Hemodialysis orders part II

1. Hemodialysis prescription,
Targeting a friendly dialysis
Jafar Alsaid M.B.CHB.MD.FASN.FACP
Assistance Professor, Ochsner Clinical School/University of Queensland ( Australia)
Nephrology Consultant. Ochsner Health system.
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8/13/2021 JAFAR ALSAID, MB.ChB. MD. FASN. FACP. AUG. 2021

2. Hemodialysis Prescription,
Targeting a friendly dialysis
Part I
• Introduction.
• Historic points
• Statistics. USRDS 2020.
• How to break the news to the
patient.
• Variables in decision for Dialysis.
• Hemodialysis Targets.
• Hemodialysis Complications
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Part II
Choosing a Filter.
QB/QD.
Dialysis adequacy.
Anticoagulation in hemodialysis.
Part III
Hemodynamics and BP.
Ultrafiltration.
Temp.
Dialysate Na.
Dialysate Ca.
Online Volume Control
mode.
Research aspects.
Jafar Alsaid M.B.CHB.MD.FASN.FACP
Assistance Professor, Ochsner Clinical School/University of Queensland ( Australia)
Nephrology Consultant. Ochsner Health system.
8/13/2021 JAFAR ALSAID, MB.ChB. MD. FASN. FACP. AUG. 2021

3. Hemodialysis prescription,
Targeting a friendly dialysis
Part II
Jafar Alsaid M.B.CHB. MD. FASN. FACP
Assistance Professor, Ochsner Clinical School/University of Queensland ( Australia)
Nephrology Consultant. Ochsner Health system.
3

4. Outline
• Looking for the balance.
• Dialysis Targets.
• Machine factors.
• Patients' factors.
• Preventing complications.
• Selecting the filter.
• Qb, Qd and filtration coefficient.
• Dialysis adequacy.
• Difference between Hemodialysis, Hemofiltration and Hemodiafiltration.
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5. https://www.dailymail.co.uk/news/article-2170881/Chinese-tightrope-walker-plummets-ground-trying-high-wire-stunt-
backwards-AND-blindfolded.html 5

6. What is our target in HD
• Clearance.
• Fluid.
• Electrolytes.
• BP.
• Acid base.
• Drugs overdose.
• Patient comfort.
• Doing no harm.
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7. Machine factors:
• Type.
• Duration & Timing.
• Filter.
• Access.
• Needles.
• QB.
• QD.
• UF.
• Anticoagulation.
Dialysate:
• Temp.
• Na.
• K.
• Ca.
• Glu.
• HCO3.
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8. • BP / Hemodynamic.
• Organ perfusion.
• Volume and fluid status.
• Urine output.
• Acute / chronic.
• Access type.
• Allergies.
• Medications.
• Surgeries.
• Bleeding. / thrombosis.
• Heart status.
• Previous sessions outcome.
• Anticipated complications.
• Quality of life.
Patient factors:
• Illness and prognosis.
• Management plan.
• Possible outcome.
• Target organs.
• Family and code status.
• Directive order.
• Financial aspect.
• Socioeconomic status.
• Home environment.
Other factors:
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9. Complications
• Hypotension / Hypoperfusion.
• Infection.
• Hypoglycemia.
• Cramps.
• Arrythmia.
• Bleeding.
• Air Embolism.
• Thromboembolism.
• Anaphylaxis & allergic.
• Altered mental status.
• Pain.
• Anxiety and Stress.
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10. Selecting a filter/kidney
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11. Filter characteristic
Dalton= gm/mol
H2O 18
Na 22.9
Cl 35
PO4 30.9
Ca 40
Urea 60
Creatinine 113
B12 1355
B2 Microglobuline 11800
Albumin 68500
• Small Molecule: < 500 Dalton
• Middle Molecule: 500-15000
• Large Molecule: >15000
Clearance: Size of the Pores.
Efficiency = KoA= mass transfer area Coefficient
low <500
middle 500-800
High >800
Flux = Kuf = Ultrafiltration Coefficient
low < 8ml/h/ mmHg
middle 8-20ml/h/mmHg
high > 20ml/h/mmHg
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Molecular wt.

12. Molecular based classification
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13. Difference between Number and size of pores and the type of
filters.
Exploring the Clinical Relevance of Providing Increased
Removal of Large Middle Molecules . Martin Wolley,1,2 Meg Jardine,3,4 and Colin A. Hutchison2,5.
Clinical Journal of the American Society of Nephrology. Clin J Am Soc Nephrol 13: 805–814, May,
2018
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14. Filter characteristic
Material.
• Cellulose
• Polysulfon.
• Polyamide.
• Polyacrelonitrate.
• Polymethyl methecrylate
Surface Area. 0.5 - 2.2 seq m.
Sterilization. Steam, G-ray, E- beam. Ethylene Oxide
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15. Qb & Qd and it’s effect on filtration coefficient
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16. Figure 1.
Qb, Qd and
Filtration
coefficient.
https://www.intechopen.com
/chapters/47460
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17. https://www.intechopen.com/chapters/47460
KT/v
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18. Water used for 3hours HD session
• Qd 800ml/min.
• 3 hours = 800 X 60 X 3 = 144000ml = 144 liters.
• Qd 500ml/min.
• 3 hours = 500 X 60 X 3 = 90000 = 90 Liters
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19. F16 HD
filter
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20. F160 HF HD
filter
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21. Dialysis adequacy KT/V.
• Blood Flow.
• Time.
• Filter surface area.
• Dialysate flow.
• Needle size.
• Access.
• Recirculation.
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22. 22

23. Basics of HD, HF and HDF

24. Diffusion (Hemodialysis) Versus Convection (Hemofiltration)
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Stefan J, Kai-Uwe, DOI. Renal Replacement Strategies in the ICU. CHEST / 132/4/ OCTOBER, 2007 :https://doi.org/10.1378/chest.07-0167

25. Hemodialysis circuit
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A Primer on Hemodialysis From an Interventional Radiology Perspective - Techniques in Vascular & Interventional Radiology (techvir.com)

26. Hemofiltration Circuit
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Ankawi et al. Critical care (2018)22:262. https: //doi.org/10.1186/s13054-018-2181-z

27. CRRT
fundamentals
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CRRT Fundamentals Pre- and Post- Test
Answers.
Published by Jared McCoy.
http://slideplayer/slie/14243355

28. Clearance Comparison between HD, HF and HDF
Clearance of difference molecules with HD, HF and HDF

29. 29
Hemofiltration – Advanced Renal Education Program; https://advancedrenaleducation.com/wparep/article/hemofiltration/

31. Deranged Physiology. Convection as a mechanism of solute removal.

32. Sieving Coefficient curves for low-flux, High flux and human
glomerular basement membrane
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I. Ledebo and P. J. Blankestijn.Sieving curves for low-flux and high-flux dialysis membranes and human... | Download Scientific Diagram
(researchgate.net). NDT Plus (2010) 3: 8–16 doi: 10.1093/ndtplus/sfp149 Advance Access publication 5 November 2009

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36. Anticoagulation in Dialysis
• The extracorporeal circuits predispose to clotting.
• 150-200ml of blood will be lost.
• Filter clotting reduces the clearance surface area.
• Unless the patient is high risk of bleeding anticoagulation is
recommended.
https://www.uptodate.com/contents/anticoagulation-for-the-hemodialysis -
procedure?search=hemodialysis%20anticoagulation&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
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37. Priming of dialysis filter and circuit
A dose of Heparin is use with priming the machine.
Heparinized solution: 1000IU/10000ml Saline solution.
Plain saline with saline flushes 100-200/hour bolus.
Predilution HDF with high blood flow.
https://www.uptodate.com/contents/anticoagulation-for-the-hemodialysis -
procedure?search=hemodialysis%20anticoagulation&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
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38. High risk of bleeding
• Sever Thrombocytopenia. Platelets < 20000
• Active bleeding.
• 72 hours of Major surgery.
• Active intracranial or extradural hemorrhage.
• Systemic anticoagulation.
• Uremic pericarditis.
• Coagulation factor VII and VIII deficiency.
https://www.uptodate.com/contents/anticoagulation-for-the-hemodialysis-
procedure?search=hemodialysis%20anticoagulation&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 38

39. Standard protocol
• Unfractionated Heparin:
• 1000-2000IU in the beginning and 500 IU. Stop one hour prior to
termination. Adjust the dose according to clotting and bleeding.
• By wt. Wt. Heparin
<50Kg 500 bolus.
50-100kg 1000 bolus.
>100kg 2000 bolus
• Bolus with declining hourly dose.
https://www.uptodate.com/contents/anticoagulation-for-the-hemodialysis -
procedure?search=hemodialysis%20anticoagulation&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
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40. Low molecular Wt. Heparin
• For 4 hour HD session given in arterial line:
• Tinzaparin: 2500 Unit.
• Enoxaparin 20 mg.
https://www.uptodate.com/contents/anticoagulation-for-the-hemodialysis -
procedure?search=hemodialysis%20anticoagulation&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
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41. Other methods of anticoagulation
Citrate:
• 2.4meq /L. partial or total replace acetate.
• requires Calcium, monitoring.
• Only for in patients.
Regional citrate infusion at 102mol/l. in arterial limb.
5% Calcium Chloride 0.5ml/min at the venous side. Adjustment with ionized
Ca.
Eugene C Kovalik, Andrew Davenport Kovalik, E., Davenport K. Anticoagulation for HD procedure.
Literature review current through: Jun 2021. | This topic last updated: Jul 01, 2020. www.uptodate.com
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42. Regional anticoagulation
Epoprostenol:
Arachedonic metabolite with vasodilation and inh. platelet aggregation.
At 4-8ng/kg/min
t1/2 3-5 min.
Metabolized by endothelium.
Nafamostat:
Serine proteas inh.
Used in Japan and South Korea.
Followed with aPTT.
Eugene C Kovalik, Andrew Davenport Kovalik, E., Davenport K. Anticoagulation for HD procedure.
Literature review current through: Jun 2021. | This topic last updated: Jul 01, 2020. www.uptodate.com
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1.Chaudhry R, Wegner R, Zaki JF, et al. Incidence and outcomes of heparin-induced
thrombocytopenia in patients undergoing vascular surgery. J Cardiothorac Vasc Anesth. 2017;
31: 1751–1757.
2. Solanki J, Shenoy S, Downs E, et al. Heparin-induced thrombocytopenia and cardiac surgery.
Semin Thorac
Cardiovasc Surg 2019; 31: 335–344.
3. McGowan KE, Makari J, Diamantouros A, et al. Reducing the hospital burden of heparin-
induced thrombocytopenia: Impact of an avoid-heparin program. Blood 2016; 127: 1954–1959.
4. *Dhakal B, Kreuziger LB, Rein L, et al. Disease burden,complication rates, and health-care
costs of heparininduced thrombocytopenia in the USA: A population-based study. Lancet

45. Recommendation
• HD for AKI: No anticoagulation. Used.
• ESRD with chronic dialysis. We use the same anticoagulation.
https://www.uptodate.com/contents/anticoagulation-for-the-hemodialysis -
procedure?search=hemodialysis%20anticoagulation&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
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46. Conclusion
• Achieving the balance in dialysis require looking at multiple variables.
• Taking in consideration the patient, the machine and the filter characteristics are
important to plan the dialysis session.
• Knowing the complication is critical to prevent them.
• Qb and Qd interact in determining the filtration coeffects.
• Sieving coefficient determine the difference between filter types as we target
normal renal function.
• Anticoagulation is vital in renal replacement therapy to maximize the clearance
and prevent complications.
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