Renal replacement therapy is therapy that replaces the normal blood-filtering function of the kidneys. It is used when the kidneys are not working well, which is called kidney failure and includes acute kidney injury and chronic kidney disease.

1. Renal Replacement Therapy
Mr.Sachin Dwivedi
College of Nursing, AIIMS Rishikesh.

2. Renal Replacement Therapy
• Renal replacement therapy is a term used to
encompass life-supporting treatments for renal
failure.
• Renal replacement therapy replaces nonendocrine
kidney function in patients with renal failure.
Techniques include intermittent hemodialysis,
continuous hemofiltration and hemodialysis, and
peritoneal dialysis.

3. What is Dialysis?
• “Dialysis is an artificial way to eliminate waste
and excess fluid from the body.”

4. HEMODIALYSIS
It is the removal of solutes and water from body across
a semipermeable membrane (dialyzer)

5. Father of hemodialysis
• Willem Kolff invented the first “artificial kidney”
• This young Dutch physician constructed the first
dialyzer (artificial kidney) in 1943.

6. PRINCIPLES underlying HD
• Diffusion
• Osmosis
• Ultra filtration & solvent drag

7. DIFFUSION
• Movement of molecules from an area of
higher concentration to an area of lower
concentration

8. OSMOSIS
• Movement of solvent molecules from lower
concentration to higher concentration

9. Ultra filtration & Solvent drag
• Water moves from an area
of high pressure to an area
of lower pressure
• Molecules which are
dissolved in the solvent also
get removed- solvent drag

10. INDICATIONS
• Acute poisoning
• Acute renal failure
• Severe edema
• Chronic renal failure
• Hepatic coma
• Metabolic acidosis
• Transfusion reaction
• Post partum renal insufficiency
• Cardiac tamponade
• Fluid overload not responding to diuretics & fluid restriction

11. CONTRAINDICATIONS
• Other chronic vascular disease.
• Inability to secure vascular access.
• Hemodynamic instability or Hemorrhage.
• Very old people.

12. VASCULAR ACCESS
1. AV FISTULA
2. AV GRAFTS
3. Percutaneous access

13. AV FISTULA
• Anastamosis of an artery to a vein
• Sites- radial artery & cephalic vein,
brachial artery & cephalic vein,
brachial artery & basilic vein
• The increased blood flow and
pressure causes the vein to dilate.

14. Pre-op care in AV fistula
• Full explanation of the procedure and aftercare
• Should be well hydrated before the surgery
• Part preparation.

15. Post op care in AV fistula
• Limb should be kept warm
&well supported to maintain the
peripheral circulation.
• Monitor the BP and maintained
at 100 systolic minimum to
reduce the risk of fistula
thrombosis.
• Avoid antihypertensive therapy
• Examine the wound site for
bleeding/swelling
• Check the blood flow
regularly(bruit/ thrill) regularly

16. Post op care of AV fistula
• Avoid using the fistula arm for carrying heavy
loads.
• Avoid tight and restrictive clothing on the arm.
• Hand exercises promote fistula maturation.
• Arm should not be used for phlebotomy
cannulations or recording the BP.
• Notify physician if any bleeding.

17. Long term care
• Keep your access clean at all times
• Be careful not to bump your access
• Don’t wear jewellery over your access
• Don’t sleep with your access arm under your head or
body.
• Check the pulse in your access every day.

18. Complications of Av fistula
• Thrombosis- due to hypotension
• Aneurysm- due to repeated area puncture
• Steal syndrome- due to reduced blood

19. ARTERIOVENOUS GRAFT
• A graft is put between an
artery &vein
• Synthetic graft(PTFE) is
used most commonly.
• Indications
- Peripheral vascular disease
- Diabetes
• Can be used after 14 days

20. Percutaneous access
• Internal jugular vein
• Subclavian vein
• Femoral vein
• Indications
- Acute dialysis
- Temporary
- Inadequate vessels
- Failed access

21. Percutaneous access

22. Post insertion care
• Correct insertion is checked by X-ray
• Check for pneumothorax & puncture of the adjacent vessels
• Maintain the patency of the catheter
- Heparin lock injected after each dialysis
- Heparin is removed & flushed with saline (0.9%)before next
dialysis
- Never flush the catheter if can’t be aspirated
• Examine the sites for any soreness, redness, or presence of
exudates.

23. Canulation
• Allow the fistula to mature.
• A thorough physical examination is done before
canulation.
• Adhere to units protocol.
• Universal precautions are followed.
• A tourniquet may be used to get the vessels
engorged.

24. Types of canulations
• Rope ladder puncture
• Area puncture
• Buttonhole puncture

25. Canulation technique
• Needles to be inserted at 45 deg to the skin
• Arterial and venous needle should be placed 5 cm
apart
• Don’t pull or push the needle blindly
• Ask for assistance if cannulations attempt had failed
for 2/3 times

26. Mechanism of Hemodialysis

27. Mechanism of Hemodialysis
• The arterial blood is passed through the dialyser and
then back to the body through the vein. Heparin is used
as an anticoagulant while passing the blood through the
machine.
• Inside the dialyser, the blood moves through the
hemofilter, which contains tiny channels that are
interposed between two cellophane membranes. These
are porous membranes.
• The outer surface of these membranes is bathed in the
dialysing fluid called dialysate. The used dialysate is

28. Mechanism of Hemodialysis
• Urea, phosphate, creatinine, and other unwanted
substances from the blood pass into the dialysate by
the concentration gradient. The essential substances
required by the body diffuse from the dialysate into the
blood.
• The dialysis machine also has several blood pumps
with pressure monitors that enable easy flow of
blood from the patient to the machine and back to the
patient. It also has pumps for the flow of fresh
dialysate and for drainage of used dialysate.

29. Dialysate
• The fluid which is pumped on the opposite side of the
semi permeable membrane to the patients blood
• It is prepared by mixing a concentrated electrolyte
solution with a buffer(bicarbonate) & purified water.

30. Composition of Dialysate
SOLUTE BLOOD DIALYSATE
SODIUM(mmol/) 130- 149 132-145
Potassium 3.5- 5 0- 3.0
Urea 2.5 – 6.5 0
Creatinine 60 – 120 0
Calcium(mmol/l) 2.2 – 2.6 0.25 -0. 75
Magnesium 0 – 85 0 – 1.0
Glucose(mg/dl) 70-160 0-200
Bicarbonate (mmol/l) 22- 26 0- 40

31. Anticoagulation
• Heparin in the beginning 2000- 5000U or 50 U/Kg and
then as a continuous infusion at 1000- 1500U/hr till
15-60 mts before the end of dialysis
• Heparin free dialysis if bleeding disorder is there.

32. Peritoneal dialysis
• Peritoneal dialysis is done by
surgically implanting a catheter in
the peritonial membrane of the
patient.
• A cleaning fluid (dialysate) is then
circulated throughout the catheter
that absorbs the waste materials
from the blood vessels in the walls
of the stomach.
• It is then drawn out and discarded.
• It is more versatile and convenient.

33. Indications
• Vascular access failure.
• Intolerance to hemodialysis.
• Congestive heart failure.
• Prosthetic valvular disease.
• Children aged 0-5 years.
• Patient preference.
• Distance from a hemodialysis center.
• Poor cardiac function.

34. Contraidications
• Crohn disease, ulcerative colitis,
current clostridium difficile
infection, and end-stage liver
disease with ascites.
• The main anatomic contraindication
to PD is an unrepaired hernia.

35. Nursing management of patients with dialysis
• Before dialysis.
• During dialysis.
• After dialysis.

36. REFERENCES
• Brunner and Suddarth's (2010)Textbook of Medical-Surgical Nursing,
10th edition, Lippincott Williams & Wilkins,.
• Black M.Joyce and Hawks Hokanson Jane. (2012). Medical Surgical
Nursing,Clinical Management for Positive Outcome.Mumbai.Elsevier
Publication.
• Black. M. Joyce et.al. (2005). Medical Surgical Nursing.8th edition .Vol.2
• Hinkle L. Janice and Cheever H. Kerry (2014).Text book of Medical-
Surgical Nursing 13th edition. NewDelhi. Wolters Kluwer publication.