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Better Care for All Hemodialysis Patients

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Hemodialysis Training Course29th of June 2013

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Update information on hemodialysis for the renal division.

Review guidelines and patient care.

Hands on session with technical support.

Evaluation for all the renal division staffing.

Aim:

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Hemodialysis basics kinetics for fluid and

electrolytes

Jafar Al-Said, M.B.CHb. MD. FASN. FACPNephrology and Internal Medicine Consultant

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Body fluid compartment.

Fluid transportation.

Definitions and terms.

Hemodialysis.

Hemofiltration.

Hemodiafiltration.

Membrane characters.

Types of Dialysis.

Indications of Dialysis.

Dialysis complications.

Scheme

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Male 0.6 of the total body wt.

Female 0.55 of the total body wt.

2/3 in intracellular. 1/3 in the extracellular.

¼ is intravascular. ¾ is interstitial.

Body fluid Compartment

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HD

70 Kg male

28Lit.

10.5Lit

3.5Lit

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Diffusion.

Convection.

Adsorption.

Ultrafiltration.

Hemodialysis.

Hemofiltration.

Hemodialfiltration.

Hemoperfusion.

Slow Low efficiency Hemodialysis (SLED).

Continuous Renal replacement (CRRT).

Definitions

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Water&

Solutes

Basic Principle of DialysisSemi permeable

membrane

Dialysate

Blood

At zero time End of dialysis session

Equilibration

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Molecular wt. (Atomic Mass) Molecule g/mol Na 22.9 Mg 24.3 Cl 35.4 K 39 Ca 40 HCO3 61 Urea 0.06kDa 60 PO4 94.7 Cr 113.1 Vit. B12 1355 B2 Microglubulin. 11,8 kDa 11,800 Albumin 66 kDa 66,000

500D-60KD

SMALL<500D

Large>500KD

Middle

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The Kidney

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HD filter

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Membrane Pores

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Principle: Solute transfer across semipermeable membranes along

concentration gradients (diffusion) Counter current flow for optimized efficacy

Selectivity: Low (dialysate composition)

Efficacy: High for small molecular weight substances (urea, creatinine,

electrolytes, buffer...) Low for higher molecular weight substances (small proteins,

mediators, etc.)

Hemodialysis

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Hemodialysis Diffusion

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Principle: - Solute transfer across semipermeable membranes by

pressure induced water flow (convection, "solute drag")

- Volume substitution (pre or post filter) Selectivity: - Low Efficacy: - Improved for higher molecular weight

solutes (small proteins, mediators, etc.) - Reduced for small molecular weight

substances (urea, creatinine, electrolytes, buffer base)

Hemofiltration

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Water flux across the membrane.

Pore size and pore size distribution.

Molecular size (molecular mass).

Molecular shape and configuration.

Charges (solutes and membranes).

Convective Transport Across Membranes: Determinants

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Hemofiltration

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Hemodialfiltration

Post-dilution

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Normal Kidney

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Hemodialysis Circuit

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Material. Pore size. Surface area. Thickness of the membrane. Sterilization methods. Urea Clearance. Creatinine Clearance. B2 Microglobulin clearance. Ultrafiltration Coefficient.

Filter characteristics

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Efficiency:Rate of removal (diffusion) of small molecules.

As Urea

Flux:Rate of removal (convection) middle molecule.

B2microglob.

Ultrafiltration Coefficient (removal of water).

Mass Area Transfer KoA.

Filter membrane specifications

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Flux

Dialyzers Urea KoA (ml/min)

Urea Clearance ml/min

UF Coeff.ml/min/mmHg

Beta2 Micro.ml/min

Low Conventional

<450 <150 <12 <10

Low High efficiency

>600 >200 variable Variable

High

High flux variable variable >12 >20

High

Hemofilters variable variable >12 >20

Performance of different Dialyzers and Hemofilters

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IONs Concentration meq/l

Na+ 132-145

K+ 0 – 4

Cl- 103 – 110

HCO3- 0 – 40

Acetate 2 -37

Ca+ 0 -3.5

Mg+ 0.5 – 1

Glucose 0 -200mg/dl

Dialysate fluid composition

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1. Provide high quality of life.

2. Reduce Complication. BP, Sugar, bleeding, ..etc.

3. Solute Clearance. KT/V.

4. Solvent Clearance. Dry wt.

Dialysis Outcome and Adequacy

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Clinical: Pulmonary edema/

Desaturation. Pericardial rub. GI symptoms. Altered Mental status. Anasarca. Bleeding tendency. Anuria/ Oliguria. Infection/sepsis.

Indication of Hemodialysis

Biochemical:

• Hyperkalemia.• Metabolic Acidosis.• Intoxication:

ASA, Alcohol, Lithium.• Inducing Hypothermia.

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Volume and Fluid equilibration. Electrolytes normalization. Correction of Acidosis. Removal of endogenous toxins. Better HTN control. Reduce uremic symptoms: GI, Neurologic. Ca X PO4. Improved Nutrition. Immunity. Reduced bleeding.

Dialysis Benefits

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Hypotension. Infection. Bleeding. Arrhythmia. Dialysis Disequilibrium syndrome. Anaphylaxis. Air Embolism. Contamination from water Aluminium,

Chlorien. Asthenia, weakness, Malnutrition.

Dialysis Complications

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Duration.QB.QD.Anticoagulation.Ultrafiltration volume.Dialysate Temp.Certain fluid replacements.Na modeling. Medications.Labs.

Basic Dialysis orders

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Better Care for All Hemodialysis Patients