Hemodialysis: History and Current Perspective

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Hemodialysis History and Current Perspective

• Nadeem A Siddiqui MD
• Dallas Nephrology Associates

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HemodialysisHistory and Current Perspective

• History of Dialysis
• Principles of Hemodialysis
• Practice of Hemodialysis
• Complications of Hemodialysis

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Dialysis

• Process by which the solute composition of a
  solution A is altered by exposing it to a
  second solution B through a semi-permeable
  membrane

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Necessary pre-requisites for Hemodialysis

• 1) Semi-permeable membrane
• 2) Anticoagulation
• 3) Knowing what to remove and how much of it

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• 1773 Nurepuel isolates Urea by boiling urine
  in a pan

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• 1828 Wohler synthesizes Urea and describes
  its molecular structure

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Thomas Graham (1805-1869)
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• 1850 Glasgow, Scotland
• Thomas Graham s experiment to demonstrate
  diffusion across a semi-permeable membrane
  (Pergamon paper)

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Dialysis Membranes

• 1750Advances in the dovelopment of smokeless
  gunpowder led to the synthesis of a strong
  Nitrocellulose called collodion. It was a
  combination of Nitric acid and cotton
• Addition of Camphor to this substance led to the
  synthesis of stable and strong plastics
• 1957Helmut Staldiger polymerized Cellulose

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1913The First Hemodialysis Experiment
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• 1937 William Thalhimer successfully lowers
  BUN by performing Hemodialysis in anephric dogs

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1926The First Human Experiment

• George Haas used a collodion tube arrangement to
  successfully dialyze human subjects
• Allergic reactions to impurities in Hirudin led
  him to abandon his experiments

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• 1937Nils Alwall used the Alwall Kidney to
  perform the first ever hemodialysis treatment at
  the university of Lund, Sweden

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• If I have seen farther it is because I have
  stood on the shoulders of Giants
• Sir Isaac
  Newton

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HemodialysisHistory and Current Perspective

• History of Dialysis
• Principles of Hemodialysis

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Mechanisms of Solute transfer

• Diffusion
• Convection

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Diffusive Clearance

• A result of random molecular motion
• Influenced by concentration gradient of the
  solute and its Molecular weight as well as by the
  membrane permeability to the solute

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Convective Clearance

• Water molecules passing through a SPM carry with
  them the solutes in their original concentration.
  This is called the solvent drag phenomenon
• Water can be made to move across a SPM by the
  application of either a hydrostatic or an osmotic
  gradient

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HemodialysisHistory and Current Perspective

• History of Dialysis
• Principles of Hemodialysis
• Practice of Hemodialysis

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The Hemodialysis circuit
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Dialysis Membranes
Membrane Hydr.Perm. Examples Biocomp.
Regen. cellulose Low flux cuprophane Poor
Modif. Cellulose Low/High Flux Cell.acetate Cell di-acet. Interm.
Synthetic High/Low flux PAN,PS,PA, PC,PMMC Good
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Dialysis Solution
Component Concentration mmol/L
Na 140
K 2
Ca 1.25 (5 mg/dl)
Mg 0.5 (1.2 mg/dl)
Acetate 3.0
Chloride 108
Bicarbonate 35
Glucose 5.6 (100 mg/dl)
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Water Purification
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Water Treatment System for Hemodialysis
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Vascular Access
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Indications for initiating Hemodialysis

• In patients with calculated creatinine clearance
  lt20 ml/min/1.73 m2 the onset of
• Uremic symptoms
• Nausea/emesis
• Altered sleep pattern
• Altered mental status
• Coma
• Stupor
• Tremor
• Asterixis
• Clonus
• Seizures

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Indications for Hemodialysis

• Pericarditis or Tamponade (urgent indication)
• Uremic platelet dysfunction (urgent indication)
• Refractory volume overload
• Refractory hyperkalemia
• Refractory Metabolic acidosis with anuria

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Indications for Hemodialysis

• Steadily worsening renal function in a patient
  with measured 24 hour urinary creatinine
  clearancelt15 ml/min when accompanied by worsening
  azotemia, poor nutritional status and refractory
  edema

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Equations for estimation of renal function

• Cockcroft and Gault equation
• MDRD Formula

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The Cockcroft-Gault equation

• Cr Cl (140-age) x wt/72(serum Cr)
• Decrease 15 for women
• Decrease 20 for paraplegia,40 for quadriplegia
• Increase 12 for AA males

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The MDRD formulaModification of diet in renal
disease study JASN2000

• GFR (ml/min/1.73m2)
• 186 x Pcr -1.154 x age -0.203 x1.212
  if black X0.742 if female
• The MDRD equation calculates GFR, hence values
  are lower than those of creatinine clearance by
  Cockcroft Gault equation.

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Measurement of nutritional status

• Physical Exam
• Skin fold thickness
• Mid arm muscle thickness
• Protein catabolic rate lt1
• Serum Albumin
• Serum Cholesterol
• Blood Lymphocyte count

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Monitoring Dialysis Adequacy
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HemodialysisHistory and CURRENT Perspective

• History of Dialysis
• Principles of Hemodialysis
• Practice of Hemodialysis
• Complications of Hemodialysis

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Complications of Hemodialysis

• Dialysis Reactions
• Intradialytic Hypotension
• Neuromuscular complications
• Dialysis dysequilibrium
• Hemolysis
• Intradialytic hypoxemia
• Postdialysis syndrome
• Cardiac arrhythmia and sudden death
• Steal syndrome
• Dialysis associated hypoxemia
• Air embolism
• Metabolic derangements

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Dialysis Reactions
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Management of Intradialytic Hypotension

1. Assess dry weight frequently
2. Avoid BP meds before HD
3. Avoid rapid UF
4. Use sequential UF and HD
5. Avoid feeding patients on HD
6. Use Sodium modeling
7. Use HCO3 based dialysate
8. Keep Hct gt33
9. Use non Cellulosic membranes
10. Keep Dialysate temperaturelt37 degrees Celsius
11. Assess cardiac function, r/o pericardial
    effusion/tamponade

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Neuromuscular Complications Muscle Cramps

• Etiology Hypo-osmolality, Carnitine deficiency,
  Hypomagnesemia, excessive inter-dialytic weight
  gain
• Rx Dietary counseling, Sodium modeling, Saline
  or 50 dextrose bolus, ? Prophylactic Quinine
  sulfate or Oxazepam

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Neuromuscular complications

• Seizures
• Restless legs syndrome
• Headache

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Dialysis Disequilibrium Syndrome (DDS)

• Risk factors Young age, severe and chronic
  azotemia, Initial dialysis treatment, High flux/
  large surface area dialyzer
• Symptoms Headache, nausea, emesis, blurred
  vision, hypertension, disorientation, muscle
  twitching

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DDS

• Pathogenesis
• Reverse urea effect ( rapid reduction of serum
  urea while CSF urea concentration remains high)
• Paradoxical CSF acidosis
• Intracerebral accumulation of idiogenic osmoles
  in uremia

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DDS

• Treatment
• Early detection of uremia, early intervention
  with dialysis
• First few treatments should aim to achieve modest
  reduction in serum urea concentration ( 30 or
  less)
• Sodium modeling, use of Bicarbonate dialysis,
  slow QB
• Prophylactic use of Mannitol is not recommended

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Intradialytic Hemolysis

• Uncommon
• From contamination of dialysate with Chloramine
  or Copper (deionization failure)
• From Methemoglobinemia from nitrate contamination

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Intradialytic Hypoxemia

• Arterial p O2 drops by 5 to 30 mm Hg during
  Hemodialysis due to central Hypoxemia.
• This is a result of a drop in CO2 that
  accompanies correction of acidosis on dialysis
• V/Q mismatch can occur due to pulmonary
  sequestration of activated leukocytes
• Acetate can induce respiratory muscle fatigue

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Intradialytic Hypoxemia

• Treatment Supplemental oxygen during
  Hemodialysis in susceptible patients