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1. Dr. Osama El-Shahat
Consultant Nephrologist
Head of Nephrology Department
New Mansoura General Hospital (international)
ISN Educational Ambassador

2.  Initiation of HD
 Multidispliary Team
 Infection control
 Water treatment
 Documentation
 Manual of HD
 Mission, Vision and goals
 Conclusion

3. Initiation of HD

4. * Access in use at first dialysis
* Pts. receiving HD via
 Native AVF
 HD catheters

5. *Infection Rates
*Dialysis adequacy
* Pts. within the Target of KT/V
*The proportion of patients who are on twice weekly HD
*Patient satisfaction

6. Preservation of residual renal function
*Residual renal function is a predictor of survival in HD
patients (decreases beta-2-microglobulin levels and
lessens the need for ultrafiltration).
*Policies and procedures should be in place to reduce
intradialysis hypotension or excessive UF and avoid the
use of nephrotoxins. (2B)
*monitored at least every 3 months

7. Multidisciplinary Team

8. 1. Awareness about kidney failure
2. Choice of RRT ( HD,PD,TX)
3. Compliance with dietary and fluid instructions and
restrictions
4. Compliance with medication instruction and
dialysis treatment prescription and schedule
5. Significance of Lab test results

9. 6. Importance of caring vascular access
7. Importance of good hygiene and infection control
8. Awarness, prevention and management of HTN, renal
bone disease, sexual and Psychological effects of RF
on patients and their families

10. 1. Discuss social condition of the patient with
doctors and nurses
2. Provide emotional and psychological support for
new patients and families
3. Evaluate home situation

11. 1. Nutritional assessment and reassessment
2. Current malnutrition related to renal failure
3. Diet history and eating habits
4. relation of lab values to the food
5. Review food and fluid intake
6. Educate medical staff on renal nutrition

12. 1. Disinfection of water treatment unit and portable
RO
2. Daily TDS, conductivity and PH
3. Checking all machines maintenance and contact
with the manufacturing companies
4. Awareness of all AAMI standards
5. Check free chlorine test

13. We suggest that machines should be replaced after
between seven and ten years’ service or after
completing between 25,000 and 40,000 hours of use for
hemodialysis, depending upon an assessment of
machine condition. (2C)

14. 1. Chart review
2. Drug related problems
3. Contribute to resolution of drug related problems
4. Educate pt as needed

15. Vascular access

16. 65% of all patients commencing hemodialysis should
commence with an AV fistula
85% of all prevalent patients on HD should
receive dialysis via a functioning AVF
Vascular access planning should commence on CKD
stage 4. (2C)

17. AVF should be placed as a minimum at three months
prior to the commencement of haemodialysis and
probably not more than one year from the expected
date of dialysis.
In individuals in whom an AV graft is deemed to be the
appropriate access, placement can be delayed until a
time closer to the expected date of dialysis.

18. Tunneled catheters should be preferred in all patients..
We recommend that venous catheters should be removed
in all seriously ill haemodialysis patients with catheter
related bacteraemia unless no alternative vascular access
can be achieved. (1B)

19. Catheter related bacteraemia episodes are relatively common
Higher rates of mortality and morbidity related to an increased
incidence of metastatic infection (e.g. discitis, endocarditis).
The annual Staphylococcus aureus bacteraemia rate should be
less than 2.5 episodes per 100 HD patients and less than 1.0 for
MRSA over 2 years

22. Water treatment unit

23. We recommend that the complete water treatment, storage
and distribution system should meet the requirements of
AAMI
The worst way to hurt patients is through the water
system, so it is expected that you know what is going on.

24.  TDS, and conductivity daily
 Microbiological culture and endotoxin assay. Monthly
 Chemical assay every sex months

25. A programme of improvement should begin immediately
if routine monitoring demonstrates that concentrations
of chemical contaminants exceed the maximum
allowable limits of AAMI. (1B)

26. Maxium recommended concentration (mg/l=ppm)
Aluminium 0.01
Calcium 2 (0.05mmol/l)
Total chlorine* 0.1
Copper 0.1
Fluoride 0.2
Magnesium 2 (0.08 mmol/l)
Nitrate (as N) 2 (equates to 9 mg/l NO3)
Potassium 2 (0.05 mmol/l)
Sodium 50 (2.2 mmol/l

27. Maximum allowable concentrations of chemical
contaminants in dialysis water which will be
monitored when indicated.(mg/l = ppm)
Barium 0.1
Beryllium 0.0004
Silver 0.005
Thallium 0.002
Zinc 0.1

28. . The microbiological quality of the dialysis fluid should
not exceed the limits specified in AAMI Quality of
dialysis fluid for haemodialysis and related therapies
(100 CFU/ml for bacteria and 0.25 EU/ml for
endotoxin).

29. If routine monitoring demonstrates microbiological
contaminant levels in excess of 50 CFU/ml and 0.125
EU/ml for bacteria and endotoxin (50% of the maximum
permitted levels) a programe of corrective measures
should be commenced immediately. (1B)

30. We recommend that a routine testing procedure for
water for dialysis should form part of the renal unit
policy.
Each unit should have standard operating procedures in
place for sampling, monitoring and recording of feed
and product water quality.

31. Infection Control

32.  What is your staff doing with hand hygiene, how do
they handle things that are shared?
 How do you prevent hepatitis spread?
 Are nurses changing gloves between patients,.
 Do you have hand washing sinks distinct from dirty
sinks?
 Can you access water hands free?

33.  What is the staff doing with the gloves. Are they
taking the gloves to the clean areas?
 How are you doing disinfection?
 How are you allowing for things that are done
between two patients?

34. Hepatitis B:
◦ Hepatitis B screening
◦ Patient serological status
◦ Vaccination, patients/staff
◦ Isolation practices
Infection control education
 Hepatitis B can survive on an inanimate surface for
several days, hence the precautions in dialysis units are
much more stringent than universal precautions.

35. Morbidities and Mortalities

36. Documentation

37. Manual of Hemodialysis

38.  Policies and procedures (patient related)
1-Dialysis request and patient specific care
2-Assessment of medical status of patient
3-Iniating & discontinuing dialysis treatment
4-Nursing care during dialysis
5-Fluid management of dialysis
6-Intravenous drug administration
7-Anticoagulant regimens

39. 8- Diagnostic testing including frequency
9- Managing vascular access
10- Adequacy of dialysis
11- Code blue arrest protocols
12- Management of complications
13- Dialyzer selection and priming
14- Water treatment & monitoring of quality
15- Preparation and monitoring of Dialyzate

40.  Infection Control
1-immunization guidelines
2-Infection prevention:
A. Cleaning procedures
B. Hand Washing
C. Handling of infectious waste
D. Handling of infected/contagious patient

41.  Equipment
1. Operating and service manual
2. Record of repair
Dress code in the treatment area

42.  Safety
1. General safety
2. Infection Control
3. Storing & handling of hazardous wast
4. Electrical safety
5. Fire safety
6. Needle injury with contaminated item
7. Staff immunization

43.  House keeping: Daily, weekly and monthly
1. Standard precautions
2. Transport of soiled materials
3. Soap/antiseptic use and dispensing

44.  Monthly
 Creatinine,BUN,URR,Na,K,Ca,Po4,ALT,Albumin,
Glucose, CBC
 Every 3 months
 Iron pannel
 Viral screening
 Every 6 months
 Lipid profile
 PTH

45. Mission
Vision
Goals

46. It is the time to take step
forward

50. High flux HD membranes
Lower serum albumin (<4g/dL) ,DM
or who have been on HD for more than
3.5 years. (2B)
The reduction ratios of beta-2-microglobulin after HDF
were 75%, after high flux HD were 60% and after low
flux HD were 20%