TO REMOVE FLUID & UREMIC WASTE PRODUCTS WHEN THE BODY IS UNABLE TO DO SO

Acute vs. Chronic Dialysis

INDICATED FOR HYPERKALEMIA, FLUID OVERLOAD OR IMPEMDING PULMONARY EDEMA, INCREASING ACIDOSIS, SEVERE CONFUSION, REMOVAL OF TOXINS FROM THE BLOOD

MAINTENANCE DIALYSIS CHRONIC RENAL FAILURE W/

PERICARDIAL FRICTION RUB UREMIC SIGNS & SYMPTOMS

AFFECTING ALL BODY SYSTEMS

DIFFUSION

› The movement of particles from an area of higher concentration to a lower concentration

› Higher concentration of toxins in the blood moves to a lower concentration of the dialysate solution

OSMOSIS

› The movement of fluids across a semi-permeable membrane from an area of lesser concentration to higher concentration of particles

› Excess water from the blood (lower concentration)moves to the dialysate bath (higher concentration)

ULTRAFILTRATION

› Movement of fluid across a semi-permeable membrane as a result of artificially created pressure gradient

› Accomplished by applying a suction/negative pressure to the dialysis membrane to attract excessive water

› More efficient than osmosis

› This pressure forces salt and water out of the blood and into the dialysate.The used dialysate with the blood wastes and excess fluid is taken away and drained.

is a method for removing waste products such as creatinine and urea, as well as excess water from the blood when the kidneys are in renal failure

1. Arterial blood passes through a DIALYZER

› (an artificial kidney) to remove wastes and excess water.

› “semi-permeable” membrane surrounding these tubes is very thin and allows only some particles to pass through

2. As blood moves through these tubes it comes into contact with a solution called DIALYSATE

› a liquid made from water, an acid solution and a bicarbonate solution.

› The dialysate liquid is circulated around the outside of the hollow fibers.

3. As a result, some waste products and electrolytes in the blood will move from the blood side of the membrane into the dialysate solution and some molecules will move from the dialysate side of the membrane into the blood.

Large molecules such as blood cells and protein are kept inside the membrane but smaller molecules such as urea and creatinine (and other biological wastes) pass through the small holes of the dialyzer’s filters into the dialysate solution.

4.Cleansed blood returns to the patient via venous access

Two normally functioning kidneys filter about 180 litres of blood a day, extracting about two litres of waste and extra water.

Your body produces hundreds of different waste molecules every second.

Some of these molecules become waste products such as CREATININE & UREA, which are the result of the normal breakdown of muscle and food (known as metabolism).

The by-product or waste products of metabolism are then turned into urine, which is contained in the bladder until it is expelled.

People with kidney failure need the help of dialysis to get rid of these normal metabolic waste products.

Dialysis CAN

Remove waste products (e.g. urea, creatinine, phosphorus, etc.)

Remove excess water

Correct high or imbalanced levels of potassium, chloride, sodium, etc. in the blood

Dialysis CAN’T

Automatically regulate blood pressure

Produce hormones like Erythropoetin (EPO)

Regulate normal calcium levels

A few signs (symptoms) of not getting enough dialysis are:

• Weakness and tiredness• Poor appetite• Feeling sick to your stomach• Trouble getting a good sleep• Itchy skin• Metallic taste in your mouth• Difficulty in concentrating• Reduced interest in sex• Difficulty breathing, especially when

exercising or laying down flat• Swelling in your hands and feetPoor blood pressure control

Dialyze all the days you’re supposed to

Dialyze for your full treatment time

Follow your diet and fluid restrictions

Take your medications regularly

Take care of your access and monitor your arterial and venous pressures.

HOW MUCH BLOOD IS BEING CLEARED FROM THE PATIENT???

K = CBi – CBo x Qb CBi K - is clearanceCBi -(concentration at the blood inlet) is

the concentration of “x” solute in the blood entering the dialyzer (arterial sample)

CBo -(concentration at the blood outlet) is the concentration of “x” solute in the blood leaving the dialyzer(venous sample)

Qb -is blood flow rate in mL/min

For example, imagine that you wanted to calculate the clearance of urea in a patient for whom:

CBi = 82 mg/dL (arterial BUN sample) CBo = 8 mg/dL (venous BUN sample) Qb = 350 mL/min

Step 1: (82 – 8) x 350 82 Step 2: 74 x 350 82 Step 3: 0.9 x 350 = 316 mL/min Therefore, during each minute of dialysis, 316 mL of this

patient’s blood has been cleared of urea.

is achieved by introducing dialysis solution into the peritoneal cavity using a silastic catheter that is inserted through the patient's abdominal wall.

1.This catheter is tunneled under the skin for stability and terminates in the peritoneal space.

2. Using this catheter, the dialysate solution is drained into the peritoneal space by gravity known as INFLOW

3. During DWELL TIME, the natural membrane lining of the peritoneal cavity acts as a dialysis membrane through which waste products and excess water from the body can pass through into the peritoneal dialysate fluid

4. This waste-containing dialysate solution is drained out of the abdomen into a plastic bag known as OUTFLOW and is discarded.

5. A new quantity is reintroduced in the next cycle.

Acute Intermittent PD› Manually/ cycler machine› Echnage rate 30 minutes to 2hours

› Most common is hourly rate:INFLOW:10min, DWELL Time:30min, OUTFLOW:20min

Continuous Ambulatory PD Continuous Cyclical PD

Acute Intermittent PD

Continuous Ambulatory PD› done at home by trained pt. or caregiver

› Exchange of 4 or 5 times/day, 24/7

› Before meals & at bedtime Continuous Cyclical PD

Acute Intermittent PD Continuous Ambulatory PD

Continuous Cyclical PD› Overnight intermittent PD w/ prolonged morning dwell time

› 2-3L exchange @ night› 2-3L dwell time in the morning› Quiet machine & extra long tubing

• must be STERILE• Dry heating is used (heating

cabinet, incubator, heating pad)• It is a HYPERTONIC SOLUTION• CONTENT:

• Electrolytes & minerals • high concentration of glucose relative

to the patient's own blood• Heparin• Antibiotics• Insulin

The highly osmolar dialysis solution causes water to move from the patient's circulation through the peritoneal membrane and into the dialysate fluid within the peritoneal cavity by the process of osmosis.

Waste products and excess electrolytes move from the patient's circulation into the dialysate solution by the process of diffusion.

Each exchange, that is draining of the old solution and replacing it with a fresh solution, takes about 45 min.

• Less complication compared to HD• Less efficient compared to

hemodialysis• 36-48hours PD = 6-8hours HD

• Candidates:• Hemodynamically unstable pt.• Patients susceptible to rapid F&E and

metabolic changes(elderly, pulmonary edema, diabetic and

CVD patients: severe HPN, heart failure)• not a satisfactory technique in patients

who are catabolic and produce high levels of nitrogenous wastes, i.e. sepsis, ARDS D

STAGE DESCRIPTION GLOMERULAR FILTRATION RATE

1 Kidney damage (e.g., protein in the urine) with normal GFR

90 or above

2 Kidney damage with mild decrease in GFR

60 to 89

3 Moderate decrease in GFR 30 to 59

4 Severe reduction in GFR 15 to 29

5 Kidney failure Less than 15

Your GFR number tells your doctor how much kidney function you have. As chronic kidney disease progresses, your GFR number decreases

The diet for patients with end-stage kidney disease who are on dialysis is usually high in protein and low in sodium, potassium, and phosphorus. Fluid intake is also restricted.

STEPS TO TAKE: Speak to the registered dietitian at

your dialysis center. Ask your dietitian to help you plan

meals with the right amount of calories.

Keep a diary of what you eat each day. Show this to your dietitian on a regular basis.

• Ask your doctor and dietitian what your ideal body weight should be. IDEAL WT. GAIN:1 – 1.5 KG IN BETWEEN TREATMENT

• Weigh yourself each day in the morning.

• If you are losing too much weight, ask your dietitian how to add extra calories to your diet.

• If you are slowly gaining too much weight, ask for suggestions on safely reducing your daily calorie intake and increasing your activity level.

If you gain weight rapidly, speak to your doctor and dietitian.› 1kg = 1L of fluid gain/ loss

A sudden increase in weight, along with swelling, shortness of breath and a rise in your blood pressure may be a sign that you have too much fluid in your body.

The purpose of this diet is to maintain a balance of electrolytes, minerals, and fluid in patients who are on dialysis.

The special diet is important because dialysis alone does not effectively remove ALL waste products.

These waste products can also build up between dialysis treatments.

• The dialysis diet controls the intake of fluid, protein, sodium, potassium, and phosphorus.

• The amounts of these nutrients in the diet are based on your blood levels of sodium, potassium, phosphorus, calcium, albumin, and urea.

• These levels are measured before and immediately after a dialysis treatment.

• Fluid restriction is based on the amount of urine output and weight gain between dialysis treatments.

PROTEIN (1.2-1.3g/kg/day)• Your body needs the right amount of protein for:

– building muscles, repairing tissue, fighting infections.

• Before dialysis, you may be asked to limit protein to slow the progression of kidney disease.

• At the start of dialysis, you will need much more protein.

• Patients on peritoneal dialysis need even more protein, because a large amount of protein can be lost in the peritoneal fluid that is discarded.

• Protein-rich foods include:– fresh meats– poultry (chicken and turkey)– fish and other seafood– eggs or egg whites– small servings of dairy products.

• Some of these protein-rich foods may also contain a lot of phosphorus, a mineral you may need to control in your diet.

SUBSTITUTE cooking oil with vegetable oil

AVOID :› seasonings › canned meats like ham, bacon,

sausage and cold cuts› salted snack foods like chips and

cracker› Any processed foods

AVOID:› certain fruits and vegetables (like

bananas, melons, oranges, potatoes, tomatoes and some juices)

› milk and yogurt› dried beans and peas› most salt substitutes

Take Calcium tabs as prescribed AVOID:

› dairy products such as milk, cheese, yogurt, ice cream and pudding

› nuts and peanut butter› dried beans and peas such as kidney

beans, split peas and lentils› beverages such as cocoa, beer and

dark cola drinks.

• During kidney failure, the amount of urine produced drops.

• The urine output usually stops completely once patients have been on dialysis for more than 6 months.

• Patients on peritoneal dialysis usually continue releasing urine for a longer time and have less restricted fluid intake.

Now the big question is….

WHAT CAN THE PATIENT EAT????

FINANCIAL PROBLEMS DIFFICULTY HOLDING JOB WANING SEXUAL DESIRES DEPRESSION, SHORTENED ATTENTION

SPAN, DECREASED LOC & ALTERED PERCEPTION DUE TO ILLNESS

BODY IMAGE DISTURBANCE ALTERED LIFESTYLE FEELINGS OF ANGER, DESPAIR &

CONCERNS REGARDING LIMITATION OF THE DISEASE

ASSESS LEARNING NEEDS TEACH DEPENDING UPON THE PT.’S

LEARNING NEEDS PROVIDE ADDITIONAL 10-15MINUTE SESSION

FOR CLARIFICATION, REPETITION & REINFORCEMENT

CONVEY A NON JUDGEMENTAL ATTITUDE ALLOW TO EXPRESS FEELINGS & REACTIONS PROVIDE & EXPLORE OPTIONS IN THE LONG RUN, DISCUSS FEELINGS OF

TERMINATING TREATMENT VIA TEAM CONFERENCES

CPUNSELING & PSYCHOTHERAPY

• CAUSE: • When fluid is removed during hemodialysis, the osmotic

pressure is increased and this prompts refilling from the interstitial space. The interstitial space is then refilled by fluid from the intracellular space.

• Excessive ultrafiltration with inadequate vascular refilling

plays a major role in dialysis induced hypotension.

• WOF:• n/v, diaphoresis, tachycardia, dizziness,

decreasing BP

• IMMEDIATE TREATMENT:• DISCONTINUE• TRENDELENBURG• NOTIFY

• CAUSE:• Occurs in late dialysis as fluid &

electrolytes leaxve extracellular space

• IMMEDIATE TREATMENT:• restoring intravascular volume through

the use of small boluses of isotonic saline.

• Prevention of cramps has been attempted with the prophylactic use of quinine sulfate at least 2 hours prior to dialysis

• IMMEDIATE TREATMENT:• Additional blankets• Lowering of environmental

temperature• Antipyretics• Assess cause: wound and blood

cultures• Temperature should be recorded at

the initiation and termination of dialysis treatment.

CAUSE:› Both acute and chronic alterations in fluid,

electrolyte, and acid-base homeostasis› Removal of antiarrhythmic medications

prior to treatment IMMEDIATE TREATMENT:

› Keep ECG monitor at bedside› Check Rhythm & Notify› Initiate actions as per rhythm› Provide medications as prescribed

CAUSE:› results from a number of biochemical

and toxic insults during the dialysis procedure.

TREATMENT:› Increase iron and folate intake› Given Erythropoietin (Epogen) & Iron

(FeSO4) substitute in between treatments

› Regular monitoring of hematocrit & hemoglobin level

• CAUSE: • rapid exchange in ECF while BBB

prevents cerebral fluid shifting

• WOF: • headache, n/v, restlessness,

decreasing LOC hypertension & seizure

• IMMEDIATE TREATMENT:• Monitor s/ sx & NOTIFY

Immediately !!!• Reduce environmental stimuli• Prepare to dialyze again at shorter

period and lower rate

HEALTHY KIDNEY!!!

HEAL THY KIDNEY!!!