DIALYSISVARIOUS MODALITIES AND INDICES USED      GUIDE :- DR. ATKAR SIR      STUDENT :- DR. ABHAY MANGE
Introduction   Dialysis from Greek dialusis= dissolution.   Dialysis is process by which the solute composition of a sol...
Initiation of dialysis in ESRD   Preparation for kidney failure:   CKD- stage 4 (estimated GFR < 30 mL/min/1.73 m2) shou...
Indications for dialysis
GENERAL PRINCIPLES OF DIALYSIS             Diffusion             Ultrafiltration
Diffusion   Movement of solute Across    semipermeable membrane From    region of high concentration to low    concentrat...
Ultrafiltration (UF)   UF occurs when water driven by    either a hydrostatic or an osmotic    force is pushed through th...
Hemofiltration and hemodiafiltration All ultrafiltered solutes below the    membrane pore size are removed at    approxim...
MODALITIES OF DIALYSIS    Intermittent1.Intermittent hemodialysis (IHD)2 .SLED, sustained low efficiency/Extended Daily D...
Hemodialysis
Hemodialysis apparatus    Blood access    Blood tubing    Blood pump    Dialyzer    Air traps    Air detectors    P...
The Hemodialysis Membrane:Dialyser   In place of glomeruli and tubules the point of exchange for HD is the    membrane in...
Dialyser   The structural          composing    dividing dialyzers into1.Cellulosic-cuprophane and cellulose   acetate, u...
Dialyser   Dialyzers are classified as   1.Conventional-    Has a membrane that is homogenous and permits effective sma...
Dialysate Circuit   In some large units, dialysate is made as a batch and stored in tanks then    simply delivered to eac...
Water Treatment   HD patients are exposed to 600 L of dialysis water a week   Water treatment systems used by dialysis c...
Hazards Associated with Dialysis Water
Microbiology of Hemodialysis Systems   Primary contaminants are water bacteria,- gram-negative bacteria, and    non tuber...
VASCULAR ACCESS   Planning for access in ESRD -when patients enter CKD stage -4   Fistula should be placed at least 6 mo...
Types of Vascular Access   Venous Access   External shunt   Internal shunt       AV fistula       AV graft
Arteriovenous Fistula   Radio-Cephalic   Brachio-cephalic   Brachio-basilic   Brachial-perforating vein fistula    (Gr...
Arterio-venous Grafts   If a primary AV fistula cannot be established,    a synthetic AV graft is the next preferred   M...
Venous Catheters   For less than 3 weeks duration   Cuff/uncuffed   For patients with AKI, poisoning, in the ICU    set...
Anticoagulation for Hemodialysis   Interaction of plasma with the dialysis membrane produces activation of the    clottin...
Anticoagulation for Hemodialysis   Systemic administration   50 to 100 U/kg of heparin at the initiation followed by a b...
Anticoagulation for Hemodialysis   Regional anticoagulation,   The extracorporeal circuit alone is anticoagulated by   ...
Anticoagulation for Hemodialysis   Low-molecular-weight heparin (LMWH)   Improvement of lipids,less osteoporosis,less pr...
DIALYSIS PRESCRIPTIONComponents of the Dialysis Prescription   Dialyzer (membrane, configuration, surface area)   Time ...
DIALYSIS PRESCRIPTION-DIALYZER TYPE   Capacity for solute clearance: Ideal dialyzer should have high clearance    of smal...
THE DIALYSIS PRESCRIPTION-Time and Blood flow   Length of treatment   Clearance of a HMW solute can be increased by leng...
DIALYSIS PRESCRIPTION:Dialysate flow /UF rateDialysate flow   Practical upper limit of effective dialysate flow is twice ...
THE DIALYSIS PRESCRIPTION-Dialysate Composition   Sodium-   Standard to have a dialysate Na+ similar to plasma Na+   Hi...
THE DIALYSIS PRESCRIPTION-Dialysate Composition   Potassium   Dialysate K - 1-3mEq/L is used in most patients   Low K+ ...
THE DIALYSIS PRESCRIPTION-Dialysate CompositionBuffer.  Acetate: Biochemically more stable and less frequent bacterial c...
THE DIALYSIS PRESCRIPTION-Dialysate Composition   Chloride.   Major anion in dialysate   Dialysate chloride determined ...
Composition of typical dialysis solutionCOMPONENT        meq/l   Na+          135-145   K+           0-4   Ca ++       ...
DIALYSIS PRESCRIPTION   Temperature.   Dialysate temperature is maintained between 36.5°C and 38°C at inlet of    dialyz...
Rx: Acute hemodialysis   Session length: Perform hemodialysis for 4 hours   Blood flow rate: 350 mL per minute   Dialyz...
Measurement of dialysis dose/Adequacy   Urea reduction ratio (URR)     URR= PREDIALYSIS BUN-POSTDIALYSIS BUN x 100       ...
Measurement of dialysis dose   Single-Pool urea kinetics.           = SP Kt                  V   K- is the dialyzer bloo...
INTRADIALYTIC COMPLICATIONS     1.Hypotension-Most common (incidence, 15% to 30%)     2.Muscle Cramps     3.Dialysis Di...
Chronic complications of HD   Anemia   Cardiovascular Disease   Vascular Calcification   Calciphylaxis   Nephrogenic ...
Daily HD/Nocturnal HD   Short daily HD (DHD)-   Five to seven treatments/ week, each lasting 1.5 to 2.5 hours   Using h...
SLED(D) : Hybrid therapy    Conventional dialysis equipment    Typically , use low blood-pump speeds of 200 mL/min and l...
Clinical indication of HD   HD for end-stage renal disease:   Conventional HD   Daily HD   Short daily HD   Nocturnal...
Continuous Renal Replacement Therapy
Introduction CRRT   CRRT emerged as a viable modality for management of hemodynamically    unstable patients with ARF.  ...
Indications for CRRT   Hemodynamically unstable patients with the following diagnoses may    be candidates for CRRT:   F...
Advantages of using CRRT   Suitable for use in hemodynamically unstable patients.   Precise volume control, which is imm...
The machine circuit in CRRT   A double lumen catheter.   Blood flow - usually set at 120ml/min.   Anticoagulant – to pr...
Slow continuous ultrafiltration (SCUF)   In SCUF -volume ultrafiltration at a    rate of 100 to 300 mL/h is performed    ...
Continuous Veno-Venous Hemofiltration     (CVVH)   In CVVH, solute clearance occurs by convection   No dialysate is used...
Continuous Veno-Venous Hemodialysis(CVVHD)               CVVHD employs diffusion to replace renal function.             ...
Continuous Veno-Venous Hemodifiltration     (CVVHFD)   CVVHDF- the patient is placed on the CRRT    machine with dialysat...
Hemoperfusion   Hemoperfusion is the method by which    anticoagulated blood is passed through a    column containing sor...
Peritoneal Dialysis
INTRODUCTION   PD involves the transport of solutes and water across a membrane• that separates    two fluid-containing c...
PERITONEAL MEMBRANE ANATOMY             Surface area - ranges from 1 to 2 m2 in an adult.             Visceral- 90% ,its...
PERITONEAL MEMBRANE HISTOLOGY   The peritoneal membrane is lined by    mesothelial cells .                               ...
PERITONEAL TRANSPORT              Three-pore model, used to develop the concept               of effective peritoneal sur...
PERITONEAL EQUILIBRATION TEST(PET)   First described by Twardowski in 1987   Standard test - to assess peritoneal transp...
PET: Sampling   Blood sample glucose/ creatinine : 0,2,4 hour   Dialysate sample:     200 ml of dialysis solution is dr...
PET   High transporters   Achieve most rapid and complete equilibration for creatinine and urea,    because they have a ...
PET   Low transporters,   Have slower and less complete equilibration for creatinine, reflecting low    membrane permeab...
PERITONEAL CLEARANCE   Clearance for a given solute is defined as the volume of plasma cleared of    that solute per unit...
THE PERITONEAL CATHETERAcute catheters-   Straight or slightly curved, relatively rigid ,side holes at the distal end.  ...
PERITONEAL CATHETERS   Straight Tenckhoff - deep and superficial cuff extrusion   Curled Tenckhoff - designed to reduce ...
Types of peritoneal catheters
PERITONEAL DIALYSIS SOLUTIONS CAPD solutions are available in volumes of 1.5, 2.0, 2.25, 2.5, or 3.0 L    Constituents o...
PERITONEAL DIALYSIS SOLUTIONS1.Osmotic Agent   Glucose , amino acids and polyglucose are availableA .Glucose.   Standard...
PERITONEAL DIALYSIS SOLUTIONSB.Amino Acids.    1.1% amino acid solutions results in ultrafiltration and solute clearance ...
PERITONEAL DIALYSIS SOLUTIONS2.PH –   Traditional lactate-based PD solutions is lowered to about 5.5 to minimize    gener...
PERITONEAL DIALYSIS SOLUTIONS4.Sodium –   sodium levels are set at about 132 to134 mM   Higher sodium concentrations wou...
PERITONEAL DIALYSIS SOLUTIONS6.CALCIUM-   CAPD solutions containing 2.0 to 2.5 mEq/L used    goal of reducing the incide...
Prescription of PD
THE PERITONEAL MODALITIES1.CONTINUOUS AMBULATORY PERITONEAL DIALYSIS (CAPD)2.AUTOMATED PERITONEAL DIALYSIS (APD)   CONTIN...
CAPD   CAPD, dialysis solution is constantly present in    the abdomen   Usually involves 4 exchanges of 1.5 to 2.5 L of...
AUTOMATED PERITONEAL DIALYSIS   APD, using a cycler, is now the fastest-growing    modality   Requires a cycling machine...
CCPD   Patient carries PD solution in the    abdominal cavity throughout the day but    performs no exchanges and is not ...
NIPD   Patient drains out fully at the end of the    cycling period, and so the abdomen is    dry day.   Because of the ...
Tidal peritoneal dialysis (TPD)   TPD was designed to optimize solute    clearance by leaving a large volume of    dialys...
HYBRID REGIMENSNight exchange device   This system was designed to provide a single extra exchange for CAPD    patients, ...
PD PLUS   CCPD does not provide adequate clearances for    some patients once residual renal function is lost.   Additio...
CLEARANCE TARGETS   TARGET Kt/V on peritoneal dialysis - 2 per week   Kt = Total Kt = peritoneal Kt+ renal Kt   Periton...
CLEARANCE TARGETS   CrCl (creatinine clearance)   CrCl = total CrCl corrected for 1.73 m2 body surface area   Total CrC...
Minimal Recommendations for PD Dose   DOQI                 CAPD    CCPD         NIPD   Kt/V per wk   2.0     2.1          ...
COMPLICATIONS OF PDA . Infectious Complications   B . Noninfectious Complications   1.Peritonitis                 1.Cath...
Acute Peritoneal Dialysis
ACUTE PERITONEAL DIALYSIS   Acute PD provides the nonvascular alternative for dialysis.   PD like other CRRT used in the...
Indications for acute PD   a. Uraemic encephalopathy   b. Severe metabolic acidosis   c. Diuretic resistant hypervolaem...
Contraindications for acute PD   Absolute                               Relative contraindications    contraindications ...
Peritoneal catheter -Acute PD   Use of an uncuffed temporary catheter,   Which will have to be replaced after 3 days is ...
Prescription of acute PD   1.Length of the dialysis session   2.Dialysate composition   3.Exchange volume   4.Exchange...
Prescription of acute PD1.length of the dialysis session PD orders for only 24 hours at a time2.Exchange volume Commonly...
Prescription of acute PD3.Dialysis solution dextrose concentration   Standard 1.5% dextrose - remove 50 to150 mL /hr 2-L ...
Prescription of acute PD5.Additive to dialysate1.Potassium: 3-5 mEq/L in PDF2.Heparin – 1000-2000 u/2 L -prevent clot3.Ins...
Complications of acute PD1.Mechanical complications   Pain on inflow   Localized outflow pain   Visceral perforations •...
DIALYSIS IN TREATMENT OF POISONINGIndications   Progressive deterioration despite intensive supportive therapy   Severe ...
CHOICE OF THERAPY   Peritoneal dialysis (PD)   Is not very effective in removing drugs from the blood,   When HD is dif...
CHOICE OF THERAPY   Hemoperfusion   More effective than hemodialysis in clearing the blood of many protein-    bound dru...
References   Handbook of Dialysis- 4th Edition;-Daugirdas, John T.; Blake, Peter G.;    Ing, Todd   Brenner and Rector;-...
Thank You !
Hemodialysis apparatus
Milestones in the development of Modern     Hemodialysis   1861- The process of dialysis was first    described by Thomas...
INTRADIALYTIC COMPLICATIONS3.Dialysis Disequilibrium Syndrome   Characterized by nausea, vomiting, headaches, and fatigue...
INTRADIALYTIC COMPLICATIONS   Treatment of intradialytic hypotension   Decreased ultrafiltration rate (1.5 L/h)   Incre...
INTRADIALYTIC COMPLICATIONS2.Muscle Cramps   Occur with up to 20% of dialysis treatments   Pathogenesis uncertain, but f...
Measurement of Kt/V   Peritoneal Kt/V is calculated by   Performance of a 24-hour collection of dialysate effluent and  ...
EXAMPLE 1    A 50-year-old man weighing 66 kg has no residual renal function. He is on CAPD    with four 2.5-L exchanges ...
Anticoagulation in high risk   Within 7 days of a major surgery or 14 days of intracranial surgery -    without heparin o...
Dialysis solution additives in acutePD   When injecting any additive into dialysis solution containers, meticulous steril...
INTRADIALYTIC COMPLICATIONS6.Dialyzer ReactionsFirst-use syndrome   Anaphylactoid reaction to new dialyzers made of cupro...
Factors determining clearance in PDpatients   Nonprescription factors    Residual renal function    Body size    Peritone...
INTRADIALYTIC COMPLICATIONS4 .Arrhythmia   Changes in potassium concentration   Can be precipitated by hypotension and c...
TAC Urea   Lowrie et al, who published the National Cooperative    Dialysis study of 151 patients in 1981, thought that  ...
Why was urea chosen?   Why not creatinine or beta2 microglobulin?   Since the BUN is dependent on both dietary urea    p...
INTRADIALYTIC COMPLICATIONS10.Toxic water system treatment contaminants   Chloramine -hemolysis   Copper -anemia   Alum...
KT/V   In this formulaDeveloped in 1985, as TAC urea was    not felt to be an adequate marker of adequacy   Gotch FA; Sa...
Calculation of KT/V   KT/V = -ln (R – 0.03) + [(4 – 3.5R) times (UF    divided by W)]     where UF is UF volume, W is th...
Post-dialysis BUN   Both access and cardiopulmonary recirculation are    prominent at the end of dialysis, so the post di...
Equilibrated (Double Pool) KT/V   Measurement of post dialysis BUN at the very end of    dialysis overestimates the degre...
   Step 1: Estimate the patients V.   Step 2: Multiply V by the desired Kt/V to get the required K × t.   Step 3: Comp...
Stop dialysate flow technique-for eKT/V   In a study of 70 patients in Glasgow, the 30 minute    post dialysis BUN was co...
Adequacy metrics   URR-CMS says it should be greater than 65%; 70    % is more reasonable   spKT/V-should be greater tha...
   In NIPD (row 1 in Fig. 19-3),    the patient drains out fully at the    end of the cycling period, and so    the abdo...
Drug              Preferred MethodCarbamazepine        HPEthylene glycol      HDLithium              HDMethanol           ...
Why weekly Kt/V and CrCl ?     Uremic Sx      No of    exchange   Overall small MW clearance is    most closely related ...
Salicylate poisoning   Indications for dialysis:     severe metabolic acidosis     serum level > 100 mg/dL (acute OD)  ...
THE PERITONEAL MODALITIES                  Continuous ambulatory PD                   (CAPD))                  Continuou...
Theophylline poisoning   Indications for dialysis:     serum  level > 100 mg/L (acute OD)     level > 60-80 mg/L? (chro...
Methanol, Ethylene Glycol   Indications for dialysis:     elevated level > 50 mg/dL     severe acidosis     increased ...
Weekly Kt/V & CrCl   Peritoneal Kt = DUN / BUN x PD drain vol            -- (2)   Renal Kt = UUN / BUN x 24H Urine vol  ...
Phenobarbital   Indications for dialysis:     level > 190-200 mg/L     failure of supportive care (ie, intractable hypo...
Lithium   Indications for dialysis:     serum  level > 6? 8? 10? (acute OD)     level > 4 ? (chronic)     level 2.5-4 ...
continuous veno-venoushemodialysis   In continuous venovenous hemodialysis, a dialysate solution runs countercurrent to t...
Criteria of PD adequacy
Acute Peritoneal Dialysis Orders   Nursing orders:       Dialysis to run_________hours       Exchange volume:_________L...
Selection for HD/PD   Clinical condition   Lifestyle   Patient competence/hygiene (PD - high risk of    infection)   A...
Physiology of peritoneal transport   depends on the following factors1.    The concentration gradient,2.    Effective per...
Prisma Haemodiafiltration
CAPDCCPDNPD
Milestones in the development of ModernHemodialysis                            :Thomas Graham (1805-1869)   The First Hemo...
Milestones in the development of ModernHemodialysisGeorge Haas used a collodiontube arrangement to successfully   George H...
Dialysis various modalities and indices used
Dialysis various modalities and indices used
Dialysis various modalities and indices used
Dialysis various modalities and indices used
Dialysis various modalities and indices used
Dialysis various modalities and indices used
Dialysis various modalities and indices used
Dialysis various modalities and indices used
Dialysis various modalities and indices used
Dialysis various modalities and indices used
Dialysis various modalities and indices used
Dialysis various modalities and indices used
Dialysis various modalities and indices used
Dialysis various modalities and indices used
Dialysis various modalities and indices used
Dialysis various modalities and indices used
Dialysis various modalities and indices used
Dialysis various modalities and indices used
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  • +3Blood cells are too big to pass through the dialysis membrane,  but body wastes begin to diffuse (pass) into the dialysis solutionDiffusion is complete. Body wastes have diffused through the membrane,  and now there are equal amounts of waste in both the blood and the  dialysis solution.
  • variant of regional anticoagulation uses sodium citrate with dialysate containing no calcium, administered in the arterial line to bind calcium, as an important co-factor in the coagulation cascade. Coagulation of the circuit is thus inhibited.Before the blood is returned to the patient, a calciuminfusion is administered via the venous line and the abilityof the blood to clot is restored.
  • Low-molecular-weight heparin (LMWH)Improvement of lipidspossibly: less osteoporosis,lesspruritus, less hair loss,less blood transfusionscompared with UFHMonitoringrequiresmeasurement of anti-factorXa-activity in venous line(aPTT and ACT areunreliable) Direct thrombin inhibitors HirudinLepirudinArgatroban In HIT type II Dose applies to high-flux-dialyzer:1st HD:bolus: 0.1 mg/kg; for subsequent HDs dosedepends on aPTT before HD:bolus: 0.05 to 0.1 mg/kgHigh risk of bleeding complications; noantidote available; target hirudin levels: 0.5to 0.8 mg/mL target aPTT 50 to 75 s Danaparoid In HIT type I
  • Hemodynamically unstable patients with the following diagnoses may be candidates for CRRT:fluid overloadacute renal failurechronic
  • Dialysis various modalities and indices used

    1. 1. DIALYSISVARIOUS MODALITIES AND INDICES USED GUIDE :- DR. ATKAR SIR STUDENT :- DR. ABHAY MANGE
    2. 2. Introduction Dialysis from Greek dialusis= dissolution. Dialysis is process by which the solute composition of a solution ―A‖ is altered by exposing it to a second solution ―B‖ through a semi-permeable membrane . Is a process for removing waste and excess water from the blood Used as artificial replacement for lost kidney function The goal of dialysis is to remove accumulated fluid and toxins to maintain their concentrations below the levels at which they produce uremic symptoms.
    3. 3. Initiation of dialysis in ESRD Preparation for kidney failure: CKD- stage 4 (estimated GFR < 30 mL/min/1.73 m2) should receive timely education about kidney failure and options for treatment Timing of therapy: Stage 5 CKD ,estimated GFR < 10mL/min/1.73m2 in diabetics and GFR < 15 mL/min/1.73m2 nondiabetics, respectively. Particular clinical considerations and certain characteristic complications - prompt early therapy
    4. 4. Indications for dialysis
    5. 5. GENERAL PRINCIPLES OF DIALYSIS  Diffusion  Ultrafiltration
    6. 6. Diffusion Movement of solute Across semipermeable membrane From region of high concentration to low concentration Diffusion depends on Concentration gradient Molecular wt. of solute Velocity of molecule in solvent Membrane resistance Membrane surface area Pore size and Duration
    7. 7. Ultrafiltration (UF) UF occurs when water driven by either a hydrostatic or an osmotic force is pushed through the membrane Those solutes that can pass easily through the membrane pores are swept along with the water called solvent drag The rate of UF will depend on the total pressure difference across the membrane (TMP)
    8. 8. Hemofiltration and hemodiafiltration All ultrafiltered solutes below the membrane pore size are removed at approximately the same rate. This principle has led to use of a technique called hemofiltration, whereby a large amount of ultrafiltration is coupled with infusion of a replacement fluid in order to remove solutes. Some times hemodialysis and hemofiltration are combined. The procedure is then called hemodiafiltration
    9. 9. MODALITIES OF DIALYSIS Intermittent1.Intermittent hemodialysis (IHD)2 .SLED, sustained low efficiency/Extended Daily Dialysis (Hybrid therapies) Continuous1.Peritoneal dialysis2.Continuous renal replacement therapy A . SCUF: Slow continuous UF B .CAVH or CVVH: Continuous AV/venovenous hemofiltration C .CAVHD or CVVHD: Continuous AV/venovenous HD D .CAVHDF or CVVHDF: ContinuousAV/venovenous Hemodiafiltration
    10. 10. Hemodialysis
    11. 11. Hemodialysis apparatus Blood access Blood tubing Blood pump Dialyzer Air traps Air detectors Pressure monitors“arterial monitor “venous monitor,” Syringe pump Blood leak detector
    12. 12. The Hemodialysis Membrane:Dialyser In place of glomeruli and tubules the point of exchange for HD is the membrane in the dialyzer Surface area, surface charge, and pore size are properties of the membrane , govern the molecules that can diffuse from blood to the dialysate. Membranes that produce little interaction with blood components are biocompatible. Reuse -should have a blood compartment volume not less than 80% of the original or a urea clearance not less than 90% of the original clearance.
    13. 13. Dialyser The structural composing dividing dialyzers into1.Cellulosic-cuprophane and cellulose acetate, use is in decline.2.Semisynthetic, and3.Synthetic - Polyacrylonitrile (PAN) and polysulfone (PS) Dialyzers may be formatted as1. Hollow fiber2. Parallel-plate
    14. 14. Dialyser Dialyzers are classified as 1.Conventional- Has a membrane that is homogenous and permits effective small solute clearance, but its clearance of middle molecules is low Cellulose based and permit complement activation 2. High-flux. – Constructed with pores that permit passage of molecules exceeding 10,000 D or more with a clearance Significant binding of protein and peptides from the blood 3.High-efficiency- When the high-flux membrane is chemically modified, hydraulic permeability as well as the permeability to HMW substances is reduced, creating a high efficiency membrane
    15. 15. Dialysate Circuit In some large units, dialysate is made as a batch and stored in tanks then simply delivered to each dialysis station and connected to the machine. In other cases, water that has been treated to remove most elements is sent to the HD machine and then mixed with a dialysate concentrate/Powder Two properties of the dialysate require constant monitoring:-conductivity and temperature. Dialysate circuit Dialysate Dialysate tubing Water treatment system:
    16. 16. Water Treatment HD patients are exposed to 600 L of dialysis water a week Water treatment systems used by dialysis centers produce high-quality water for safe dialysis, Essential Components of Water Purification Temperature-blending valves -mix incoming hot and cold water to provide an optimum water temperature for downstream components. Water softeners- often sodium-containing cation exchange resins- remove calcium, magnesium, and other polyvalent cations from the feed water Granular activated-carbon filters (GAC)- absorb chlorine, chloramines,and other organic substances from the water Primary purification process-Reverse osmosis/Deionization
    17. 17. Hazards Associated with Dialysis Water
    18. 18. Microbiology of Hemodialysis Systems Primary contaminants are water bacteria,- gram-negative bacteria, and non tuberculous mycobacteria Nontuberculous mycobacteria in particular are problematic.They do not produce endotoxins, but they are more resistant to germicides than gram- negative bacteria Pyrogenic reactions (PRs) - incident rate of 0.5% to 12%. PR can be defined as chills and/or fever (temperature>37.8°C ) in a previously afebrile patient with no recorded signs or symptoms of infection before dialysis.
    19. 19. VASCULAR ACCESS Planning for access in ESRD -when patients enter CKD stage -4 Fistula should be placed at least 6 months before the anticipated start of HD treatments. This timing allows for access evaluation and additional time for revision to ensure a working fistula Exact timing of placement of vascular access will be determined by rate of decline renal function
    20. 20. Types of Vascular Access Venous Access External shunt Internal shunt  AV fistula  AV graft
    21. 21. Arteriovenous Fistula Radio-Cephalic Brachio-cephalic Brachio-basilic Brachial-perforating vein fistula (Gracz ) Complications Stenosis,thrombosis, Ischemia and edema of limb, Pseudoaneurysm,infection,ccf
    22. 22. Arterio-venous Grafts If a primary AV fistula cannot be established, a synthetic AV graft is the next preferred Made of ePTFE(Polytetrafluoroethylene) also known as Gortex Procedure- graft to the artery, a tunneling under the skin, and anastomosis to a vein. Can be used 2 wks after insertion Expected to last 3 to 5 years Complications:- clotting,aneurysms and infection
    23. 23. Venous Catheters For less than 3 weeks duration Cuff/uncuffed For patients with AKI, poisoning, in the ICU setting for CRRT Short-term bridge until more permanent access in CKD Preferred site - right internal jugular vein Complications: Thrombosis, Infection, Risk of permanent central venous stenosis or occlusion, Discomfort and cosmetic , Lower blood flow rates Use of subclavian venous catheters is generally contraindicated in dialysis patients except as a last resort.
    24. 24. Anticoagulation for Hemodialysis Interaction of plasma with the dialysis membrane produces activation of the clotting cascade- thrombosis – dysfunction Dialyzer thrombogenicity is determined by Dialysis membrane composition Rate of blood flow through dialyzer and UF rate Length, diameter, and composition of blood lines Most widely used anticoagulant for dialysis is heparin Monitor - activated clotting time (ACT) /APTT Heparin administration usually ceases at least 1 h before the end of dialysis
    25. 25. Anticoagulation for Hemodialysis Systemic administration 50 to 100 U/kg of heparin at the initiation followed by a bolus of 100 U/hr Target ACT is approximately 50% above baseline Fractional anticoagulation, Bolus of (10–50 U/kg), followed by an infusion of 500 to 1000 U/hr Utilized to achieve less intensive anticoagulation Target ACT is maintained at 25% (fractional) or 15% (tight fractional), above the baseline These approaches generally reserved for patients with a higher risk of bleed.
    26. 26. Anticoagulation for Hemodialysis Regional anticoagulation, The extracorporeal circuit alone is anticoagulated by Administering 500 to 750 U/hr into the arterial line and by the parallel administration of protamine(1 mg /100u) into the venous line Requires frequent checks of the ACT from the arterial and venous line Variant of regional anticoagulation Uses sodium citrate with dialysate containing no calcium, For patients at high bleeding risk, Dialysis without any anticoagulation. Using the saline flush technique HD is initiated at a high blood flow rate to reduce thrombogenicity, and the Dialyzer is flushed every 15 to 60 minutes with 50 mL of saline. Used in pericarditis,recent major surgery ,IC bleed/surgery
    27. 27. Anticoagulation for Hemodialysis Low-molecular-weight heparin (LMWH) Improvement of lipids,less osteoporosis,less pruritus, less hair loss,less blood transfusions compared with UFH Direct thrombin inhibitors Hirudin ,Lepirudin ,Argatroban -In HIT
    28. 28. DIALYSIS PRESCRIPTIONComponents of the Dialysis Prescription Dialyzer (membrane, configuration, surface area) Time Blood flow rate Dialysate flow rate Ultra filtration rate Dialysate composition Dialysate temperature Anticoagulation
    29. 29. DIALYSIS PRESCRIPTION-DIALYZER TYPE Capacity for solute clearance: Ideal dialyzer should have high clearance of small- and middle-molecular weight uremic toxins and Negligible loss of vital solutes Biocompatibility: Cost Low blood volume compartment UF coefficient (KUF)-determines quantity of pressure that must be exerted across dialysis membrane to generate a ultrafiltrate High-flux membranes are defined a having >UF coefficient 15 mL/h/mm Hg Acceptable reuse parameters, the fiber bundle volume must be >80% of the initial , UF rate must >20% of the manufacturer‘s stated value, and the dialyzer should not leak .
    30. 30. THE DIALYSIS PRESCRIPTION-Time and Blood flow Length of treatment Clearance of a HMW solute can be increased by lengthening HD Increasing time decreases LMW solute removal and does not result in equivalent increases in LMW solute removal -diminishing return Blood flow As blood and dialysate flow rates increase,resistance and turbulence within dialyzer also increase leads to decline in clearance per unit time Increase blood flow ,Efficacy of vascular access may affect solute clearance due to recirculation
    31. 31. DIALYSIS PRESCRIPTION:Dialysate flow /UF rateDialysate flow Practical upper limit of effective dialysate flow is twice blood flow rate, beyond which gain in solute removal is minimal High flow rates should be confined to blood flows >300 mL/minUF rate prescription. Goal is to achieve estimated dry weight Tolerance determined by vascular refilling UF modeling may reduce intradialytic complication On-line monitoring of blood volume changes may help prescription
    32. 32. THE DIALYSIS PRESCRIPTION-Dialysate Composition Sodium- Standard to have a dialysate Na+ similar to plasma Na+ Higher dialysate Na+- in patients prone to intradialytic hypotension Hyponatric dialysate- prevent interdialytic hypertension,exaggerated thirst, and excessive interdialytic weight gain. Hyponatric dialysate, -interdialytic decline in plasma osmolality result in dialysis disequilibrium, Sodium modeling or sodium ramping, in which the initial dialysate sodium concentration is greater than or equal to 145 mEq/L and second half session is abruptly reduced Historically,- hyponatric levels (130–135 mEq/L) to favor diffusive sodium loss during the dialysis
    33. 33. THE DIALYSIS PRESCRIPTION-Dialysate Composition Potassium Dialysate K - 1-3mEq/L is used in most patients Low K+ should be used with caution due to association between use of Low K+ dialysate with SCD Calcium. Patients with hypocalcemia, positive intradialytic calcium balance may be desired for control of metabolic bone disease Standard dialysate calcium -2.5-3.0 mEq/L is used Dialysate calcium also affect hemodynamic stability during HD procedure
    34. 34. THE DIALYSIS PRESCRIPTION-Dialysate CompositionBuffer. Acetate: Biochemically more stable and less frequent bacterial contamination Associated with cardiovascular instability and intradialytic hypotension due to slow conversion of acetate into bicarbonate Acetate accumulation also can cause nausea, vomiting, headache, fatigue,decreased myocardial contractility, peripheral vasodilatation, and arterial hypoxemia Bicarbonate: Replaced acetate as standard dialysate buffer Dialysate bicarbonate concentrations of 30-35 mEq/L now commonly used
    35. 35. THE DIALYSIS PRESCRIPTION-Dialysate Composition Chloride. Major anion in dialysate Dialysate chloride determined to maintain electrical neutrality Glucose. Osmotic agent for UF Optimal 100-200 mg/dL for most patients High dialysate glucose (>200 mg/dL)- increases risk for hyperosmolar syndrome, postdialysis hyperglycemia and hyponatremia,and hypertriglyceridemia Glucose-free dialysate may potentiate hypoglycemia (especially in DM) Magnesium Many centers use a dialysate magnesium concentration of 1 mEq/l
    36. 36. Composition of typical dialysis solutionCOMPONENT meq/l Na+ 135-145 K+ 0-4 Ca ++ 2.5-3.5 Mg++ 0.5-0.75 Cl- 98-124 Acetate 2-4 Hco3- 30-40 Dextrose 11 g PH 7.1-7.3
    37. 37. DIALYSIS PRESCRIPTION Temperature. Dialysate temperature is maintained between 36.5°C and 38°C at inlet of dialyzer Lower dialysate temperature may reduce intradialytic hypotension and also increase cardiac contractility, improve oxygenation,increase venous tone New accurate monitors allow isothermic HD Microbiological characteristics Medical Instrumentation standards
    38. 38. Rx: Acute hemodialysis Session length: Perform hemodialysis for 4 hours Blood flow rate: 350 mL per minute Dialyzer:-Dialyzer membrane: choice Dialysis solution composition (variable): Dialysis solution flow rate: 500 mL per minute Dialysis solution temperature: 35 to 36°C Fluid removal orders:-Use ultrafiltration control device/Remove 2.2 L over 4 hours at a constant rate Anticoagulation orders
    39. 39. Measurement of dialysis dose/Adequacy Urea reduction ratio (URR) URR= PREDIALYSIS BUN-POSTDIALYSIS BUN x 100 PREDIALYSIS BUN The fractional decrease in BUN during a single HD Simple to calculate K/DOQI guidelines suggest urea reduction ratio at least 65%
    40. 40. Measurement of dialysis dose Single-Pool urea kinetics. = SP Kt V K- is the dialyzer blood water urea clearance (L / hour), t - is the time on dialysis(hr) V- is the volume of total body water(L) Most commonly applied method for quantifying HD in clinical practice KDOQI-2006 adequacy guidelines = 1.2
    41. 41. INTRADIALYTIC COMPLICATIONS  1.Hypotension-Most common (incidence, 15% to 30%)  2.Muscle Cramps  3.Dialysis Disequilibrium Syndrome  4.Dialyzer Reactions First-use syndrome/ second-use syndrome  5.Arrhythmia  6.Cardiac arrest  7.Intradialytic Hemolysis  8.Hypoglycemia  9.Hemorrhage  10.Toxic water system treatment contaminants- hemolysis/anemia/osteomalacia and encephalopathy/Fluoride bone disease and cardiac arrhythmia  11.Infectious complications
    42. 42. Chronic complications of HD Anemia Cardiovascular Disease Vascular Calcification Calciphylaxis Nephrogenic Systemic Fibrosis Nutrition Infection
    43. 43. Daily HD/Nocturnal HD Short daily HD (DHD)- Five to seven treatments/ week, each lasting 1.5 to 2.5 hours Using high-flux membranes at blood flow rates greater than 400 mL/min and dialysate flow rates of 500 to 800 mL/min. This form of therapy is associated with a significant improvement in serum albumin levels. Nocturnal HD (NHD) Five to seven times per week, each lasting 6 to 8 hours, Using biocompatible membranes at blood flow rates of 200 to 300 mL/min and dialysate flows of 200 to 300 mL/min Personal preference is the major arbiter of this regimen selection Large interdialytic weight gains may benefit
    44. 44. SLED(D) : Hybrid therapy  Conventional dialysis equipment  Typically , use low blood-pump speeds of 200 mL/min and low dialysate flow rates of 300 mL /min for 6 to 12 hours daily  Excellent small molecule detoxification  Cardiovascular stability as good as CRRT  Reduced anticoagulation requirement  11 hrs SLED comparable to 23 hrs CVVH  Decreased costs compared to CRRT  SLED allows units where CRRT equipment or personnel are unavailable to offer a treatment modality that should achieve similar benefits as CRRT
    45. 45. Clinical indication of HD HD for end-stage renal disease: Conventional HD Daily HD Short daily HD Nocturnal HD HD for acute renal failure: Conventional HD Slow low-efficiency dialysis (SLED) Continuous renal replacement therapy:
    46. 46. Continuous Renal Replacement Therapy
    47. 47. Introduction CRRT CRRT emerged as a viable modality for management of hemodynamically unstable patients with ARF. ( as in septic shock , AMI , severe GI bleeding ,ARDS or condition with or at risk for cerebral edema) Treatment occurring 24 hours a day Blood flow of 100 to 200 mL/min Dialysate flow of 17 to 40 mL/min CRRT membranes that are high flux - higherly permeable to water , LMW solutes. Classified by access type and method of solute clearance. Current technology permits any of these treatments with the same machine
    48. 48. Indications for CRRT Hemodynamically unstable patients with the following diagnoses may be candidates for CRRT: Fluid overload Acute renal failure Chronic renal failure Life-threatening electrolyte imbalance Major burns with compromised renal function Drug overdose Contraindications for CRRT Patient or family refusal of therapy Inability to establish vascular access
    49. 49. Advantages of using CRRT Suitable for use in hemodynamically unstable patients. Precise volume control, which is immediately adaptable to changing circumstances. Very effective control of uremia, hypophosphatemia and hyperkalemia. Rapid control of metabolic acidosis Improved nutritional support (full protein diet). Available 24 hours a day with minimal training. Safer for patients with brain injuries and cardiovascular disorders (particularly diuretic resistant CCF). Complications of CRRT The most common complications encountered include bleeding, infection, fluid & electrolyte imbalances, hypothermia, and hemodynamic instability
    50. 50. The machine circuit in CRRT A double lumen catheter. Blood flow - usually set at 120ml/min. Anticoagulant – to prevent blood clotting on the filter. Dialysis fluid, which runs in countercurrent to the blood, standard rate is 1 L per hour. A bag to collect the ultrafiltrate. Replacement fluid MACHINE-Prisma and Prismaflex systems from CGH Medical Inc. Fresenius USA
    51. 51. Slow continuous ultrafiltration (SCUF) In SCUF -volume ultrafiltration at a rate of 100 to 300 mL/h is performed to maintain fluid balance No fluids are administered either as dialysate or replacement fluids, Indication include volume overload in patients with CCF refractory to diuretics. SCUF cannot be used to provide total renal replacement therapy
    52. 52. Continuous Veno-Venous Hemofiltration (CVVH) In CVVH, solute clearance occurs by convection No dialysate is used. Typically, hourly ultrafiltration rates of 1 to 2 L/h are used Intravenous ‗‗replacement fluid‘‘ is provided to replace the excess volume that is being removed and replenish desired solutes,can be administered either prefilter or postfilter. Effective method of solute removal and Indicated for uremia or severe acidosis or electrolyte imbalance with or without fluid overload Major advantage is that solutes can be removed in large quantities , maintaining a net zero or even a positive fluid balance
    53. 53. Continuous Veno-Venous Hemodialysis(CVVHD)  CVVHD employs diffusion to replace renal function.  Blood flow rate through the is similar to that for continuous hemofiltration.  Dialysate is run through the filter at 1 to 2 L/hr.  This results in a urea clearance of 17 to 34 mL/min,  One can futher increase the clearance of urea by combining hemofiltration with the continuous HD procedure.  CVVHD is very similar to traditional hemodialysis,  Effective for removal of small to medium sized molecules
    54. 54. Continuous Veno-Venous Hemodifiltration (CVVHFD) CVVHDF- the patient is placed on the CRRT machine with dialysate running on the opposite side of the filter and replacement fluid either before or after the filter. Combines the benefits of diffusion and convection for solute removal. The use of replacement fluid allows adequate solute removal even with zero or positive net fluid balance for the patient.. In CVVHDF the amount of fluid in the effluent bag equals the fluid removed from the patient plus the dialysate and the replacement fluid.
    55. 55. Hemoperfusion Hemoperfusion is the method by which anticoagulated blood is passed through a column containing sorbent particles Activated charcoal particles and resin beads contained in hemoperfusion devices have been used Certain resins are most effective for removal of lipid-soluble drugs Antibody- or antigen- coated particle Hemoperfusion devices have been constructed for the removal of specific toxins.
    56. 56. Peritoneal Dialysis
    57. 57. INTRODUCTION PD involves the transport of solutes and water across a membrane• that separates two fluid-containing compartments. These two compartments are (a) the blood in the peritoneal capillaries, (b) the dialysis solution in the peritoneal cavity Popularity because of simplicity, convenience, and relatively low cost. Peritoneal transport comprises three processes Diffusion, ultrafiltration, and absorption The amount of dialysis achieved and the extent of fluid removal depends on the Volume of dialysis solution infused ( dwell), How often this dialysis solution is exchanged, and Concentration of osmotic agent present
    58. 58. PERITONEAL MEMBRANE ANATOMY  Surface area - ranges from 1 to 2 m2 in an adult.  Visceral- 90% ,its blood supply from the superior mesenteric artery, venous drainage via portal system  Parietal 10%, important in PD, receives blood from the lumbar, intercostal, and epigastric and drains into IVC  Blood flow = 50 to 100 mL/min  Lymphatic drainage via stomata in the diaphragmatic peritoneum,
    59. 59. PERITONEAL MEMBRANE HISTOLOGY The peritoneal membrane is lined by mesothelial cells . Mesothelium Under the mesothelium is the interstitium, - a gel-like matrix , peritoneal capillaries and lymphatics Peritoneal membrane - six resistances to solute Sub serosal loose zone transport: 1. Stagnant capillary fluid film 2.Capillary endothelium itself, Blood vessels 3. Endothelial basement membrane, 4. Interstitium, 5. Mesothelium, and 6.Stagnant fluid film overlies mesothelium.
    60. 60. PERITONEAL TRANSPORT  Three-pore model, used to develop the concept of effective peritoneal surface area.  Large pores - 20 to 40 nm,protein  Small pores -4.to 6.0 nm. , Large number of these, Transport of small solutes, such as Urea, creatinine, sodium, Potassium, with water.  Ultrapores (aquaporins) <0.8nm. Transport of water only  Effective peritoneal surface area is the area of the peritoneal surface that is sufficiently close to peritoneal capillaries to play a role in transport
    61. 61. PERITONEAL EQUILIBRATION TEST(PET) First described by Twardowski in 1987 Standard test - to assess peritoneal transport High transporters – Low transporters- High-average and low-average transporter
    62. 62. PET: Sampling Blood sample glucose/ creatinine : 0,2,4 hour Dialysate sample:  200 ml of dialysis solution is drained into the bag, mixed well, a 10 ml sample is taken, and the remaining 190 ml is reinfused back  after 2 and 4 hours, another sample is taken. Calculate –1.D/P creatinine at 2 and 4 hours2. D/D0 glucose at 2 and 4 hours3.Volume of UF in the drainage bag
    63. 63. PET High transporters Achieve most rapid and complete equilibration for creatinine and urea, because they have a relatively large effective peritoneal surface area or high intrinsic membrane permeability . High transporters rapidly lose their osmotic gradient for UF because the dialysate glucose diffuses into the blood through the highly permeable• membrane. High transporters have the highest D/P Cr, values but have low net ultrafiltration and low D/D0 G values. They also have higher dialysate protein losses and so tend to have lower serum albumin values High transporters do best on PD regimens that involve frequent short- duration dwells (e.g., APD),
    64. 64. PET Low transporters, Have slower and less complete equilibration for creatinine, reflecting low membrane permeability or small effective peritoneal surface area. They thus Have low D/P Cr, and high D/D0 G with good net ultrafiltration. Dialysate protein losses are lower, and serum albumin values tend to be higher Low transporters should do best on regimens based on long-duration, high-volume dwells, so that diffusion is maximized High-average and low-average transporters Have intermediate values for these ratios and for ultrafiltration and protein losses
    65. 65. PERITONEAL CLEARANCE Clearance for a given solute is defined as the volume of plasma cleared of that solute per unit time. Clearance is the net result of diffusion plus ultrafiltration minus absorption Peritoneal clearance can be increased by Maximizing time on peritoneal dialysis (i.e., no dry time), Maximizing concentration gradient (i.e., more frequent exchanges as in and larger dwell volumes), Maximizing effective peritoneal surface area (i.e., larger dwell volumes), Maximizing peritoneal fluid removal
    66. 66. THE PERITONEAL CATHETERAcute catheters- Straight or slightly curved, relatively rigid ,side holes at the distal end. A metal stylet or flexible wire -guide insertion Do not have cuffs to protect against incidence of peritonitis Increases prohibitively beyond 3 days of use.Chronic catheters- Constructed from silicone rubber or polyurethane and Usually have two Dacron (polyester) cuffs Dacron cuffs provoke a local inflammatory response that progresses to form fibrous and granulation tissue within 1 month and act as anchor. Chronic catheters function successfully for 2 or more years Implanted by surgical dissection or peritoneoscopy
    67. 67. PERITONEAL CATHETERS Straight Tenckhoff - deep and superficial cuff extrusion Curled Tenckhoff - designed to reduce omental obstruction of the catheter and to minimize inflow pain. More difficult to reposition . Toronto-Western - silastic disc 5 cm apart at the tip of its intra-abdominal part to stabilize it and prevent visceral wrapping, Impossible to reposition Missouri Swan-neck -less omental attachment and catheter migration, no deep and superficial cuff , difficult to reposition No particular catheter is definitively superior to the standard silicon Tenckhoff in terms of outcome Complications of peritoneal catheters ;-pericatheter leak, outflow failure due to migration and omental attachment, and infection of the exit site or catheter
    68. 68. Types of peritoneal catheters
    69. 69. PERITONEAL DIALYSIS SOLUTIONS CAPD solutions are available in volumes of 1.5, 2.0, 2.25, 2.5, or 3.0 L Constituents of PD solutions are1. Osmotic agent2. pH3. GDP content,4. Buffer used;5. Calcium6. Sodium7. K+
    70. 70. PERITONEAL DIALYSIS SOLUTIONS1.Osmotic Agent Glucose , amino acids and polyglucose are availableA .Glucose. Standard dialysis solutions contain glucose as the osmotic agent. Glucose is safe, effective, readily metabolized, and inexpensive. Not an ―ideal‖ because of : rapid absorption; the potential for metabolic derangements Studies have suggested more hypertonic glucose have more rapid deterioration in peritoneal membrane function
    71. 71. PERITONEAL DIALYSIS SOLUTIONSB.Amino Acids. 1.1% amino acid solutions results in ultrafiltration and solute clearance rates similar to those using 1.5% dextrose solutions. for only one dwell daily because of potential to exacerbate uremia and acidosis.C. Icodextrin. This is a mixture of glucose polymers with a mean MW of about 20,000 kD. Icodextrin induces ultrafiltration by oncotic rather osmotic pressure Most useful for the long nocturnal dwell of CAPD and the APD Function in long-term PD patients is better preserved in those using icodextrin as compared with glucose Use limited to one dwell a day, because of its time course of action, its relatively high cost, and possible toxic effects
    72. 72. PERITONEAL DIALYSIS SOLUTIONS2.PH – Traditional lactate-based PD solutions is lowered to about 5.5 to minimize generation of GDPs during heat sterilization Lowering pH further cause infusion pain in patients. A pH of 5.5 on infusion is normally well tolerated, and rises rapidly as bicarbonate diffuses into the peritoneal cavity from the plasma. Dual-chamber bags3.GDPs. Heat sterilization process leads to generation of GDPs, which have toxic effects on the peritoneal membrane. The principal strategy to deal with this is the use of multicompartmental solution bags where the glucose, having been heat-sterilized at a very low pH
    73. 73. PERITONEAL DIALYSIS SOLUTIONS4.Sodium – sodium levels are set at about 132 to134 mM Higher sodium concentrations would lead to less diffusive removal of sodium during dwells. Low-sodium solutions have been proposed as a means of augmenting sodium removal but would likely lead to hyponatremia, as well as a requirement for more glucose to maintain a given osmolarity5.BUFFER- Bicarbonate-based PD solutions are increasingly used. Both pure bicarbonate solutions and bicarbonate/lactate mixtures are available.
    74. 74. PERITONEAL DIALYSIS SOLUTIONS6.CALCIUM- CAPD solutions containing 2.0 to 2.5 mEq/L used goal of reducing the incidence of the hypercalcemia that is sometimes associated with oral calcium and vitamin D administration7. MAGNESIUM- levels of 0.5 or 0.25 mM and this can occasionally result in magnesium depletion8.TEMPERATURE. PD solutions are usually warmed to body temperature prior to inflow.
    75. 75. Prescription of PD
    76. 76. THE PERITONEAL MODALITIES1.CONTINUOUS AMBULATORY PERITONEAL DIALYSIS (CAPD)2.AUTOMATED PERITONEAL DIALYSIS (APD) CONTINUOUS CYCLING PERITONEAL DIALYSIS (CCPD ) NOCTURNAL INTERMITTENT PERITONEAL DIALYSIS (NIPD) TIDAL PD3.HYBRID REGIMENS NIGHT EXCHANGE DEVICE PD PLUS ACUTE PD
    77. 77. CAPD CAPD, dialysis solution is constantly present in the abdomen Usually involves 4 exchanges of 1.5 to 2.5 L of solution daily, with the Night dwell 8 to 9 hours and day dwells 4 to 6 hours each Drainage and inflow of fresh dialysis solution are performed manually, Control of body fluid volume achieved, Normalization of blood pressure is possible in most patients. Disadvantage requirement for multiple procedural sessions and peritonitis
    78. 78. AUTOMATED PERITONEAL DIALYSIS APD, using a cycler, is now the fastest-growing modality Requires a cycling machine called a cycler Main advantage of CCPD is the ability to provide continuous therapy without the need for on/off procedures during the day. Therapy of choice for most patients who require assistance in carrying out their dialysis (e.g., children, the dependent elderly, nursing home residents Main disadvantages of CCPD are the need for a cycler
    79. 79. CCPD Patient carries PD solution in the abdominal cavity throughout the day but performs no exchanges and is not attached to a transfer set. At bedtime, the patient hooks up to the cycler, which drains and refills the abdomen with solution three or more times in the course of the night. In the morning, the patient, with the last dwell remaining in the abdomen, disconnects from the cycler Patient free to go about daily activities.
    80. 80. NIPD Patient drains out fully at the end of the cycling period, and so the abdomen is dry day. Because of the absence of a long- duration day dwell, clearances are generally lower on NIPD than on CCPD, Indicated if there is good residual renal function or If there are mechanical contraindications to walking about with solution in the abdominal cavity (e.g., leaks, hernias, back pain).
    81. 81. Tidal peritoneal dialysis (TPD) TPD was designed to optimize solute clearance by leaving a large volume of dialysis solution in the peritoneal cavity throughout the dialysis session. Initially, the peritoneal cavity is filled with a volume of solution to be as large as possible without causing discomfort-2 to 3 L. 50% tidal volume common The peritoneal cavity is drained completely only at the end of the dialysis session Indications - are poor catheter function or to avoid drain pain
    82. 82. HYBRID REGIMENSNight exchange device This system was designed to provide a single extra exchange for CAPD patients, at a predetermined time, most often while the patient is asleep Enhances ultrafiltration, and so the device is useful for patients, typically high transporters, who have net fluid resorption after long dwells
    83. 83. PD PLUS CCPD does not provide adequate clearances for some patients once residual renal function is lost. Additional day exchanges may be required These additional day exchanges also improve ultrafiltration as the single day dwell is too long for effective net fluid removal. PD Plus,- patient returns to the cycler in the afternoon drains the dialysate that has been in the peritoneal cavity since that morning, and Then refills from the large-volume solution containers (3 to5 L) that will used to provide solution for cycling that night
    84. 84. CLEARANCE TARGETS TARGET Kt/V on peritoneal dialysis - 2 per week Kt = Total Kt = peritoneal Kt+ renal Kt Peritoneal Kt = 24-hour dialysate urea nitrogen content/serum urea Renal Kt = 24-hour urine urea nitrogen content/serum urea nitrogen Total Kt = peritoneal Kt+ renal Kt
    85. 85. CLEARANCE TARGETS CrCl (creatinine clearance) CrCl = total CrCl corrected for 1.73 m2 body surface area Total CrCl = peritoneal CrCl + renal CrCl Peritoneal CrCl = 24-hour dialysate creatinine content/serum creatinine Renal CrCl = 0.5 (24-hour urine creatinine content/serum creatinine + 24- hour urine urea nitrogen content/serum urea )
    86. 86. Minimal Recommendations for PD Dose DOQI CAPD CCPD NIPD Kt/V per wk 2.0 2.1 2.2 CrCl per wk 60 63 66
    87. 87. COMPLICATIONS OF PDA . Infectious Complications B . Noninfectious Complications 1.Peritonitis  1.Catheter Malfunction-Obstruction 2.Relapsing Peritonitis -Malposition 3. Exit-Site Infection  2. Pain-Pain on Inflow/ Outflow 4.Tunnel Infection  3. Generalized Pain -Back Pain , -Shoulder Pain  4. Abdominal Fullness  5.Membrane-Related Complication - Ultrafiltration Failure, - Sclerosing Encapsulating Peritonitis  6. Hernias and Abdominal Wall or Genital Edema  7.Metabolic
    88. 88. Acute Peritoneal Dialysis
    89. 89. ACUTE PERITONEAL DIALYSIS Acute PD provides the nonvascular alternative for dialysis. PD like other CRRT used in the intensive care setting, Less efficient than hemodialysis in the treatment of acute problems May not be the dialytic therapy of choice for extremely catabolic
    90. 90. Indications for acute PD a. Uraemic encephalopathy b. Severe metabolic acidosis c. Diuretic resistant hypervolaemia with pulmonary oedema in patients with cardiovascular compromise d. Uraemic neuropathy e. Hyperkalaemia not amenable to medical management f. Hypothermia g. Hemorrhagic pancreatitis
    91. 91. Contraindications for acute PD Absolute  Relative contraindications contraindications  Recent abdominal or cardiothoracic Recent surgery requiring surgery abdominal drains;  Diaphragmatic peritoneo-pleural connections Known fecal or fungal peritonitis  Severe respiratory failure  Abdominal wall cellulitis Known pleuroperitoneal fistula.  Severe gastro-esophageal reflux disease  Low peritoneal clearances  Life-threatening hyperkalemia  Severe acute pulmonary edema  Extremely high catabolysis
    92. 92. Peritoneal catheter -Acute PD Use of an uncuffed temporary catheter, Which will have to be replaced after 3 days is recommended Acute peritoneal dialysis has traditionally been done using manual exchanges. Increasingly, automated cyclers are being used instead
    93. 93. Prescription of acute PD 1.Length of the dialysis session 2.Dialysate composition 3.Exchange volume 4.Exchange time -Inflow time /Dwell time /Outflow time 5.Additive to dilaysate 6.Monitoring
    94. 94. Prescription of acute PD1.length of the dialysis session PD orders for only 24 hours at a time2.Exchange volume Commonly 0.5 L – 2 L, adjusted Size of patient‘s peritoneal cavity Severity of uremic syndrome Start with small volume -minimal leak Lager volume grater clearance Hypercatabolic : high volume/cycle smaller patients, pulmonary disease,hernias volume reduced
    95. 95. Prescription of acute PD3.Dialysis solution dextrose concentration Standard 1.5% dextrose - remove 50 to150 mL /hr 2-L exchange volume 4.25% solution- can result in an ultrafiltration rate of 300-400 mL/ hour. Most effective during the initial 15 to 30 minutes, When require very rapid fluid removal. Such patients can be treated initially with two or three in and out (zero dwell time) 2-L exchanges of 4.25% solution.4.Exchange time Combined time for inflow, dwell &drain commonly is 1 hour Inflow -10 min.( 200ml/min.) Depend on high-abdomen(manual) Dwell -Cataboic pt. : dwell 30 min. More stable pt.: longer dwell (Continuous equilibration peritoneal dialysis ,CEPD) Drain( outflow) 20-30 min.
    96. 96. Prescription of acute PD5.Additive to dialysate1.Potassium: 3-5 mEq/L in PDF2.Heparin – 1000-2000 u/2 L -prevent clot3.Insulin -1.5%=8-10u, 2.5%=10-14, 4.5%=14-20 u4.Antibiotics6.Monitoring Fluid balance Clearance –Electrolyte –BUN/Cr –Glucose
    97. 97. Complications of acute PD1.Mechanical complications Pain on inflow Localized outflow pain Visceral perforations •Bloody dialysate •dialysate leakage Abdominal distension & respiratory compromise2.Infectious complications -Peritonitis up to 12% of cases Frequently developing within the first 48 hours Contamination during connection or disconnection of each new exchange3.Medical complications Hypovolemia & Hypotension Hyperglycemia .hypernatremia
    98. 98. DIALYSIS IN TREATMENT OF POISONINGIndications Progressive deterioration despite intensive supportive therapy Severe intoxication with depression of midbrain function leading to hypoventilation, hypothermia, and hypotension Development of complications of coma, such as pneumonia or septicemia Impairment of normal drug excretory function in the presence of hepatic, cardiac, or renal insufficiency Intoxication with agents with metabolic and/or delayed effects (e.g., methanol, ethylene glycol, ) Intoxication with an extractable drug or poison, which can be removed at a rate exceeding endogenous elimination by liver or kidney.
    99. 99. CHOICE OF THERAPY Peritoneal dialysis (PD) Is not very effective in removing drugs from the blood, When HD is difficult to institute quickly, such as in small children, . hypothermic poisoned patient, PD maybe useful. Hemodialysis Therapy of choice for water-soluble drugs, especially those of LMW along with a low level of protein binding, Examples - ethanol, ethyl glycol, lithium, methanol, and salicylates. HD not very useful in removing lipid-soluble drugs .
    100. 100. CHOICE OF THERAPY Hemoperfusion More effective than hemodialysis in clearing the blood of many protein- bound drugs and lipid-soluble drugs Continuous hemodiafiltration, hemoperfusion. useful in drugs with moderately large volumes of distribution and slow intercompartmental transfer times to prevent post therapy rebound of plasma drug levels. Continuous hemoperfusion - in theophylline, and phenobarbital toxicity and Continuous hemodiafiltration -in ethylene glycol and lithium toxicity
    101. 101. References Handbook of Dialysis- 4th Edition;-Daugirdas, John T.; Blake, Peter G.; Ing, Todd Brenner and Rector;-The Kidney -8thEdition
    102. 102. Thank You !
    103. 103. Hemodialysis apparatus
    104. 104. Milestones in the development of Modern Hemodialysis 1861- The process of dialysis was first described by Thomas Graham (Glasgow) 1913-Artificial kidney developed John Abel (Baltimore) 1924-First human dialysis –------------------ GeorgeHaas(Giessen) 1943-Rotating drum dialyzer - Dr. Willem Kolff, a Dutch physician, constructed the first working dialyzer in 1943 during the Nazi occupation of the Netherlands 1966-Internal AV fistula developed Brescia, Cimino (New York) 1977 -Continuous arteriovenous haemofiltration described
    105. 105. INTRADIALYTIC COMPLICATIONS3.Dialysis Disequilibrium Syndrome Characterized by nausea, vomiting, headaches, and fatigue Can result in life-threatening seizures, coma, and arrhythmias Pathogenesis from rapid rates of change in solute concentration and pH in the central nervous system Most commonly occurs with high initial solute concentrations Treatment strategies Use of smaller surface area dialyzers Reduced rates of blood and dialysate flow Cocurrent (rather than countercurrent) dialysate flow High dialysate sodium Intravenous administration of diazepam
    106. 106. INTRADIALYTIC COMPLICATIONS Treatment of intradialytic hypotension Decreased ultrafiltration rate (1.5 L/h) Increased dialysate sodium Increased dialysate calcium concentration Variable sodium and/or ultrafiltration modeling Decreased dialysate temperature Use of biocompatible membranes Minimize short-acting antihypertensiveswithin 4 hours of dialysis (especially vasodilators) Midodrine, 5 to 10 mg, administered 30 to 60 minutes before hemodialysis
    107. 107. INTRADIALYTIC COMPLICATIONS2.Muscle Cramps Occur with up to 20% of dialysis treatments Pathogenesis uncertain, but frequently related to acute extracellular volume contraction Treatment of muscle cramps Decreased ultrafiltration rate Administration of normal or hypertonic saline Pharmacologic agents (quinine sulfate, diazepam,vitamin E, carnitine) Increased estimated dry weight
    108. 108. Measurement of Kt/V Peritoneal Kt/V is calculated by Performance of a 24-hour collection of dialysate effluent and measurement of its urea content. This is then divided by the average plasma urea level for the same 24-hour period to give a clearance term Residual renal Kt is calculated in the same way using a 24-hour collection of urine
    109. 109. EXAMPLE 1 A 50-year-old man weighing 66 kg has no residual renal function. He is on CAPD with four 2.5-L exchanges daily, and his net UF is 1.5 L. His V by the Watson formula is 36 L, and his BSA by the DuBois formula is 1.66 m2. Serum urea nitrogen is 70 mg/dL (25 mmol/L), and serum creatinine is 10 mg/dL (885 mcmol/L). The urea nitrogen and creatinine (after correction for glucose) levels in the 24-hour dialysate collection are 63 mg/dL (22.5 mmol/L) and 6.5 mg/dL (575 mcmol/L), respectively. Calculate his Kt/V and CrCl. Calculations using mg: Kt urea per day = 24-hour drain volume xD/P urea = 11.5 X 63/70 = 10.35 L per day. Daily Kt/V = 10.35 L/36 L = 0.288 L. Weekly Kt/V = 0.288 XSS 7 = 2.02 L. Creatinine clearance per day = 24-hour drain volume X D/P creatinine = 11.5 X 6.5/10 = 7.48 L per day. Corrected for 1.73 m2 BSA = 7.48 X 1.73/1.66 = 7.80 L per day. Weekly CrCl = 7.8 X 7 = 55 L per week
    110. 110. Anticoagulation in high risk Within 7 days of a major surgery or 14 days of intracranial surgery - without heparin or by regional anticoagulation. Within 72 hours of a biopsy of a visceral organ -without heparin or regional anticoagulation. >7 days past a major surgery or 72 hours past a biopsy - fractional heparinization.. Pericarditis -without heparin or by regional anticoagulation. Minor surgery within the previous 72 hours -fractional anticoagulation. Anticipated major surgery within 8 hours of HD -without heparin or with tight fractional anticoagulation. If they are within 8 hours of a minor procedure,-fractional anticoagulation is appropriate
    111. 111. Dialysis solution additives in acutePD When injecting any additive into dialysis solution containers, meticulous sterile technique must be followed to prevent bacterial contamination of the dialysis solution and peritonitis. Potassium. Standard peritoneal dialysis solutions contain no potassium, but when the patient is hypokalemic, potassium chloride (3â€―5 mEq/L) can be added. Even in normokalemic patients, failure to add potassium chloride may result in hypokalemia (especially with 60-minute exchanges) if the patients total-body potassium content is normal or low and the oral intake is poor. It must also be remembered that glucose absorption and correction of acidosis with peritoneal dialysis promotes a shift of extracellular potassium into cells, lowering the serum concentration. If moderate to severe metabolic acidosis is being corrected, addition of even 5 mEq/L of potassium to dialysis solutions may not prevent hypokalemia, and parenteral supplementation may be required. Higher concentrations of potassium in the dialysis solution have been used on a short-term basis, but caution is advised. Heparin. Sluggish dialysate flow from catheter obstruction by fibrin clots may occasionally be seen in acute peritoneal dialysis. This is usually a result of the slight bleeding that may accompany catheter insertion or irritation of the peritoneum by the catheter. Heparin (1,000 units/2 L) added to the dialysis solution can be helpful in preventing or treating this problem. Because heparin is not absorbed through the peritoneum, there is no increased risk of bleeding. Insulin. Because glucose is absorbed from the dialysis solution, supplemental insulin administration may be required for the diabetic patient undergoing acute peritoneal dialysis. Regular insulin may be added to the dialysis solution (Table 21-3) before infusion. The blood glucose level must be monitored closely and the dose of insulin tailored to the needs of the patient. To minimize the risk of hypoglycemia after dialysis has been stopped, insulin should not be added to the last exchange of a treatment session. Antibiotics. Intraperitoneal administration of antibiotics is efficient and provides an alternative route for patients with poor vascular access and for those with peritonitis (see Chapter 24). Intraperitoneal administration or P.383 more frequent IV or PO dosing may be required for antibiotics (e.g., aminoglycosides) whose clearances are enhanced by peritoneal dialysis (see Chapter
    112. 112. INTRADIALYTIC COMPLICATIONS6.Dialyzer ReactionsFirst-use syndrome Anaphylactoid reaction to new dialyzers made of cuprophane: Alternative pathway complement activation Ethylene oxide exposure Bradykinin generation through the kallikrein-kininogen pathway Treatment with epinephrine and steroidsNonspecific type B dialyzer reactions  The principal manifestations are chest pain, back pain.  Complement activation has been suggested to be a culprit.  Management is supportive. Dialysis can usually be continued,  Prevention-dialyzer reuse or trying a different dialyzer membrane
    113. 113. Factors determining clearance in PDpatients Nonprescription factors Residual renal function Body size Peritoneal transport characteristics Prescription factors (a) CAPD: Frequency of exchanges Dwell volume Tonicity of dialysis solution (b) APD: Number of day dwells Volume of day dwells Tonicity of day dwells Time on cycler Cycle frequency Cycler dwell volumes Tonicity of cycler solution
    114. 114. INTRADIALYTIC COMPLICATIONS4 .Arrhythmia Changes in potassium concentration Can be precipitated by hypotension and coronary ischemia Treatment similar to that for patients with normal renal function5.Cardiac arrest Uncommon in outpatient dialysis Related to day of week and dialysate potassium ,concentration7.Intradialytic Hemolysis8.Hypoglycemia9.Hemorrhage
    115. 115. TAC Urea Lowrie et al, who published the National Cooperative Dialysis study of 151 patients in 1981, thought that following the BUN was not the best way to measure adequacy Developed the time average concentration (TAC) of urea Patients in the high TAC group had higher hospitalization and more withdrawal from the study Lowrie EG et al N Eng J Med 1981; 305 (20) 1176
    116. 116. Why was urea chosen? Why not creatinine or beta2 microglobulin? Since the BUN is dependent on both dietary urea production and dialysis removal, it was felt that this would be the best metric It is also easy to measure
    117. 117. INTRADIALYTIC COMPLICATIONS10.Toxic water system treatment contaminants Chloramine -hemolysis Copper -anemia Aluminum -osteomalacia and encephalopathy Fluoride bone disease and cardiac arrhythmia11.Infectious complications Endotoxin exposure (pyrogenic reactions) from contaminated dialysate or reuse Infectious outbreaks (eg, Mycobacterium chelonei) related to improper dialyzer reuse
    118. 118. KT/V In this formulaDeveloped in 1985, as TAC urea was not felt to be an adequate marker of adequacy Gotch FA; Sargent JA: A mechanistic analysis of the NCDS. Kidney Int 1985 Sept; 28 (3): 526-534
    119. 119. Calculation of KT/V KT/V = -ln (R – 0.03) + [(4 – 3.5R) times (UF divided by W)] where UF is UF volume, W is the post- dialysis weight in kg and R is the ratio of post-dialysis to pre-dialysis BUN
    120. 120. Post-dialysis BUN Both access and cardiopulmonary recirculation are prominent at the end of dialysis, so the post dialysis BUN should not be measured immediately during high blood flow Both have pretty much dissipated by two minutes after dialysis
    121. 121. Equilibrated (Double Pool) KT/V Measurement of post dialysis BUN at the very end of dialysis overestimates the degree of urea removal, as it takes about 30 minutes after dialysis for urea to come out of cells and ―equilibrate‖ with the extra- cellular content eKT/V is about 0.21 lower than sKT/V It is inconvenient to keep the patient an extra 30 minutes
    122. 122.  Step 1: Estimate the patients V. Step 2: Multiply V by the desired Kt/V to get the required K × t. Step 3: Compute required K for a given t, or the required t for a given K.  Estimate V. This is best done from anthropometric equations incorporating height, weight, age, and gender as devised by Watson (Table A-2). If the patient is African American, add 2 kg to the Watson value for Vant. Alternatively, one can use the Hume-Weyers equations or the nomogram derived from them (Table A-2, Figs. A-5 and A-6). Assume that, in this case, the estimated V is 40 L.  Compute the required K × t. If the desired Kt/V is 1.5 and estimated V is 40 L, then the required K × t is 1.5 times V, or 1.5 × 40 = 60 L.  Compute the required t or K. The required K × t can be achieved with a variety of different combinations
    123. 123. Stop dialysate flow technique-for eKT/V In a study of 70 patients in Glasgow, the 30 minute post dialysis BUN was compared with the stop dialysate flow BUN Possible to estimate eKT/V by getting a BUN within 5 minutes of completion A regression equation was generated: 30 min BUN = 1.06 times (5 min BUN) + 0.22 Traylor JP et al. AM J of Kidney Dis 2002 Feb; 39(2): 308-314
    124. 124. Adequacy metrics URR-CMS says it should be greater than 65%; 70 % is more reasonable spKT/V-should be greater than 1.4 – 1.6 eKT/V should be greater than 1.2 – 1.4-this is the most accurate metric If a patient is getting metrics equal to or greater than above, is that patient getting adequate dialysis? Maybe not
    125. 125.  In NIPD (row 1 in Fig. 19-3), the patient drains out fully at the end of the cycling period, and so the abdomen is “dry― all day. Because of the absence of a long-duration day dwell, clearances are generally lower on NIPD than on CCPD, its use may be indicated if there is good residual renal function or if there are mechanical contraindications to walking about with solution in the abdominal cavity (e.g., leaks, hernias, back pain).
    126. 126. Drug Preferred MethodCarbamazepine HPEthylene glycol HDLithium HDMethanol HDMethotrexate HFPhenobarbital HPProcainamide HFSalicylate HD or HPTheophylline HP or HDValproic acid HD or HP
    127. 127. Why weekly Kt/V and CrCl ? Uremic Sx No of exchange Overall small MW clearance is most closely related to uremic toxicity CANUSA study  680 CAPD patients  weekly Kt/V 0.1 = 5% patient survival  CrCl 5 L/1.73m2/wk = 7% patient survival  No evidence of a plateau effect over the range of the clearance  Kt/V = 2.1 Predicted 2-yr survival 78% CrCl = 70 L/1.73m2
    128. 128. Salicylate poisoning Indications for dialysis:  severe metabolic acidosis  serum level > 100 mg/dL (acute OD)  level > 60 mg/dL (elderly, chronic OD) Note:  check units!! (mg/dL vs mg/L)  alkalinize serum and urine  dialysis preferred: can correct electrolyte and fluid abnormalities
    129. 129. THE PERITONEAL MODALITIES  Continuous ambulatory PD (CAPD))  Continuous Cycler-assisted PD (CCPD)  Nightly PD (NPD)  Intermittent PD (IPD)  Tidal PD
    130. 130. Theophylline poisoning Indications for dialysis:  serum level > 100 mg/L (acute OD)  level > 60-80 mg/L? (chronic)  seizures Notes:  HP or high-flux HD  Control Sz w/ phenobarbital  Rx hypotension w/ beta blockers
    131. 131. Methanol, Ethylene Glycol Indications for dialysis:  elevated level > 50 mg/dL  severe acidosis  increased osmolal gap > 10-15 mmol/L Notes:  HD only - not adsorbed to AC  give blocking drug (EtOH, 4-MP) - Note: need to increase dosing during dialysis
    132. 132. Weekly Kt/V & CrCl Peritoneal Kt = DUN / BUN x PD drain vol -- (2) Renal Kt = UUN / BUN x 24H Urine vol -- (3) Weekly Kt = { (2) + (3) } x 7 -- (4) Kt / V = (4) / (1) Peritoneal Clcr = Dcr / Pcr x PD drain vol -- (5) Renal Clcr = { ( Ucr/Pcr + UUN/BUN) / 2 } x 24h UV -- (6) Weekly Clcr = { (5) + (6) } x 7 x ( 1.73 / BSA )
    133. 133. Phenobarbital Indications for dialysis:  level > 190-200 mg/L  failure of supportive care (ie, intractable hypotension) Notes:  rarelyseen anymore  HP > HD  repeated dose AC shortens half-life but not length of coma
    134. 134. Lithium Indications for dialysis:  serum level > 6? 8? 10? (acute OD)  level > 4 ? (chronic)  level 2.5-4 with severe Sx? Notes:  2-compartment model, very slow redistribution from tissues  patients rarely get quick improvement  difficult to evaluate need and benefit  IV saline ―diuresis‖ may be nearly as effective
    135. 135. continuous veno-venoushemodialysis In continuous venovenous hemodialysis, a dialysate solution runs countercurrent to the flow of blood at a rate of 1 to 2.5 L/h (Fig. 6). Solute removal occurs by diffusion. Unlike IHD, the dialysate flow rate is slower than the bloodflow rate, allowing small solutes to equilibrate completely between the bloodand dialysate. As a result, the dialysate flow rate approximates urea and creatinineclearance. Ultrafiltration is used for volume control but can allow for some convective clearance at high rates. Continuous venovenous hemodiafiltration(Fig. 7) combines the convective solute removal of CVVH and the diffusivesolute removal of continuous venovenous hemodialysis. As in CVVH, the highultrafiltration rates used to provide convective clearance require the administrationof intravenous replacement fluids. Replacement fluids can be administered prefilter or postfilter. Postfilter replacementfluid results in hemoconcentration of the filter and increased risk of clotting, especially when the filter fraction is greater than 30%. The filtrationfraction is the ratio of ultrafiltration rate to plasma water flow rate and is dependenton blood flow rate and hematocrit [17]. Prefilter replacement fluiddilutes the blood before the filter, resulting in reduced filter clotting. Dilutionof solutes before the filter reduces solute clearance by up to 15% by loweringthe diffusion driving force and convective concentration.
    136. 136. Criteria of PD adequacy
    137. 137. Acute Peritoneal Dialysis Orders Nursing orders:  Dialysis to run_________hours  Exchange volume:_________L  Warm dialysis fluid to 37°C.  Exchange time: Inflow 10 minutes Dwell_________minutes Outflow 20 minutes or as long as fluid drains freely DO NOT LEAVE FLUID IN ABDOMEN  Strict intake and output to be kept on fluid intakeâ€―output record.  Dialysate balance to be recorded on peritoneal dialysis record.  Dialysis fluid running balance to be maintained at:_________L.  Dialysate solution:_________%  Additives to dialysate: Medication Dose Frequency _________ _________/2 L q exchange or ×_________exchanges _________ _________/2 L q exchange or ×_________exchanges
    138. 138. Selection for HD/PD Clinical condition Lifestyle Patient competence/hygiene (PD - high risk of infection) Affordability / Availability
    139. 139. Physiology of peritoneal transport depends on the following factors1. The concentration gradient,2. Effective peritoneal surface area,3. Intrinsic peritoneal membrane resistance ,4. Molecular weight of the solute concerned,( Mass transfer area coefficient ,Peritoneal blood flow)B. Ultrafiltration depends on Concentration gradient for the osmotic agent (i.e., glucose) Effective peritoneal surface area Hydraulic conductance of the peritoneal membrane Sieving. Sieving occurs when solute moves along with water across a semipermeable membrane by convection, but some of the solute is held back, or sieved. C. Fluid absorption- occurs via the lymphatics1. Intraperitoneal hydrostatic pressure2. Effectiveness of lymphatics
    140. 140. Prisma Haemodiafiltration
    141. 141. CAPDCCPDNPD
    142. 142. Milestones in the development of ModernHemodialysis :Thomas Graham (1805-1869) The First Hemodialysis Experiment 1913
    143. 143. Milestones in the development of ModernHemodialysisGeorge Haas used a collodiontube arrangement to successfully George Haasdialyze human subjects

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