This document discusses chronic kidney disease and hemodialysis. It provides information on assessing kidney function, the causes and treatment of chronic kidney disease, and preparing patients for renal replacement therapies like hemodialysis and peritoneal dialysis. It describes the dialysis process, equipment used, and some potential acute complications of hemodialysis treatment.

1. Chronic Kidney DiseaseChronic Kidney Disease
Dr.Lissy Thomas.Dr.Lissy Thomas.
Senior Consultant,Senior Consultant,
Nephrology.Nephrology.

2. Case -1Case -1
Diabetic for 20 yrs, work up showed CrDiabetic for 20 yrs, work up showed Cr
1.0, urine with +++ protein.1.0, urine with +++ protein.
Report from previous yr showing theReport from previous yr showing the
same results.same results.
Does he have chronic kidney disease?Does he have chronic kidney disease?

3. Case 2Case 2
21 yr old male , admitted with road traffic21 yr old male , admitted with road traffic
accident , developed renal failure requiringaccident , developed renal failure requiring
dialysis during the hospital stay.dialysis during the hospital stay.
He is undergoing dialysis treatment, 15He is undergoing dialysis treatment, 15thth
dialysis on the 40dialysis on the 40thth
hospital stay.hospital stay.
He has no significant medical history andHe has no significant medical history and
a routine checkup done a month prior toa routine checkup done a month prior to
admission was showing normal urineadmission was showing normal urine
analysis and renal function.analysis and renal function.

4. Case 3Case 3
A 82 yr old , urine Cr 1.2, urine analysisA 82 yr old , urine Cr 1.2, urine analysis
normal. He is only 50 kg wtnormal. He is only 50 kg wt
Doctor calculated GFR beforeDoctor calculated GFR before
administering antibiotic and it was lessadministering antibiotic and it was less
than 50ml/minute.than 50ml/minute.
What would you tell his son if he ask youWhat would you tell his son if he ask you
about his kidney function?.about his kidney function?.

5. Case 4Case 4
50 yr old diabetic with normal urine50 yr old diabetic with normal urine
analysis and no microalbuminuria ,withanalysis and no microalbuminuria ,with
serum Cr 0.8.(done 2 weeks beforeserum Cr 0.8.(done 2 weeks before
hospital admission).hospital admission).
Admitted with fever and urosepsis withAdmitted with fever and urosepsis with
hypotension- Cr 2.6, urine with plenty ofhypotension- Cr 2.6, urine with plenty of
pus cells , RBC and +++ protein.pus cells , RBC and +++ protein.

6. Calculation of GFRCalculation of GFR
(140-age) x weight (in kg)(140-age) x weight (in kg)
72 x P72 x PCrCr
For females multiply the result by 0.85For females multiply the result by 0.85

10. Management of CKDManagement of CKD
Treatment of reversible causes .Treatment of reversible causes .
Preventing the progression of renalPreventing the progression of renal
disease.disease.
Treatment of complications of CKD .Treatment of complications of CKD .
Treatment of complications of ESRD.Treatment of complications of ESRD.
Identifying and preparing pts for RRTIdentifying and preparing pts for RRT

11. Reversible causesReversible causes
Decreased renal perfusion.Decreased renal perfusion.
RASRAS
Diuretic use.Diuretic use.
Hypotension –drugs, cardiogenic.Hypotension –drugs, cardiogenic.
Sepsis.Sepsis.
Drugs which lower GFR –ACEI,NSAID.Drugs which lower GFR –ACEI,NSAID.

12. Reversible causes -contdReversible causes -contd
Nephrotoxic drugsNephrotoxic drugs
Avoid nephrotoxic drugs in pts with CKD,Avoid nephrotoxic drugs in pts with CKD,
IV contrast, NSAID, Aminoglycosides.IV contrast, NSAID, Aminoglycosides.
amphoterecin etcamphoterecin etc

13. Reversible causes -contdReversible causes -contd
Urinary tract obstructionUrinary tract obstruction
BPH and outlet obstructionBPH and outlet obstruction
Kidney stone and obstruction.Kidney stone and obstruction.

14. Slowing rate of progression of CKDSlowing rate of progression of CKD
By reducing the intraglomerular HTN.By reducing the intraglomerular HTN.
BP control <130/80.BP control <130/80.
Reduced protein intake.Reduced protein intake.
Lowering cholestrol.Lowering cholestrol.
Smoking cessation.Smoking cessation.

15. Treatment of complications of CKDTreatment of complications of CKD
Volume overload-Volume overload-
Hyperkalemia.Hyperkalemia.
Metabolic acidosis.Metabolic acidosis.
Hyperphosphatemia.Hyperphosphatemia.
Secondary hyperparathyroidism.Secondary hyperparathyroidism.
HTNHTN
Anemia.Anemia.
Dyslipedemia.Dyslipedemia.

16. Treatment of complications ofTreatment of complications of
ESRDESRD
Uremic bleeding.Uremic bleeding.
Malnutrition.Malnutrition.
Pericarditis.Pericarditis.
Thyroid dysfunction.Thyroid dysfunction.
Uremia and uremic symptoms.Uremia and uremic symptoms.

17. Choices of RRTChoices of RRT
Transplantation.Transplantation.
Hemodialysis.Hemodialysis.
Peritoneal Dialysis.Peritoneal Dialysis.

18. TransplantationTransplantation
Not all pts appropriate candidate.Not all pts appropriate candidate.
Improve quality of life.Improve quality of life.
Donor availability main problem.Donor availability main problem.
Living related, living unrelated andLiving related, living unrelated and
Cadaveric donors.Cadaveric donors.
Details later….Details later….

19. Hemodialysis.Hemodialysis.
Home verus in-center therapy.Home verus in-center therapy.
Usual maintenance dialysis 3Usual maintenance dialysis 3
times/week,each session 4 hrs.times/week,each session 4 hrs.
Long nocturnal hemodialysis.- usually 5-6Long nocturnal hemodialysis.- usually 5-6
nights per week, each session 8-10 hrs.nights per week, each session 8-10 hrs.
Short daily dialysis at home- gainingShort daily dialysis at home- gaining
popularity.popularity.

20. Peritoneal dialysis.Peritoneal dialysis.
At home dialysis.At home dialysis.
Very convenient for pt’s who wish to work.Very convenient for pt’s who wish to work.
For pt’s who wish to travel.For pt’s who wish to travel.
For very young children and infants.For very young children and infants.
For pt’s with severe cardiovascular illness.For pt’s with severe cardiovascular illness.
For pt’s with difficult vascular access.For pt’s with difficult vascular access.

21. Contraindications to PDContraindications to PD
Unsuitable peritoneum- due to priorUnsuitable peritoneum- due to prior
surgery, malignancy.surgery, malignancy.
Hernia.Hernia.
Poorly controlled diabetes.Poorly controlled diabetes.
Back pain may get worse.Back pain may get worse.

22. Contra indications for dialysis.Contra indications for dialysis.
No absolute contraindications.No absolute contraindications.
Pt’s with advanced disease in an organPt’s with advanced disease in an organ
system other than kidneys usually excluded ( egsystem other than kidneys usually excluded ( eg
–end stage heart disease, liver disease etc).–end stage heart disease, liver disease etc).
Pts with advanced malignancy.Pts with advanced malignancy.
Un co-operative patients.Un co-operative patients.

23. Preparation for hemodialysis.Preparation for hemodialysis.
Access placement.Access placement.
3 types of access- primary A-V fistula,3 types of access- primary A-V fistula,
A-V graft.A-V graft.
double lumen cuffeddouble lumen cuffed
tunneled catheter.tunneled catheter.

24. Primary A-V fistula.Primary A-V fistula.
Usually on non-dominant upper extremity.Usually on non-dominant upper extremity.
End –to-side vein-to-artery anastomosis.End –to-side vein-to-artery anastomosis.
Usually wrist (radio-cephalic) or upper armUsually wrist (radio-cephalic) or upper arm
(brachio -cephalic OR brachio-basilic).(brachio -cephalic OR brachio-basilic).
Better to do it 6 months prior to anticipatedBetter to do it 6 months prior to anticipated
dialysis.dialysis.

25. A-V graftA-V graft
By anastomosing a synthetic conduitBy anastomosing a synthetic conduit
between artery and vein.between artery and vein.
Usually a polytetrofluroethylene (PTFE)Usually a polytetrofluroethylene (PTFE)
graft.graft.

26. A-V graftA-V graft
Straight fore arm- radio-cephalic.Straight fore arm- radio-cephalic.
Looped fore arm- brachio-cephalic.Looped fore arm- brachio-cephalic.
Straight upper arm -brachial –axillary.Straight upper arm -brachial –axillary.
Looped upper arm – axillary –axillary.Looped upper arm – axillary –axillary.

27. Complications of graft/ fistulaComplications of graft/ fistula
Infection.Infection.
Thrombosis.Thrombosis.
Aneurysm – in 3-5%.Aneurysm – in 3-5%.
Hand ischemia due to steal ,more (6%)inHand ischemia due to steal ,more (6%)in
brachiocephalic.brachiocephalic.
High output heart failure ( pt’s with severeHigh output heart failure ( pt’s with severe
heart failure should be excluded fromheart failure should be excluded from
having permanent access.)having permanent access.)

28. Tunneled cuffed catheter.Tunneled cuffed catheter.
Mostly from IJ.Mostly from IJ.
Can be used immediately.Can be used immediately.
Usually in pt’s with no access, or in pt’sUsually in pt’s with no access, or in pt’s
with failed access.with failed access.
Infection most common, severeInfection most common, severe
complication.complication.
Can get clotted too.Can get clotted too.

29. Preparation for PDPreparation for PD
Insert PD catheter 2-3 weeks prior toInsert PD catheter 2-3 weeks prior to
initiation of PD.initiation of PD.
Two type of PD.- CAPD,CCPD.Two type of PD.- CAPD,CCPD.
If pt choose CCPD, buy machine earlyIf pt choose CCPD, buy machine early
etc.etc.

30. Indications to start dialysis.Indications to start dialysis.
Pericarditis/ pericardial effusion, pleuritis.Pericarditis/ pericardial effusion, pleuritis.
Neurological dysfunction- encephalopathy,Neurological dysfunction- encephalopathy,
psychiatric disturbances, seizure etc.psychiatric disturbances, seizure etc.
Bleeding diathesis due to uremia.Bleeding diathesis due to uremia.
Fluid overload refractory to diuretics.Fluid overload refractory to diuretics.
Hyperkalemia refractory to treatment.Hyperkalemia refractory to treatment.

31. Indications.Indications.
Metabolic acidosis refractory to treatment.Metabolic acidosis refractory to treatment.
Hyper phosphatemia and hypocalcemiaHyper phosphatemia and hypocalcemia
refractory to treatment.refractory to treatment.
Deterioration in nutritional statusDeterioration in nutritional status
accompanied by nausea, vomiting.accompanied by nausea, vomiting.
Refractory anemia.Refractory anemia.
Otherwise unexplained decline inOtherwise unexplained decline in
functioning.functioning.

32. Hemodialysis.Hemodialysis.
Pts blood pumped through the dialysisPts blood pumped through the dialysis
machine to remove waste products andmachine to remove waste products and
excess water.excess water.

34. Dialysis apparatusDialysis apparatus
Dialyzer.Dialyzer.
Dialysate.Dialysate.
Tubings.Tubings.
Machine.Machine.

35. Solute clearanceSolute clearance
Diffusion.Diffusion.
ConvectionConvection

36. Diffusion.Diffusion.
Primary means of waste removal.Primary means of waste removal.
Depends on - concentration of solute,Depends on - concentration of solute,
membrane surface area, porosity andmembrane surface area, porosity and
thickness of membrane, size of solutethickness of membrane, size of solute
,flow rate of blood and dialysate,flow rate of blood and dialysate
Usual blood flow – 300-500mlUsual blood flow – 300-500ml
Usual dialysate flow – 500 -800 mlUsual dialysate flow – 500 -800 ml

37. Convective TransportConvective Transport
Most important for large solutes .Most important for large solutes .
By high rate of fluid transport, solutesBy high rate of fluid transport, solutes
dragged along with fluid.dragged along with fluid.

38. Fluid removal.Fluid removal.
By hydrostatic pressure gradientBy hydrostatic pressure gradient
generated by the dialysis machine.generated by the dialysis machine.
The TMP cause fluid to cross from highThe TMP cause fluid to cross from high
pressure blood compartment to lowpressure blood compartment to low
pressure dialysate compartment.pressure dialysate compartment.

39. DialyzerDialyzer
Hollow fiber.Hollow fiber.
Parellel plateParellel plate

40. Difft category of dialyzersDifft category of dialyzers
Type of membrane .Type of membrane .
Synthetic, cellulose, substitutedSynthetic, cellulose, substituted
cellulose etc.cellulose etc.

41. DialyzerDialyzer
Blood volume capacityBlood volume capacity
Usually 60-120 ml ( blood lines 100-Usually 60-120 ml ( blood lines 100-
150 ml)150 ml)
Surface area- Large surface area –betterSurface area- Large surface area –better
clearance.clearance.

42. DialyzerDialyzer
Ultrafiltration coefficient- Low KUf lowUltrafiltration coefficient- Low KUf low
permeability of water,so higher TMP topermeability of water,so higher TMP to
achieve UF and vice versa.achieve UF and vice versa.
But newer machines with controlled UF.But newer machines with controlled UF.

43. Dialyzer.Dialyzer.
Usually reported as small solute clearanceUsually reported as small solute clearance
and large solute clearance ,and at difftand large solute clearance ,and at difft
blood flows.blood flows.
Usually we use small clearance one forUsually we use small clearance one for
first dialysis, and large clearance one forfirst dialysis, and large clearance one for
large pts.large pts.

44. DialyzerDialyzer
Capacity to reuse.Capacity to reuse.
Sterilization – usually by ethylene oxide,Sterilization – usually by ethylene oxide,
but pts with allergies can use the onesbut pts with allergies can use the ones
with gamma irradiation, steamwith gamma irradiation, steam
autoclaving.autoclaving.

45. Dialysate.Dialysate.
Sodium – 135 – 155 meq/lSodium – 135 – 155 meq/l
K 0 – 4 meq/lK 0 – 4 meq/l
Calcium 1.25 – 1.75 mmol/lCalcium 1.25 – 1.75 mmol/l
Magnesium 0 – 0.75 mmol/lMagnesium 0 – 0.75 mmol/l
Chloride 87- 120 meq/lChloride 87- 120 meq/l
Bicarbonate 25-40 meq/lBicarbonate 25-40 meq/l
Glucose 0 -0.20 gm/dlGlucose 0 -0.20 gm/dl

46. Dialysis tubings.Dialysis tubings.
Arterial line carry blood from pt to theArterial line carry blood from pt to the
dialyzer.dialyzer.
Venous line carry dialyzed blood back toVenous line carry dialyzed blood back to
patient.patient.

47. Dialysis machine.Dialysis machine.
Blood pump to move blood betweenBlood pump to move blood between
patient and dialyzer.patient and dialyzer.
A delivery system to transport dialysisA delivery system to transport dialysis
solution.solution.
Monitoring devices –pressure monitors,Monitoring devices –pressure monitors,
venous air trap and air detector,temptvenous air trap and air detector,tempt
sensor etcsensor etc

48. Acute complicationsAcute complications
Hypotension.Hypotension.
Cramps.Cramps.
Nausea, vomiting.Nausea, vomiting.
Headache.Headache.
Chest pain.Chest pain.
Fever and chills.Fever and chills.

49. Hypotension.Hypotension.
Rapid fluid removalRapid fluid removal
Inaccurate dry weight.Inaccurate dry weight.
Cardiac- arrhythmias,pericardial effusion.Cardiac- arrhythmias,pericardial effusion.
Intake of antihypertenisives.Intake of antihypertenisives.
Low Hb, low sugar.Low Hb, low sugar.
Intake of meals immediately before or duringIntake of meals immediately before or during
dialysis.dialysis.
Low sodium dialysate.Low sodium dialysate.
Reaction to dialyzer membrane (not now)Reaction to dialyzer membrane (not now)

50. Treatment of hypotensionTreatment of hypotension
Place pt in trendelenburg position.Place pt in trendelenburg position.
Stop UF.Stop UF.
Reduce blood flow.Reduce blood flow.
Give saline.Give saline.
Further treatment based on etiology.Further treatment based on etiology.

51. Disequilibrium syndrome.Disequilibrium syndrome.
First described in 1962.First described in 1962.
Neurological symptoms of varyingNeurological symptoms of varying
severity.severity.
New pts just being started on dialysis atNew pts just being started on dialysis at
greater risk.greater risk.
Predisposing factors – increased BUN,Predisposing factors – increased BUN,
extremes of age, severe MA, preexistingextremes of age, severe MA, preexisting
seizure disorder.seizure disorder.

52. Symptoms.Symptoms.
Nausea, Vomiting.Nausea, Vomiting.
Restlessness and headache.Restlessness and headache.
Blurred vision, confusion.Blurred vision, confusion.
Seizure, coma.Seizure, coma.
Death.Death.

53. Treatment.Treatment.
Prevention.Prevention.
R/O other causes for the symptom.R/O other causes for the symptom.
Treatment of seizure.Treatment of seizure.