Renal dialysis

The kidneys’ role…

Remove waste productsFluid controlBP controlRBC productionKeeping bones healthy

When our kidneys fail…

We may feel sick, sleepy, confused or nauseous. (waste products)

We will feel tired and pale. (RBC)We may have ankle swellings & start

to feel breathless. (extra fluid)We may have bad breath & loss of

appetite. (waste products)

PRESENTED BY

ANU ISSAC

RENAL DIALYSIS

• First form of dialysis practised by Romans.

• 1854- the term dialysis was used for the first time by Thomas Graham.

• 1913- first article on hemodialysis- ‘Artificial kidney’

• 1920’s- first dialysis performed by George Hass

• 1948- first successful dialysis in Mount Sinai hospital by Willem Kolff

Historical background

Dialysis is the movement of fluid and molecules across a semipermeable membrane from one compartment to another.

Clinically, dialysis is a technique in which substances move from the blood through a semipermeable membrane and into a dialysis solution (dialysate)

DEFINITION OF DIALYSIS

INDICATIONS

Dialysis: Methods

Hemodialysis Peritoneal Dialysis

OSMOSIS

Principles of dialysis

DIFFUSION

Ultrafiltration

Hemodialysis

Hemodialysis…

4-6 hours

Hemodialysis: Functions

Cleanses the blood of accumulated waste products

Removes the by-products of protein metabolism (urea, creatinine & uric acid)

Removes excessive fluidsMaintains or restores the buffer system

of the bodyMaintains or restores electrolyte levels

Removal of solutes and water from the blood across a semipermeable membrane

Definition

Selective filter for removing toxic or unwanted solutes from the blood

Dialyser

Basic flow path geometriesRectangular cross section, parallel plate

dialyser.

CIRCULAR CROSS SECTION; HOLLOW FIBER DIALYSER

Organic cellulose derivatives

Synthetic membranes

Membranes used in hemodialysis.

DIALYSATE

The fluid that is pumped through the dialyser on the opposite side of the semi permeable membrane to the patients blood.

Correct the chemical composition of uremic blood to normal physiological levels.

SOLUTE CONCENTRATION

SODIUM (mmol/L) 135- 143

POTASSIUM(mmol/L) 0-4

CHLORIDE 100- 111

CALCIUM 1.25 – 1.75

MAGNESIUM 0.75- 1.5

BICARBONATE 30- 35

GLUCOSE 0- 25 gm

Usual composition of hemodialysis dialysate

Sodium chloride ; Na+ 176 gm ; 82 mEq/L

Potassium chloride ; K+ 5.50 gm ; 2.0 mEq/L

Calcium chloride ; Ca + 8.00 gm ; 3.0 meq/L

Magnesium chloride ; Mg ++, Cl -

2.75 gm ; 0.75 mEq/L, 88.0 mEq/L

Acetic acid 9.0 gm ; 4.0 mEq/L

Purified water 1 liter

Concentrated acidic solution [ 'A' solution]

Sodium chloride 235 gms

Sodium bicarbonte 600 gms

Na + 55 mmoles

HCO3- 35 mmoles

Cl- 20 mmoles

Bicarbonate solution (B solution)

Na + - 137 mEq/LK + - 2 mEq/LCa ++ - 3.0 mEq/LMg ++ - 0.75 mEq/LCl ‾ - 108 mEq/LHCo3‾ 35 mEq/LCH3COO‾ 4 mEq/L

Final solution ( dialysate)

FiltrationActivated carbon filters (adsorption)Water softnersReverse osmosis (RO)De ionizationUltraviolet light exposure

Methods to treat water for dialysis

The removal of air

The removal of any chemicals

Preparation of the dialyser

PERMANENT VASCULAR ACCESSArterio venous fistula’s (AVF’s)

Arterio venous grafts (AVG’s)

Shunts

ACCESS FOR HEMODIALYSIS

Arterio venous fistula

Internal AV Fistula…

Advantages Disadvantages

less danger of clotting and bleeding can be used indefinitely decreased incidence of infection no external dressing required freedom of movement

cannot be used immediately after insertion venipuncture is required for dialysis infiltration of needles → hematoma aneurysm in the fistula Arterial steal syndrome Congestive heart failure

Arterio venous graft

Internal AV Graft…

Advantages Disadvantages

less danger of clotting and bleeding can be used indefinitely decreased incidence of infection no external dressing required freedom of movement

cannot be used immediately after insertion venipuncture is required for dialysis infiltration of needles → hematoma aneurysm in the fistula Arterial steal syndrome Congestive heart failure

External AV Shunt

Access is formed by the surgical insertion of 2 silastic cannulas into an artery or vein in the forearm or leg to form an external blood path.

External AV Shunt…

Advantages Disadvantages

can be used immediately after insertion no venipuncture necessary for dialysis

external danger of disconnecting or dislodging the shunt risk of hemorrhage, infection or clotting skin erosion around the catheter site

Rope ladder puncture

Area puncture

Button hole puncture

Cannulation of AVF

Thrombosis

Stenosis of fistula

Aneurysm

Steal syndrome

Infection

Complications of AVF

Subclavian vein

Internal jugular vein

Femoral vein

Temporary access sites

for acute dialysisIn the patient who is imminently awaiting a

kidney transplant for maturation of AV accessLimited availability of vesselsPatients undergoing plasmapheresisFor continuos renal replacement therapiesPatients on peritoneal dialysis requiring

temporary hemodialysis because of peritonitis.

Temporary access is used insituations like…..

Subclavian (vein) Catheter…

may be inserted for short term or temporary use in acute renal failure

usually filled w/ heparin & capped to maintain patency between dialysis treatments

may be left in place for up to 6 wks if complications do not occur

Femoral (vein) Catheter… may be inserted for

short term or temporary use in acute renal failure

client should not sit up more than 45° or lean forward, or the catheter may kink & occlude.

an IV infusion pump w/ microdrip tubing should be used if a heparin infusion through the catheter is prescribed

Weight

Blood volume monitoring

Blood pressure

Temperature and pulse

Serum biochemistry and hematology

Assessment of the patient

Kt / V – 1.2

URR – 65%Albumin - >35 g/LPotassium – 3.5 – 6.5 mmol/LPhosphate - < 1.8 mmol/LCalcium – b/w 2.2 and 2.6 mmol/LHb - > 10 g/L

Target pre-dialysis values

URR( urea reduction ratio) = 100 (1- Ct/Co)

Ct= post dialysis ureaCo= pre dialysis urea

ETO Gamma irradiation Steam sterilization Electron or e-beam sterilization

Sterilization of dialyser

HypotensionMuscle cramps Loss of blood Hepatitis Sepsis Disequilibrium syndrome Vascular steal Dialyser Reaction HemolysisAir embolism

Complications of hemodialysis

Control of HIV and HBsAg in dialysis unit

Home hemodialysis

PERITONEAL DIALYSIS

PERITONEAL DIALYSISAdequate Patient Care in the Most

Biocompatible Way

ACCESS FOR DIALYSIS

•

COMPOSITION OF DIALYSATE

Sodium 132- 142

Potassium 0- 4

Calcium 2.5- 3.5

Magnesium 0.5- 1.5

Lactate 35- 40

Chloride 101- 107

pH 5.0- 5.8

Dextrose 1.5- 4.25 gm/dL

Inflow (fill) – 10 minutes

Dwell ( equilibration) – 20 minutes to 8 or more hours

Drain - 15 to 30 minutes

Phases of peritoneal dialysis

Automated peritoneal dialysis (APD)

Continuous ambulatory peritoneal dialysis (CAPD)

Types of peritoneal dilaysis

Continuous cycling peritoneal dialysis ( CCPD)

Nocturnal intermittent peritoneal dialysis (NIPD)

Intermittent peritoneal dialysis (IPD)

Tidal peritoneal dialysis (TPD)

Forms of APD

Automated Peritoneal Dialysis

Requires a peritoneal cycling machine called a cycler

Can be done as intermittent peritoneal dialysis, continuous cycling peritoneal dialysis, or nightly peritoneal dialysis

CAPD: Equipments

CAPD Cycle…

1. The dialysate is instilled into the peritoneal cavity through an implant catheter attached to a transferline, which is attached to a bag of dialysate.

2. Once the fluid has been instilled completely into the peritoneal cavity, the empty bag and transferline are folded up and worn in a cloth pouch beneath the clothing. Thus, the patient is free to ambulate and resume his normal daily activities.

CAPD Cycle…

3. When it is time to drain off the effluent, the bag is unfolded, placed on the floor and drainage is achieved by gravity. A new bag of dialysate is then attached to the transferline and the process is repeated. Usually the solution exchange procedure takes about 15 minutes.

o FREEDOM FROM DIALYSIS MACHINE

o CONTROL OVER DAILY ACTIVITIES

o OPPURTUNITIES TO AVOID DIETARY RESTRICTIONS

Advantages of CAPD

History of multiple abdominal surgeries.

Recurrent hernias

Obesity

Pre –existing vertebral disease

Severe obstructive pulmonary disease

CONTRAINDICATIONS

Exit site infectionPeritonitisAbdominal painOutflow problemsHernias Lower back problemsBleedingPulmonary complicationsProtein lossCarbohydrate and lipid abnormalitiesEncapsulating sclerosing peritonitis & loss of

ultrfiltration

Complications of peritoneal dialysis

Venous access therapies [venovenous]

Arterial access therapies [arteriovenous]

Continuous renal replacement therapy

Venous access therapies

o Continuous venovenous ultrafiltration (CVVU)

o Continuous venovenous hemofiltration (CVVH)

o Continuous venevenous hemodialysis (CVVHD)

ARTERIAL ACCESS THERAPIES

SLOW CONTINUOUS ULTRFILTRATION (SCUF)

CONTINUOUS ARTERIOVENOUS HEMOFILTRATION (CAVH)

CONTINUOUS ARTERIOVENOUS HEMODIALYSIS (CAVHD)

1) Fluid volume excess related to fluid accumulation/ inadequate dialysis

2) Risk for fluid volume deficit related to rapid removal of fluid during treatment

3) Risk for altered tissue perfusion related to risk of vascular access clotting/ disconnection

4) Risk for infection related to presence of access site and invasive procedure

5) Body image disturbance related to presence of access site.

NURSING MANAGEMENT

Pain/discomfort related to dialysis process.Altered thought process related to dialysis

diaequilibrium syndrome Ineffective individual/ family coping related to

diagnosis of chronic illnessNoncompliance to prescribed treatment

regimen

a)Imbalanced nutrition, less than body requirement related to protein loss in the dialysate

b)Risk for infection realted to presence of peritoneal dialysis catheter.

c) risk for imbalanced fluid volume related to hypertonicity of the dialysate or inadequate exchange.

 d) activity intolerance to related to fatiguee) risk for complications related to the disease

condition and dialysis procedure

Preitoneal dialysis

1) TUCKER MARTIN SUSAN, CANOBBIO. M. MARY, PAQUETTE VARGO ELEANOR WELLS FYFE MARJORIE, PATIENT CARE STANDARDS, COLLOBORATIVE PRACTICE PLANNING GUIDES, 6TH EDITION, 1996, MOSBY PUBLICATIONS, USA, PAGE NO:- 690-696.

2) THOMAS NICOLA, RENAL NURSING, THIRD EDITION (2008). BALLIERE TINDALL, ELSEVIER PUBLICATIONS, CHINA, PAGE NO: 181-244.

3) KALLENBACH Z. JUDITH, GUTCH F.C, STONER H.MARTHA., COREA L. ANNA, REVIEW OF HEMODIALYSIS FOR NURSES AND DIALYSIS PERSONNEL, SEVENTH EDITION, 2005, ELSEVIER PUBLICATION ,MISSOURI, PAGE NO: 61- 136.

4) LEWIS. L SHARON,HEITKEMPER McLEAN, MARGARET, DIRKSEN RUFF SHANNON, O’BRIEN GRABER PATRICIA, BUCHER LINDA, LEWIS MEDICAL AND SURGICAL NURSING, ASSESSMENT AND MANAGEMENT OF CLINICAL PROBLEM, 7TH EDITION, 2011, ELSEVIER PUBLICATIONS, India, PAGE NO: 1216-1223.

5) NISSENSON R. ALLEN, FINE N. RICHARD, HANDBOOK OF DIALYSIS THERAPY, 4TH EDITION (2008), ELSEVIER PUBLICATIONS, PHILADELPHIA.

6) MASSRY G. SHAUL, GLASSOCK J. RICHARD, TEXTBOOK OF NEPHROLOGY, VOLUME 2 , 3RD EDITION, 1995, WILLIAM AND WILKINS PUBLICATIONS, USA, PAGE NO: 1510-1600.

Bibliography