Dialysis principal, modalities, its role as renal replacement therapy (R.R.T.). Indications for dialysis, other R.R.T. options how to choose, and their limitations. HD technique, terminology; e.g. dry weight, U.F., Dialysis prescription, Dialysis adequacy. HD monitoring, complications, management. HD session case management.

1. (for undergraduates 3rd year Integrated Medicine)
Compiled by:, 2021 © COPYRIGHTED
Nour EL Huda Mohamed
Assist. Lecturer Int. Med. Depart.
El-Minia University, Egypt.
Ahmed Redwan
Assist. Lecturer Int. Med. Depart.
El-Minia University, Egypt.

2. Topics Covered:
 Dialysis principal, modalities, its role as renal
replacement therapy (R.R.T.).
 Indications for dialysis, other R.R.T. options how to
choose, and their limitations.
 HD technique, terminology; e.g. dry weight, U.F.,
Dialysis prescription, Dialysis adequacy.
 HD monitoring, complications, management.
 HD session case management. Approach for real-
Life patient with dialysis complication: group-case
discussion.

4. Diffusion Convection

6. 1-Dialysis = diffusion =
passive movement of
solutes across a semi-
permeable membrane
down concentration
gradient
Good for small molecules
2-(Ultra)filtration =
convection = solute + fluid
removal across semi-
permeable membrane
down a pressure gradient
(solvent drag)
Better for removal of fluid and
medium-size molecules

9.  Hemodialysis (HD): = solute passively diffuses down
concentration gradient (diffusion is the main mechanism)
 Dialysate flows countercurrent to blood flow.
 Urea, creatinine, K move from blood to dialysate
 Ca and bicarbonate move from dialysate to blood.
 Hemofiltration (HF): uses hydrostatic pressure gradient
to induce filtration / convection plasma water + solutes
across membrane.
 Hemodiafiltration (HDF): combination of dialysis and
filtration.

11. HD technique
The technique involves continuous blood
filtration through air sealed anti-coagulated extra
corporeal circulation driven by non traumatic blood
pump system through closely monitored
preprogrammed hemodialysis machine.
The standard guideline-accepted protocol for
HD session are thrice weekly on alternative days
and 4 hour /session.
Special HD protocols are applied in
pregnancy, first HD sessions, and other situations
regarding dialysis indication(s) and patient state.

15.  Hemodialysis treatment was a breakthrough in
the 20th century.
 Mortality and morbidity rates are still high.
 Annual mortality rate in chronic HD patients 20-25%.
 CVD accounts for 43% of all cause mortality in HD.
 Current HD schedule provides only 10% of the
clearance of the native kidneys.!!
 The strict balance between achieving dialysis
adequacy and avoiding HD complications
remains as a challenge.

16. Adequacy Complications

17. Adequacy of dialysis refers to how well we remove toxins and
waste products from the patient’s blood, and has a major impact on their
well-being and the ultimate goal : patient quality of life (QOL).
Adequqte HD results in the most favorable mortality and
morbidity outcomes and improved patient survival.

18.  Fluid control.
 Blood pressure control.
 Phosphorus and Hb level control.
 Measuring dialysis adequacy:
 – Urea Reduction Rate (URR).
 – Urea Kinetic Modeling (K t/v)

19. Renal replacement therapy (RRT) is
a term used to refer to modalities of
treatment that are used to replace the toxins
filtering functions of a normal kidney, that
partially replaces non-endocrine kidney
function in patients with renal failure and is
occasionally used for some forms of
poisoning.

20. 1. Plasma ultrafiltration; excretion of water soluble toxins and
maintain the volume balance (euvolemia).
2. Maintain electrolytes balance.
3. Maintain acid-base balance.
4. Endocrinal; erythropoietin (EPO) production guarding
against anemia, and final Vitamin D activation.
5. Renin Angiotensin Aldosterone System (RAAS); control of
BP.
6. Metabolic; gluconeogenesis (extrahepatic site for Glucose
production), storage and metabolism for folic acid &
vitamin B12.
7. Immune; contribute of both humoral and cellular immunity.

26. Modalities of RRT
Intermittent hemodialysis
(IHD)
Peritoneal dialysis
Hybrid therapies, like
SLEDD
Continuous renal
replacement therapy
(CRRT)
Kidney transplantation
(Renal Tx)

27. The choice of right RRT modality suitable for the patient’s
dialysis indication, hemodynamics, and associated comorbidities are
the key for uncomplicated goal-reaching session.

43.  Definition: A decrease in systolic BP ≥20 mm Hg or a
decrease in MAP ≥ 10 mm Hg associated with symptoms.
 Complication: cardiac arrhythmias, coronary and
 Long-term side effects: volume overload due to
suboptimal ultrafiltration, LVH, and interdialytic
hypertension
★
 Why is it important?
 Whatever the underlying cause, patients with
hemodialysis-associated hypotension appear
to have increased mortality.

44.  A third of dialysis patients
 Poor nutritional status and hypoalbuminemia.
 Severe anemia.
 Advanced age (Age > 65 years old).
 Cardiovascular disease.
 Large interdialysis weight gain.
 Low blood pressure (predialysis systolic BP <100 mm Hg) .
 Low body mass.

45.  Low calcium
dialysate
 Eat shortly
before dialysis

46. Ultrafiltration
Osmolality
Fall
Warm
Dialysate
Bio-incom-
patibility
Endotoxin
Acetate
Dialysate
Volume
Vasopressors
Vasodilatator
Cell
Dysfunction
Complement
Activation,
Cytokine release
Hypoxemia
Heart Disease
Vascular
Disease
Autonomic
Dysfunctio
n
Hormonal
Dysfunctio
n
Medication
s
Sepsis
Infection
Vasovagal
stim.
HYPOTENSiON
CARDIAC
OUTPUT
PERIPHERAL
RESISTANCE
PATHOGENESIS MEDIATORS PATHOPHYSIOLOGY PATIENT

47. EPISODIC
HYPOTENSION,
typically occurs during the
latter stages of dialysis; this is
associated with vomiting,
muscle cramps, and other
vagal symptoms (such as
yawning).
CHRONIC PERSISTENT
HYPOTENSION
in long-term patients with pre-
dialysis systolic blood
pressures of less than 100
mmHg.

48.  Although occasionally
asymptomatic, patients
with hypotension may
suffer from :
◦ light-headedness.
◦ muscle cramps.
◦ Nausea & vomiting.
◦ dyspnea.
 Keep it in Mind
 Changes in Plasma
osmolality.
 True dry weight.
 Autonomic Neuropathy.
 Acetate.
 Na & Mg.
 Cardiac Diseases.
Be patient in your
management

49.  The acute management of low blood pressure
associated with hemodialysis includes the
following:
 Ultrafiltration should either be stopped or the rate
decreased. The patient should then be observed carefully
 The patient should be placed in the Trendelenburg position.
(if respiratory status allows this)
 The blood flow rate should be reduced.
 Ultrafiltration can be resumed (at a slower rate, initially)
once vital signs have stabilized.
Don’t Miss
Vital Signs

50.  Use of an i.v. bolus of 0.9% saline (100 mL or more, as
necessary) is the first-line therapy for hypotension.
 As an alternative to saline, glucose or albumin solutions
can be used to treat the hypotensive episode; albumin is
costly and offers little benefit over other approaches.
 use of hypertonic saline appears to offer no benefit over
0.9% saline for equivalent sodium loads. It is best
avoided if a high dialysis solution sodium is being used.
 Nasal oxygen administration is not generally of benefit
during hypotensive episodes, though it may have value in
selected patients.

52.  Improvement in cardiovascular performance in
cardiac patients:
 Midodrine (dose, 2.5 mg if<70 kg, 5 mg if >70 kg)
the selective alpha-1 adrenergic agonist) in
patients with autonomic neuropathy with severe
hemodialysis hypotension not responsive to the
above measures.
 Carnitine .
 Blood transfusion or erythropoietin therapy
 Adenosine receptor antagonist.
 Vasopressin infusion.
 Avoidance of food intake during HD session.

53. IVCD
Bioimpedence ECF/TBW
cGMP, ANP

54.  35-86% of hemodialysis patients
 common complication of hemodialysis treatments
and mostly involves the muscle of the lower
extremities resulting in early termination of a
hemodialysis session.
 Usually occur near the end of hemodialysis
treatments
 More common during the first month of dialysis
than in subsequent periods.
★

55.  Electrolyte disturbance
1. Acute hyponatremia (due to the
use of low sodium dialysate) will
result in constriction of blood
vessels and subsequent muscle
cramps.
2. Hypokalemia, Hypomagnesemia
and Hypocalcemia, especially in
patients treated with relatively
low-calcium dialysis solution (1.5
mM).
 Large UF volumes of
fluid.. Plasma volume
depletion & hypotension
reduce extracellular volume
----->skeletal muscle
irritability.
 Patients below dry
weight
 Carnitine deficiency:
Carnitine is a naturally
occurring amino acid which
facilitates the entry of fatty
acids into mitochondria for
energy production.

56.  vitamin E: Considering the potential toxicity of
quinine, vitamin E ,400 IU daily at night , is
recommended as the initial treatment of choice.
 L-carnitine supplementation:
 supplemental doses (5 to 100 mg/kg) of L-
carnitine have been administered either IV at
the end of each dialysis session, orally, or via
addition to the dialysate.
 The most economical and practical way may be
either the oral ingestion of approximately 660 to
990 mg daily, or 2 to 3g just prior to HD.

57. Magnesium
Prazosin :Sympathetic activation
plays a role in HD-associated
skeletal muscle
cramps and pharmacologic
attenuation.
-low doses prazosin (0.25 to 1.0 mg)
at the start of the
dialysis session may prevent muscle
cramps
Sequential compression devices
(SCD)

58.  up to 10% of routine dialysis treatments.
 multifactorial.
 Most episodes in stable patients are probably related to
hypotension.
 Can be an early manifestation of the so-called
disequilibrium syndrome . type A and type B varieties of
dialyzer reactions, inefficient HD.
 Gastroparesis, very common in diabetes but also seen in
nondiabetic patients, is exacerbated by hemodialysis and
may play a role in some patients.
 Contaminated or incorrectly formulated dialysis solution
(high sodium, calcium) may cause nausea and vomiting as
part of of symptoms.
★

59.  The first step is to treat and avoid any associated
hypotension.
 Treatment of the cause
 Vomiting may be particularly problematic when
associated with a hypotension-induced reduction in
the level of consciousness due to the risk of
aspiration.
 Persistent symptoms unrelated to hemodynamics
may benefit from metoclopramide. Sometimes a
single predialysis dose of 5- 10 mg is sufficient.

60.  Etiology: Headache is common during dialysis;
its cause is largely unknown.
 It may be a subtle manifestation of the
disequilibrium syndrome or hypotension.
 In patients who are coffee drinkers, headache
may be a manifestation of caffeine withdrawal as
the blood caffeine concentration is acutely
reduced during the dialysis treatment.
 With atypical or particularly severe headache, a
neurologic cause (particularly a bleeding event
precipitated by anticoagulation) should be
considered.
★

61. Acetaminophen can be given during
dialysis.
Prevention: Decreasing dialysis solution
sodium also may be helpful in patients
being treated with high sodium levels.
A cup of strong coffee may help prevent
(or treat) caffeine withdrawal symptoms.

62.  Mild chest pain or discomfort (often associated with
some back pain) occurs in 1- 4% of dialysis
treatments. The cause is unknown.
 Exclusion of cardiac disease.
 There is no specific management or prevention
strategy, though switching to a different variety of
dialyzer membrane may be of benefit.
 occurrence of angina during dialysis is common and
must be considered in the differential diagnosis, along
with numerous other potential causes of chest pain
(e.g., hemolysis, air embolism, pericarditis).
★

63. HD by itself is a risk factor for angina
1. Hypo and hypertension
2. Anemia
3. Hypoxemia
4. Volume overload
5. Hyperlipdemia
6. Acetate intolerance

64. 1. O2
2. Discontinue HD session
3. Reduce blood flow, stop UF
4. ECG and cardiac enzymes
5. Sublingual nitrates
6. Sedation
7. Treat the possible cause
8. Predialysis administration of nitroglycerin patch one
hour prior to session.
9. Slow blood flow rate
10. Bicarbonate dialysate usage.

65.  30-48% of dialysis patients
 during dialysis are especially common in
patients with Electrolyte imbalance, receiving
digitalis, those with CAD, advanced age,
myocardial dysfunction, and LVH
 Ventricular arrhythmias in dialysis patients are
common during dialysis and between
treatments; with ranges widely from 5 to 75
percent.
 Supraventricular arrhythmias are also common.
★ Arrhythmias

66. Unexpected or recurrent hypotension
during dialysis can be a sign of
pericardial effusion or impending cardiac
tamponade.
Management: depends on hemodynamic
instability.
★ Cardiac tamponade

67. Is a serious complications rare to be seen
nowadays
Routes of Air:
1. Air leakage around tubing joints
2. Unattended IV infusion
3. The use of air to return blood in the end of
dialysis session
4. Usage of dialysis catheter carries the risk
of air embolism
★

68. In seated patients: air migrates to cerebral
venous system, disturbed consciousness,
convulsions.
In recumbent: air migrates to the Rt
ventricles forming foam which pass to the
lungs dyspnea, cough and chest tightness.

69. 1. Stop blood pump
2. Place the patient in trendelenberg position on
left side with the chest and head tilted
downwards to trap the air in the Rt ventricle
3. O2
4. Sedation
5. Other measures: dexamethasone to reduce
brain edema, heparin to improve
microcirculation???

70. Itching, a common problem in dialysis
patients, is sometimes precipitated or
exacerbated by dialysis.
itching is simply present chronically, and is
noticed in the course of the treatment while
the patient is forced to sit still for a
prolonged period of time.
★

71.  Pruritogenic substancemast cell release
histamine, IL-2, …cascade of nerve
conduction to induce in perception of itch
★

72.  Seizures are not uncommon in patients
undergoing hemodialysis.
★

73. 1. Uremic encephalopathy
2. Dialysis disequilibrium syndrome
3. Drugs, such as erythropoietin (in large dose)
4. Hemodynamic instability, whether hypotension or
hypertension
5. CVS disease, such as hypertensive
encephalopathy, infarction, hemorrhage, and
subdural hematoma
6. Dialysis dementia due to aluminum intoxication
7. Electrolyte disorders, such as hypocalcemia,
hypoglycemia hypernatremia
8. Alcohol withdrawal.
9. Air embolism

74.  The emergency treatment of seizures in the dialysis
patient includes the following:
 Stopping dialysis
 Securing a patent airway
 Stabilizing the circulation
 Blood should be sampled for serum levels of glucose,
calcium, sodium, magnesium and other electrolytes,
marked abnormalities of which may suggest the
underlying cause of the seizure.
 I.V glucose should be administered if hypoglycemia is
suspected, particularly in diabetic patients.

75.  If seizures persist, a benzodiazepine should be
administered, such as 5 to 10 mg of diazepam given
by slow intravenous push.
 The dose can be repeated at five minute intervals to
a maximum total dose of 20 to 30 mg.
 If administered, an antidote for diazepam (flumazenil)
should always be available if respiratory depression
occurs.
 Initial diazepam therapy may be followed by a
loading dose of phenytoin (10 to 15 mg/kg) given at a
rate no greater than 50 mg/min;
 ECG monitoring should be performed during this
infusion.

76.  Long-term therapy with antiepileptic medications may
not be required if the patient's seizure is due to a
reversible cause.
 If not, maintenance therapy with phenytoin,
carbamazepine, or valproic acid can be used to prevent
recurrent seizures.
 Phenytoin is the most common medication used for the
treatment of seizures in dialysis patients.
 usual loading and maintenance dosages of phenytoin
should be administered.
 The target blood level for total phenytoin should be in
the range of approximately 4 to 10 mg/L, approximately
one-half that in subjects with normal function due to the
decline in protein binding in uremia.

77. Certain antiepileptic medications, such
as phenobarbital is removed by dialysis
and must be supplemented if
therapeutic levels are to be maintained.
Fortunately, the more commonly used
drugs, phenytoin, carbamazepine, and
valproic acid — are nondialyzable, and
require no postdialysis supplementation.

78. These include dysequilibrium syndrome,
hypersensitivity reactions, intracranial
bleeding, hemolysis
★

79.  It is a set of systemic and neurologic
symptoms often associated with characteristic
EEG findings that can occur either during or
following dialysis.
 Early manifestations include nausea, vomiting,
restlessness, HTN, ms cramps and headache.
 More serious manifestations include seizures,
and coma.
★

80. The cause of the disequilibrium syndrome
is controversial.
When the plasma solute level is rapidly
lowered during dialysis, the plasma
becomes hypotonic with respect to the
brain cells and water shifts from the
plasma into brain tissue.
Others incriminate acute changes in the
pH of the cerebrospinal fluid during
dialysis as the cause of this disorder.

81. The full-blown disequilibrium syndrome,
including coma and/or seizures, can still be
precipitated when an acutely uremic patient
is dialyzed too energetically.
Milder forms of the syndrome may still occur
in long-term dialysis patients, manifesting as
nausea, vomiting, or headache.

82.  Mild disequilibrium. Treatment is symptomatic.
If develop in an acutely uremic patient during dialysis, the blood
flow rate should be reduced to decrease the efficiency of solute
removal and pH change, and consideration should be given to
terminating the dialysis session earlier than planned.
Hypertonic sodium chloride or glucose solutions can be
administered as for treatment of muscle cramps.
 Severe disequilibrium.
 If seizures, or coma occur in the course of a dialysis session,
dialysis should be stopped. The differential diagnosis of severe
disequilibrium syndrome should be considered.
 C.T brain

83. •
This is a broad group of events that results from
interaction between blood constituents and the HD
membrane.
•
In the past, many of these reactions were grouped
under the term “first-use” syndrome because they
presented much more often when new dialyzers
were employed. Similar reactions occur with reused
dialyzers.
•
There are two types, an anaphylactic type (type A)
and a nonspecific type (type B).
★

84. Factor Type A Type B
Incidence 5/100,000 3—5/100
Onset Usually first 5 min, and may be
delayed for up to 30 min.
Usually after 30 min and
may be much later
Severity Ranging from mild to severe. Usually mild and an
improvement of symptoms
occurs with continuation
of dialysis
Manifestations itching, burning sensation at the
access site, urticaria, flushing,
cough, sneezing, wheezing,
abdominal cramps, diarrhea,
headache, back and chest pain,
nausea, vomiting, fever, chills,
dyspnea, hypotension, potentially
resulting in cardiac arrest and death
. Allergic patients appear to be
predisposed to this type of reaction.
chest and back pain,
dyspnea, nausea,
vomiting, and
hypotension. Anaphylaxis
is extremely rare.

85. Factor Type A Type B
Cause Ethylene oxide (allergy)
ACE inhibitors and high flux
AN69 dialyzers (Bradykinin)
Acetate dialysate and
Heparin.
High flux dialyzers used in
conjunction with bicarb
dialysate (bacterial peptides)
Hydroxyl group (Complement
activation)
Treatment Stop dialysis immediately
Do not return blood
Epinephrine, anti-
histamines, steroids,
bronchodilators and or
vasopressors.
Continue dialysis
No specific treatment (supportive)

86. Factor Type A Type B
Prevention •Depends on cause In all
cases, rinse the dialyzer
well immediately prior to use
•Change suspected
sensitized patients to a
gamma- or steam- sterilized
dialyzer
•Stop ACE inhibitor therapy
in affected patients If the
reaction occurred while
using the AN69 membrane,
use a different membrane.
•Pretreatment with
antihistamincs and or
steroids in patients with
previous history of type A
reaction.
•Use of biocompatible
membranes.
•Put patient on a reuse
program without bleach if using
an unsubstituted cellulose
membrane (membrane is
coated with plasma protein
which results in reduction of
complement activation)

87.  Acute hemolysis during dialysis may be a
medical emergency.
 Manifestations
• back pain, chest tightness, and shortness of breath.
• A dramatic deepening of skin pigmentation may occur. a
pink discoloration of the plasma in centrifuged blood
samples, and a marked fall in the hematocrit.
• If massive hemolysis is not detected early, then
hyperkalemia can result due to release of potassium
from the hemolyzed erythrocytes, leading to muscle
weakness, ECG abnormalities, and, ultimately, cardiac
arrest.
★

88. Acute hemolysis has been reported in 2
primary settings:
• Kinks may develop in the arterial blood line.
Hemolysis (usually subclinical) may also appear when
blood flow rate is high and relatively small needle
sizes are used.
• Problems with dialysis solution. These are:
 Overheated dialysis solution
 Hypotonic dialysis solution (insufficient concentrate-to-water
ratio)
 Dialysis solution contaminated with formaldehyde,
chloramine (from city water supply), copper (from copper
piping), fluoride, nitrates (from water supply), zinc, and
hydrogen peroxide.

89.  Blood pump should be stopped immediately and
the blood lines clamped.
 Hemolyzed blood has a very high potassium
content and should not be reinfused.
 Be prepared to treat the resultant hyperkalemia
and possible drop in hematocrit.
 Careful observation and hospitalization should be
considered as Delayed hemolysis of injured
erythrocytes may continue for some time after the
dialysis session.

90. Severe hyperkalemia may occur, and this
may require additional dialysis or other
measures
A complete blood count, reticulocyte
count, and levels of haptoglobin, (LDH),
and methemoglobin should be obtained.
Dialysis solution water (chloramine,
nitrates, metals) and, if reprocessed, the
dialyzer (residual sterilant) need to be
assessed as well.