The document discusses dialysis as a renal replacement therapy for patients with kidney failure or injury. It describes the process of diffusion and ultrafiltration that occurs during hemodialysis and peritoneal dialysis to remove waste and excess fluid. Complications related to each type of dialysis are also outlined. Nursing considerations are provided for pre-dialysis assessment, monitoring patients during treatment, and post-dialysis care.

1. JOHNY WILBERT, M.SC[N]
LECTURER,
APOLLO INSTITUTE OF HOSPITAL
MANAGEMENT AND ALLIED SCIENCE

2. dialysis is the process of removing
excess water, solutes and toxins from
the blood in those whose native kidneys
have lost the ability to perform these
functions in a natural way. This is
referred to as renal replacement therapy

3. Dialysis may be used in those with rapidly
developing loss of kidney function, called acute
kidney injury (previously called acute renal
failure); or slowly worsening kidney function,
called Stage 5 chronic kidney disease, (previously
called chronic kidney failureand end-stage renal
disease and end-stage kidney disease).
Dialysis is used as a temporary measure in either
acute kidney injury or in those awaiting kidney
transplant and as a permanent measure

4. Dialysis works on the principles of
the diffusion of solutes and ultrafiltration of
fluid across a semi-permeable membrane.
Diffusion is a property of substances in water
tend to move from an area of high
concentration to an area of low concentration.
Blood flows by one side of a semi-permeable
membrane, and a dialysate, or special dialysis
fluid, flows by the opposite side.

5.  A semipermeable membrane is a thin layer of material
that contains holes of various sizes, or pores. Smaller
solutes and fluid pass through the membrane, but the
membrane blocks the passage of larger substances (for
example, red blood cells, large proteins).
 This replicates the filtering process that takes place in
the kidneys when the blood enters the kidneys and the
larger substances are separated from the smaller ones
in the glomerulus.
 Dialysate
Composed of sterile water, electrolytes/chemicals and
dextrose
Dextrose concentration determines osmotic pressure
in PD exchange

6.  Acute indications
 Indications for dialysis in the patient with acute kidney
injury are summarized with the vowel mnemonic of
"AEIOU":[17]
 Acidemia from metabolic acidosis in situations in which
correction with sodium bicarbonate is impractical or may
result in fluid overload.
 Electrolyte abnormality, such as severe hyperkalemia,
especially when combined with AKI.
 Intoxication, that is, acute poisoning with a dialyzable
substance.
 Overload of fluid not expected to respond to treatment
with diuretics
 Uremia complications, such
as pericarditis, encephalopathy, or gastrointestinal
bleeding.

7.  Chronic indications
 Chronic dialysis may be indicated when a patient
has symptomatic kidney failure and low glomerular
filtration rate (GFR < 15 mL/min

8. There are three primary and two secondary
types of dialysis:
hemodialysis (primary),
 peritoneal dialysis (primary),
 hemofiltration (primary),
hemodiafiltration (secondary)
 intestinal dialysis (secondary).

9. Hemodialysis
In hemodialysis, the patient's blood is pumped
through the blood compartment of a dialyzer,
exposing it to a partially permeable membrane.
The dialyzer is composed of thousands of tiny
hollow synthetic fibers.
The fiber wall acts as the semipermeable
membrane.
 Blood flows through the fibers, dialysis solution
flows around the outside of the fibers, and water
and wastes move between these two solutions.
 The cleansed blood is then returned via the
circuit back to the body..

10. Ultrafiltration occurs by increasing the
hydrostatic pressure across the dialyzer
membrane This usually is done by applying a
negative pressure to the dialysate compartment
of the dialyzer.
This pressure gradient causes water and
dissolved solutes to move from blood to
dialysate and allows the removal of several
litres of excess fluid during a typical 4-hour
treatment

11.  Dialysis machine and a dialyser clean
the blood
 Blood and dialysis fluids do not mix
 Can take up to 3-6 hours
 Usually 3 times per week
 Either inpatient or outpatient by trained
staff

14. Peritoneal dialysis
In peritoneal dialysis, a sterile solution
containing glucose (called dialysate) is run
through a tube into the peritoneal cavity,
the abdominalbody cavity around the intestine,
where the peritoneal membrane acts as a
partially permeable membrane.
This exchange is repeated 4–5 times per day

15.  Instillation of dialysis fluids into the
peritoneal space via a surgically-inserted
catheter
 Most catheters are silicone
 Fluid is removed to take out toxins
 Most common types include:
Chronic ambulatory
Continuous cyclical
Chronic intermittent

17. Hemofiltration
Hemofiltration is a similar treatment to
hemodialysis, but it makes use of a different
principle. The blood is pumped through a dialyzer
or "hemofilter" as in dialysis, but no dialysate is
used.
 A pressure gradient is applied; as a result, water
moves across the very permeable membrane
rapidly, "dragging" along with it many dissolved
substances, including ones with large molecular
weights, which are not cleared as well by
hemodialysis.

18. Hemodiafiltration
Hemodiafiltration is a combination of
hemodialysis and hemofiltration, thus
used to purify the blood from toxins
when the kidney is not working normally
and also used to treat acute kidney
injury (AKI).

19. Intestinal dialysis
In intestinal dialysis, the diet is supplemented
with soluble fibres such as acacia fibre, which
is digested by bacteria in the colon.
This bacterial growth increases the amount of
nitrogen that is eliminated in fecal waste.

20. Hemodialysis Vascular Access
 Provides location for easy access to patient’s
blood for dialysis
 Higher flows rate of bood
 cannulation can lead to stenosis or
thrombosis
 Early detection of stenosis can lead to
intervention before thrombosis occurs

21. AV Fistula
 Vein cross-cut, attached end-to-side to artery
 High-pressure flow dilates and thickens vein
 Best alternative:
Lowest infectious risk
Longest lasting with least thromboses
 Drawbacks
Takes 2-4 months to mature
Only about 50% ever mature

22. AV Graft
 Tube made of biocompatible material (gortex)
attached end-to-side to artery and vein
 Often required in patients with vascular disease,
occluded distal veins
 Advantages
Ready to use when swelling resolves (~2
weeks)
Able to use in most patients
 Disadvantages
High stenosis/thrombosis rate
Moderate infectious risk

24. Catheter
Intra juguar vein is most common site ,
Some times femoral vein
 Tunnelled under skin to reduce communication
from skin flora with blood
 Advantages
Ready for use immediately
 Disadvantages
High infectious risk
High thrombosis risk
A/W increased mortality
 Can be a sign of poor pre-dialysis care or
extensive vascular disease

26. Complications of heamodialysis
• Infection
• Nutritional Deficiencies
• Low Blood Pressure
• Muscle Cramps
• Clotting Issues
• Movement Issues
• Dry and Itching Skin

27. Complications related to vascular Access in
Hemodialysis
1. Infection
2. Catheter clotting
3. Central venous thrombosis
4. Stenosis or thrombosis
5. Ischemia of the affected limb
 6. Development of an aneurysm

28. Peritoneal Dialysis (PD ) complication
Patients may experience both psychological and physical
problems like
• Body image -- catheter outside , size and shape of
abdomen
• Fluid overload
• Dehydration
• Discomfort- uncomfortable when fluid in full or blotted
– backache , shoulder pain
• Poor drainage : a. Constipation b. Catheter displacement
• Leaks
 Tunnel infection
• Peritonitis
• Back pain

29. Nursing considerations Hemodialysis:
 Nursing interventions for H D
 1. Explain procedure to client
 2. Cannulating & connecting to HD machine
 3. Monitor hemodynamic status continuously
 4. Monitor acid-base balance
 5. Monitor electrolytes
 6. Insure sterility of system
 7. Maintain a closed system
 8. Discuss diet and restrictions on: a. Protein intake b.
Sodium intake c. Potassium intake d. Fluid intake

30. Pre-dialysis care
Weight: Determines amount of fluid to be
removed during dialysis •
Vital signs: BP for hypo and hypertension;
temperature for sepsis; respiration for fluid
overload •
Potassium level: Determines potassium level in
dialysate (in the chronic setting, this is done
monthly unless the patient is symptomatic

31. Review Medications
• Hold drugs that pass through the dialysis
membrane, such as piperacillin, folic acid, and
other water-soluble vitamins.
• Hold antihypertensive drugs, especially if
systolic pressure is below 100, per physician
order
• Review need for blood products

32. Check access site
• Assess fistula or graft for infection
• Assess circulation in distal portion of
extremity
• Auscultate for bruit
• Palpate for thrill
• No IV or blood draws in that arm
 • No BP in arm

33. During dialysis
Watch for
• Hypotension
• Muscle cramps
• Nausea and vomiting
• Headache
• Itching
• Less commonly: disequilibrium syndrome,
hypersensitivity reaction, arrhythmia, cardiac
tamponade, seizures, air embolism

34. Post-Dialysis care
• Monitor BP; report hypotension or
hypertension
• Watch for bleeding
• Check weight and compare (weight loss should
be close to fluid removal goal set during
treatment)
• Document unusual findings • Assess access site
for bruit, thrill, exudate, signs of infection,
bleeding • Give missed meds, if indicated