohols, lithium, theophylline, procainamide,
salicylates, atenolol, and sotalol.
Indications for dialysis in AKI

 Overload: fluid overload or pulmonary edema not

responsive to aggressive diuresis

 Uremia: mental status changes attributable to uremia,

uremic pericarditis, or neuropathy, bleeding diatheses,
or vomiting associated with uremia.
Initiation of dialysis in CKD
 CKD stage 4 (GFR < 30 mL/min/1.73 m2) pts and
family members, should receive education about
kidney failure and options for its treatment.

 Initiate maintenance dialysis after an assessment of

 uremic features
 evidence of protein-energy wasting
 metabolic abnormalities and/or volume overload mgt
Components of dialysis
Prescription
 Haemodialysis is a form of treatment and requires a
prescription

 Prescription depends on individual characteristics and

should be tailored to suit the individual needs

 Choosing a prescription depends on the dialysis

modality to be employed
 Goal of HD is to achieve
 Dialysis adequacy
 Electrolyte balance
 Volume regulation
Dialysis Prescription
 For the goal of attaining adequate Kt/V and URR
values, the principle variables are:
 duration of treatment,
 Frequency
 blood flow,
 dialysate flow,
 dialyzer size.
Dialysis Prescription
 Duration of treatment:
 typically btw 3-4 hours in length
 thrice weekly
 Time can be ↑ if Kt/V and/or URR reflect poor dialysis
Dialysis Prescription
 Frequency: Different dialysis modalities exist
 Intermittent in-center HD: usually 3x weekly
 Intermittent home HD
 Short daily HD (about 6x weekly)
 Nocturnal HD (6-8hrs, 6x weekly)
Dialysis Prescription
 KDOQI guidelines recommend in-center short
frequent hemodialysis as an alternative to
conventional Rx after considering

 individual patient preferences,

 the potential quality of life and
 physiological benefits, and
 the risks of these therapies.
Dialysis Prescription
Blood flow rate: Largely depends on type
of access used.
1. Arteriovenous fistulas (AVFs): Best. Flow rates of
600-800cc/min. Can maintain patency at flows of
200cc/min.
2. Arteriovenous grafts (AVG): Flow rates of 1000 to
1500 cc/min.
Dialysis Prescription
3. Cuffed tunneled dialysis catheters: Placed in IJV
4. Femoral catheters
 Aim is to achieve blood flow rates of 400-500cc/min
for fistula and graft, 350-400cc/min for catheters.
AV Fistula
PTFE Graft
Cuffed Tunneled
Catheter
 Dialysate flow: btw 500-800cc/min. Increasing the
flow beyond 800 has no added benefit
 Dialyzer size: A dialyzer is a rigid polyurethrane shell
( ≈30cm long), containing hollow fibres (capillaries) of
dialysate membrane.

 A larger exposed surface area can be used to help

improve adequacy

 Dialyser efficiency: measured as KoA (mass transfer urea

coefficient). Could be high flux >600 or low flux <300
Electrolyte balance
 Dialysate: A solution of ultrapure water,
 Na + (132-150mmol/L),
 K + (usually 1.0 – 3.0mmol/L),
 Ca 2+ (1.0 – 1.25mmol/L),
 Mg 2+,
 Cl – ,
 dextrose,
 Buffer(usually HCO3)
 Ultrapure water is generated in a treatment plant
Dialysate Potassium concentration
 Depends on the patient’s pre-HD K+ concentration.

 Serum K+ ≥5.5 mEq/L→ a dialysate K+ of 2- 3 mEq/L

 If propensity toward arrhythmias, 3 mEq/L bath is

preferred to avoid precipitating hypokalemia.

 A dialysate K+ of 4 mEq/L →patients with

hypokalemia or persistent serum K+ <3.5 mEq/L.

 Serum K+ >6.5 to 7.0 mEq/L or ECG changes

hyperkalemia, → 0 or 1 mEq/L dialysate K+.
Sodium modelling
 140 - 145 mEq/L is appropriate in most cases

 ↓ serum Na+ levels indicate excessive free water

intake and managed through fluid restriction.

 Serum sodium <130mEq/L→ the dialysate sodium conc

<= 15 - 20 mEq/L above the serum levels.

 Hypernatremia should also be corrected slowly.

 Dietary Na+ <100mmol/day intake (equivalent to 6g

NaCl)
Calcium concentrations
 Guidelines recommend ↓ dialysate Ca 2+ to maintain
neutral or negative Ca 2+ balance to prevent vascular
calcification.

 ↑ patient: dialysate gradients associated with SCD

 Dialysate Ca 2+ of 1.25mmol/L normally used.

 May be increased to 3-3.5mmol/l in

 persistent hypercalcemia,
 concurrent acidosis
Dialysate bicarbonate
 Usually of 35 - 38 mEq/L to correct the metabolic
acidosis associated with chronic renal failure.

 For those susceptible to alkalosis, lower bath of 20 - 28

mEq/L can be used. E.g.

 total parenteral nutrition (TPN),

 vomiting or nasogastric suction,
 poor protein intake,
 Respiratory alkalosis.
Volume Regulation: Ultrafiltration
 Fluid restriction to limit intradialytic weight gains to
<4 kg
 Ultrafiltrate should not be ˃ 10% of patient’s body
water
 >4 to 5 L of ultrafiltrate → uncomfortable fluid shifts
and intradialytic hypotension.

 Patients with low residual kidney function (< 2

ml/min) undergoing 3x weekly HD require 3 hours
minimum.
Volume Regulation: Ultrafiltration
 Additional sessions or longer treatment times for pts
with
 large weight gains,
 high ultrafiltration rates,
 poorly controlled blood pressure,
 difficulty achieving dry weight,
 poor metabolic control (such as hyperphosphatemia,
metabolic acidosis, and/or hyperkalemia).
Anticoagulation
 Heparinization during HD minimizes clotting of the
dialysis circuit during the treatment.

 For patients with evidence of bleeding, no heparin is

prescribed. This includes

 Uraemic gastritis,
 GI bleeding
 Pericardial effusion
 Haemorrhagic stroke
 Recent surgery
 Post transplant patients
Anticoagulation

 Risk factors for Clotting include

 high hemoglobin and hematocrit,
 a high rate of ultrafiltration,
 low blood flow on dialysis.

 Both unfractionated and LMWH can be used.

Dialysis Adequacy
 Dialysis can be considered adequate if it
 provides relief of uraemic symptoms
 controls acidosis, fluid balance, and serum K +.
 It should also allow a feeling of physical and
psychological well-being.

 Adequacy is mainly modelled by 2 equations

 Kt/V
 urea reduction ratio.
Urea as a surrogate marker
 Small, water-soluble breakdown of amino acids and
dependent on protein intake and breakdown.

 Now considered a good surrogate marker for other

pathogenic solutes

 Advantages include
 Abundance in renal failure
 Ease of measurement,
 Wide volume of distribution
 Good dialyzability
Dialysis Adequacy
 Kt/V: is a ratio that relates the volume of cleared
plasma (Kt) to the volume of urea distribution (V).
 K = dialyser urea clearance.(ml/min)
 t = time on dialysis.(min)
 V = volume of distribution of Ur (estimated from patient
size).(ml)
Dialysis Adequacy
 Describes the volume of urea cleared during a dialysis
session relative to the volume of urea distributed
throughout the body.

 spKt/V: single pool urea clearance

 eKt/V: equilibrated urea clearance
 stdKt/V: Weekly standard urea clearance
KDOQI guidelines on Adequacy
 A target single pool Kt/V (spKt/V) of 1.4 per session
for patient treated thrice weekly, with a minimum
delivered spKt/V of 1.2.

 If significant residual native kidney function (Kr), the

dose of hemodialysis may be reduced.

 For hemodialysis schedules other than thrice weekly, a

target standard Kt/V of 2.3 volumes per week with a
minimum delivered dose of 2.1
Dialysis Adequacy
 Urea reduction rate (URR) similarly reflects the
removal of urea

 URR = (BUNpre–BUNpost)/BUNpre

 K/DOQI guidelines recommend the attainment of a

minimal URR of 65% and a target URR of 70%.
Complications of Haemodialysis
 The most common complications during hemodialysis
are,
 hypotension,
 cramps,
 nausea and vomiting,
Complications of Haemodialysis
 headache,
 chest pain,
 back pain,
 itching.
 Haemolysis
 Clotting of extra-corporeal unit
 First use syndrome/dialyser reaction
 Accidental disconnection
 Hard water syndrome,
 Air embolism
Intradialytic hypotension
 IDH is defined as a fall in SBP >20mmHg (or MAP
>10), associated with symptoms, or a fall to SBP
<100mmHg.

 Symptoms associated with IDH include:

 Cramps, abdominal pain, or nausea (reduced gut
perfusion).
 Yawning, sighing, anxiety, or dizziness (reduced cerebral
perfusion).
 Chest pain or arrhythmias
IDH
 Causes
 Volume-related
 Large weight gain (high ultrafiltration rate)
 Short weekly dialysis time (high ultrafiltration rate)
 Excessively low target (“dry”) weight
 Antihypertensive medications
 Eating during treatment
 Anemia
IDH
 2. Inadequate vasoconstriction
 High dialysis solution temperature
 Autonomic neuropathy
 3. Cardiac factors
 Diastolic dysfunction
IDH
 4. Other causes
 a. Pericardial tamponade
 b. Myocardial infarction
 c. Occult hemorrhage
 d. Septicemia
 e. Dialyzer reaction
 Immediate management of IDH:
 Stop ultrafiltration (UF).
 Trendelenburg position.
 IVF 0.9% NaCl as a 250mL bolus.
 Recheck BP.
 Thorough clinical review (including medications) to
prevent future episodes
Disequilibrium Syndrome

 Clinical features: nausea and vomiting, agitation,

headache, seizures, loss of consciousness.

 Cause: high blood urea levels being reduced too

rapidly. Usually occurs during first dialysis session
(with high blood flows). Leads to cerebral edema

 Prevention: use a dialyser with small surface area,

commence blood flow rate at 150-200mL/min. Limit
first session to 2h. Mannitol infusion,50% dextrose
infusion
Conclusion
 Haemodialysis is a life-sustaining procedure for the
treatment of ESRD

 In AKI, it provides rapid correction of fluid and electrolyte

abnormalities that pose an immediate threat to the
patient’s well-being.

 In CKD, it results in a dramatic reversal of uremic

symptoms and helps improve the patient’s functional
status and survival.

 To achieve these goals, the dialysis prescription must

ensure that an adequate amount of dialysis is delivered to
the patient.
Thanks for
listening
References
 Cheng,S., Vijayan,A. The Washington Manual Nephrology
Subspecialty Consult.3rd Edition.St. Louis,Missouri: Lippincott
Williams and Wilkins; 2012: 538-562
 Daudirdas,J.T.,Blake,P.G., Ing,T.S. Handbook of Dialysis. 5th
Edition. Philadelphia: Lippincott Williams and Wilkins; 2015
 Steddon,S., Ashman,N.,Chesser, A.,Cunningham,J. Oxford
Handbook of Nephrology.2nd Edition. Oxford, UK: Oxford
University Press;2014:274-308
 Bamgboye,E.L. The looming epidemic of kidney failure in
Nigeria. MetroHealth: 2015
 Hemodialysis Prescription & Adequacy, KDOQI guidelines,Oct
2015
 Palmer,B.F., The Dialysis Prescription and Urea modelling.
www.kidneyatlas.org