RENAL REPLACEMENT THERAPIES

Dialysis
Hemodialysis
Peritoneal dialysis
Renal replacement/transplant
DIALYSIS
The process of removing waste products and excess fluid from the body. Dialysis is necessary
when the kidneys are not able to adequately filter the blood.
Types
Hemodialysis
Peritoneal dialysis
Principles
Diffusion:
Diffusion is the movement of molecules from a high
concentration to a low concentration.
Osmosis:
A process by which molecules of a solvent tend to pass
through a semi permeable membrane from a less concentrated
solution into a more concentrated one.
Ultra filtration:
During hemodialysis treatments, water and sodium are not
ordinarily removed by diffusion but rather through the process of
ultra filtration. Ultra filtration is commonly accomplished by
lowering the hydrostatic pressure of the dialysate compartment of a
dialyzer, thus allowing water containing electrolytes and other
permeable substances to move from the plasma to the dialysate.
HEMODIALYSIS
Hemodialysis is a method that is used to achieve the
extracorporeal removal of waste products such as creatinine and
urea and free water from the blood when the kidneys are in a state of renal failure.
History
Many have played a role in developing dialysis as a practical treatment for renal failure, starting
with Thomas Graham of Glasgow, who first presented the principles of solute transport across a semi
permeable membrane in 1854. The artificial kidney was first developed by Abel, Rountree, and Turner in
1913. The artificial kidney was developed into a clinically useful apparatus by Kolff in 1943 1945.
Willem Kolff was the first to construct a working dialyzer in 1943. The first successfully treated patient
was a 67-year-old woman in uremic coma who regained consciousness after 11 hours of hemodialysis
with Kolff's dialyzer in 1945.
By the 1950s, Willem Kolff's invention of the dialyzer was used for acute renal failure, but it was
not seen as a viable treatment for patients with stage 5 chronic kidney disease (CKD). At the time,
doctors believed it was impossible for patients to have dialysis indefinitely for two reasons. First, they
thought no man-made device could replace the function of kidneys over the long term. In addition, a
patient undergoing dialysis suffered from damaged veins and arteries, so that after several treatments,
it became difficult to find a vessel to access the patient's blood.
The original Kolff kidney was not very useful clinically, because it did not allow for removal of excess
fluid. Swedish professor Nils Alwall encased a modified version of this kidney inside a stainless steel
canister, to which a negative pressure could be applied, in this way effecting the first truly practical
application of hemodialysis, which was done in 1946.

Vascular access
In hemodialysis, three primary methods are used to gain access to the blood: an intravenous
catheter, an arteriovenous fistula (AV) or a synthetic graft. The type of access is influenced by factors
such as the expected time course of a patient's renal failure and the condition of his or her vasculature.
Patients may have multiple accesses, usually because an AV fistula or graft is maturing and a catheter
is still being used. The creation of all these three major types of vascular accesses requires surgery.
Intravenous catheter
Catheter access, sometimes called a CVC (central venous catheter), consists of a plastic
catheter with two lumens (or occasionally two separate catheters) which is inserted into a large vein
(usually the vena cava, via the internal jugular vein or the femoral vein) to allow large flows of blood to
be withdrawn from one lumen, to enter the dialysis circuit, and to be returned via the other lumen.
However, blood flow is almost always less than that of a well functioning fistula or graft.
AV fistula
AV (arteriovenous) fistulas are recognized as the preferred
access method. It requires joining of an artery and a vein together
through anastomosis. Since this bypasses the capillaries, blood
flows rapidly through the fistula. One can feel this by placing one's
finger over a mature fistula. This is called feeling for "thrill" and
produces a distinct 'buzzing' feeling over the fistula. One can also
listen through a stethoscope for the sound of the blood
"whooshing" through the fistula, a sound called bruit.
Fistulas are usually created in the non dominant arm and
may be situated on the hand, the forearm (usually a radio
cephalic fistula, or so-called Brescia-Cimino fistula, in which the
radial artery is anastomosed to the cephalic vein), or the elbow
(usually a brachiocephalic fistula, where the brachial artery is
anastomosed to the cephalic vein). Though less common, fistulas
can also be created in the groin, though the creation process differs. A fistula will take a number of
weeks to mature, on average perhaps 46 weeks.
During treatment, two needles are inserted into the fistula, one to draw blood and one to return
it. The orientation of the needles takes the normal flow of the blood into account. The "arterial" needle
draws blood from the "upstream" location while the "venous" needle returns blood "downstream".
Advantages
Lower infection rates
Higher blood flow rates and
Lower incidence of thrombosis
Complications
If a fistula has a very high blood flow and the vasculature that supplies the rest of the limb is
poor, a steal syndrome can occur, where blood entering the limb is drawn into the fistula and returned
to the general circulation without entering the limb's capillaries. This results in cold extremities of that
limb, cramping pains, and, if severe, tissue damage. Aneurysm, a bulging in the wall of the vein where
it is weakened by the repeated insertion of needles over time. Fistulas can also become blocked due to
blood clotting or infected if sterile precautions are not followed during needle insertion at the start of
dialysis. Excessive bleeding can also occur.
AV graft
AV (arteriovenous) grafts are much like fistulas in most
respects, except that an artificial vessel is used to join the artery
and vein. The graft usually is made of a synthetic material, often

PTFE (Polytetrafluroethylene). Grafts are inserted when the patient's native vasculature does not permit
a fistula. They mature faster than fistulas, and may be ready for use several weeks after formation.
More options for sites to place a graft are available, because the graft can be made quite long. Thus a
graft can be placed in the thigh or even the neck (the 'necklace graft').

Complications
Narrowing
Thrombosis (clotting).
Infection
Dialyzer
The dialyzer is the key to hemodialysis. In hemodialysis, blood is removed from the body and
filtered through a man-made membrane called a dialyzer, or artificial kidney, and the filtered blood is
returned to the body. The dialyzer has a semi permeable hollow fibre membrane that contains
thousands of tiny cellophane tubules that act as semi permeable membrane made of cellulose or
synthetic materials. The blood flows through the tubules, while dialysate circulates around the tubules.
There are two sections in the dialyzer, the section for dialysate and the section for the blood.
The two sections are divided by a semi permeable membrane so that they dont mix together. A semi
permeable membrane has microscopic holes that allow only some substances to cross the membrane.
The blood flows through the tubules, while the dialysate circulates around the tubules. The exchange of
waste from the blood to the dialysate occurs through the semi permeable membrane of the tubules.
Because it is semi permeable, the membrane allows water and waste like urea, potassium, and extra
fluid to pass through, but does not allow blood cells and proteins to pass through because they are too
big.
Types of dialyzers
Hollow fiber
Flat plate or parallel flow plate dialyzer
Coil dialyzer.
Hollow Fiber dialyzer
This is most common type contains fine capillaries with semi permeable membrane enclosed in
a plastic cylinder. Blood flows through these capillaries as the system pumps dialysate in an opposite
direction on the outside of the capillaries.
Flat-plate or Parallel Flow Plate dialyzer
It has two or more layers of semi permeable membrane bound by a semi rigid or rigid structure.
Blood ports are located at both ends between the membrane and dialysate flows in opposite direction
along the outside of the membranes.
Coil dialyzer
Consist of one or a more semi permeable membrane tubes supported by a mesh and wrapped
concentrically around a central core. Blood passes through a coil as the dialysate circulates at a high
speed around the coil and the mesh work. Heparin is used to prevent clot formation during dialysis.
Dialysate
Dialysate, also called dialysis fluid, dialysis solution or bath, is a solution of pure water,
electrolytes and salts, such as bicarbonate and sodium. The purpose of dialysate is to pull toxins from
the blood into the dialysate. The way this works is
through a process called diffusion. Due to the
difference in concentration, the waste will move
through the semi permeable membrane to create
an equal amount on the both sides. The dialysis
solution is then flushed down the drain along with
the waste. The electrolytes in the dialysis solutions
are also used to balance electrolytes in the
patients blood. The extra fluid is removed through
a process called filtration.
Procedure

After initial assessment a small dose of anticoagulant (heparin) may be instilled into the shunt
between dialysis procedure to prevent blood clots from forming and obstructing the shunt. The patient
is the put on the machine. Patient with a vascular access will get two needle sticks in their access;
one needle takes blood out of the body, the other needle puts it back. As blood is pushed through the
blood compartment in one direction at a flow rate of 200-500 ml/min, suction of vacuum pressure pulls
the dialysate through the dialysate compartment in a counter current, or opposite direction at a rate of
300-900ml/min. These opposing pressures work to drain excess fluids or water out of the bloodstream
and into the dialysate, a process called ultra filtration.
A second process called diffusion moves waste products in the blood across the membrane and
into the dialysate compartment. Urea, creatinine, and the nitrogen end products of protein metabolism
from the blood pass through the membrane and into the dialysate, which is then discarded. At the
same time, electrolyte and other chemicals in the dialysate solution cross the membrane into the blood
compartment. The purified, chemically balanced blood is then returned to the body through second
needle. Each dialysis session lasts 2 to 6 hours. Most people undergo three dialysis sessions each week,
for four to five hours each time using their dialysis access. During dialysis, a person also receives
medications to replace hormones the kidneys are unable to produce.
Nursing Care
Record the vital signs and blood pressure in sitting and standing position.
Auscultate heart for rate, rhythm and abnormalities
Observe respiratory rate rhythm and quality
Assess for edema.
Check the mental status and condition of patency in the access site.
Check the last date of dialysis and evaluate the previous lab data.
Place the patient in a comfortable position supine or sitting in a recliner chair with feet elevated.
Make sure the site is wall supported and resting on a clean drape.
Explain the procedure to the patient if the patient is undergoing the haemodialysis for the first
time.
Use standard precaution in all cases to prevent the transmission of infection
Wash hands before and after the procedure.
Follow aseptic techniques throughout the procedure.
Report immediately any machine malfunction and keep it ready for use at any time.
Avoid unnecessary handling of shunt tubing.
Inspect the shunt for patency, check for any clots, serum, cell separation, temperature of the
silastic tubing.
Check for any bleeding after removing the AV fistula needle, if bleeding persist soak the sponge
and apply thrombin solution.
Monitor patients vital signs carefully and blood pressure every minutes.
Check the weight of the patient before and after the procedure.
Check the clotting time of the patients blood sample and sample from the dialyzer periodically.
Ensure the patient receive light meals during procedure.
Complications
Hyperpyrexia
Dialysis disequilibrium syndrome (headache, nausea, vomiting, restless, hypertension, muscle
cramp, backache, and seizures).
Hypovolemia and hypotension.
Hyperglycaemia and hypernatremia.
Cardiac arrhythmias.
Angina.
Reduce toxins, air embolism, chest pain, dyspnoea coughing and synopsis.
Hemolysis (chest pain, dyspnoea, cherry red blood, hyperkalmia).

Work for the students

Care of Vascular Access in Hemodialysis (Roll No: 1-10)

PERITONEAL DIALYSIS
A dialysis technique that uses the patient's own body
tissues inside the abdominal cavity as a filter to remove the
waste products.
Peritoneal dialysis is a form of dialysis where a special
fluid is infused into the peritoneal cavity a container in the
stomach which is surrounded by arteries and veins through
which blood flows. The excess waste from these blood vessels
diffuses into the fluid through a semi permeable membrane
that encloses the peritoneal cavity. The peritoneal membrane
is used as a semi permeable membrane across which excess
wastes and fluids move from blood in peritoneal vessels into a
dialysate solution that has been instilled into the peritoneal
cavity.
Peritoneal dialysis involves repeated cycles of instilling
dialysate in the peritoneal cavity, allowing time i.e. dwell time for substance exchange and then
removing the dialysate. Usually 30-40 min., maximum exchange happening in the first 5 min.
Equilibrium happens between blood and dialysate within 15-30 min. peritoneal dialysis is performed to
remove toxic substances and metabolic wastes and re-establish normal fluid and electrolyte balance.
Indications
Peritoneal dialysis is indicated for patients with:
Chronic renal failure.
Cardiovascular instability.
Vascular access problems that prevent hemodialysis, fluid overload or electrolyte imbalance.
It has been used for overdose of drugs and toxins.
Procedure
Peritoneal dialysis access
To gain access to the peritoneum, a catheter, or flexible
hollow tubes, is surgically placed in the lower abdomen. The
preferred insertion site is 3 to 5cm below the umbilicus, an area
that is relatively avascular and has less fascial resistance. Its about
a foot long (about12inch), but only four or five inches of lies outside
the body. Catheter insertion is done in an operating room, often
with local anaesthesia.
Before the procedure, the skin is prepared with a local
antiseptic to reduce skin bacteria and the risk of contamination and
infection. Physician instructs the patient to tighten the abdominal
muscles by raising the head then the peritoneum is punctured with
a trocar. A peritoneal catheter is placed into the patients peritoneal space between the two layers of
the peritoneum below the waistline. This catheter is used to perform an exchange. Then the physician
secures the catheter with a purse-string suture and applies
antimicrobial ointment and a sterile dressing over the site to
prevent chances of infection.
Peritoneal dialysis treatment
Peritoneal catheter is placed into the patients peritoneal
space is used to perform am exchange. An exchange is the process
of draining dialysate from the abdomen and introducing fresh

dialysate into the abdomen. The entire exchange takes 1 to 4 hours, depending on the prescribed dwell
time. The length of time the dialysis solution stays in the peritoneal cavity during peritoneal dialysis is
known as the dwell time.
The exchange process has three steps: filling or infusion, dwell time, and draining. The fill step involves
installing a bag of sterile dialyzing solution (dialysate) into the patients peritoneal cavity through the
catheter by gravity. The amount of solution is usually 1500 to 2000 mL which is infused within 5 to 10
minute. The solution is left to dwell in the abdomen for several hours, allowing time for the waste
products from the blood to pass through the peritoneal membrane into the dialysate solution.
At the end of the dwell time, the drainage portion of the exchange begins. The tube is clamped
and the solution drains from the peritoneal cavity by gravity through a closed system. Drainage phase
is usually completed in 10 to 30 minutes. The drainage fluid is normally colourless or straw-coloured
and should not be cloudy. Urea, creatinine and metabolic end products are cleared from blood by
diffusion and osmosis, across a semi permeable membrane i.e. peritoneal membrane. Urea cleared at
the rate of 15 20 ml/min, creatinine takes time 36 to 48 hours. Ultra flirtation water remove occurs in
PD through an osmotic gradient created by adding Dextrose to the dialysate.
Types of peritoneal dialysis
There are two principal types of peritoneal dialysis.
1. Continuous Ambulatory Peritoneal Dialysis ( CAP):
This requires no machinery and can be done by the patient or a caregiver. In the CAPD 1.5 to 3.0
liter of peritoneal dialysate is instilled into the abdomen approximately every day, about four to
five times per day and left in place for 4 to 10 hours. In CAPD, there are usually 4 dialysis cycles
every 24 hours with 8 hours dwell overnight. It is then replaced with a fresh solution straight
away.
In this procedure the person instils 2L of dialysate from a collapsible bag, into the peritoneal
cavity through a disposable plastic tube (Line set). The tube is secured to the permanent
catheter on one end and attaches to the bag on the other end by means of a device (spike).
When the dialysate solution is instilled into the peritoneal cavity the bag and line to be
disconnected. After the equilibration period the line is reconnected to the catheter and the
dialysate is drained from the peritoneal cavity and a new 2 L bag of dialysate solution is infused.
2. Automated Peritoneal Dialysis (ADP):
Cycler equipment is used to deliver dialysate for ADP. The automated cycler times and controls
the fill, dwell and drain phases. The machine cycles 4 to 8 exchange per night with 1 to 2 hours
per exchange. Sometimes medications are added to the dialyzing solutions. Such as heparin to
prevent clotting of the catheter, insulin for the patient with diabetes, or antibiotics is there is
infection. ADP can be done as continuous cyclic peritoneal dialysis, intermittent peritoneal
dialysis and nightly peritoneal dialysis.
Continuous Cyclic Peritoneal Dialysis (CCPD):
CCPD is the most common type of PD. In continuous cyclic peritoneal dialysis the
exchanges are usually performed by a machine called a cycler. It is generally done
during the night while the patient sleeps. The machine them infuse fresh fluid and
remove it after 2-3 hours and infuse fresh fluid. Usually the cycles are shorter in CCPD.
This needs to be done every night. Each session lasts from 10to 12 hours. After spending
the night attached to the machine, the majority of people keep fluid inside their abdomen
during the day until the tubing is reattached to the cycler machine at bedtime. Some
patients may require another exchange during the day.
Intermittent Peritoneal Dialysis (IPD):
This hospital-based treatment is performed 3 to 4 times a week. A machine administers
and drains the dialysate solution, and sessions can take 12 to 24 hours.
Nightly Peritoneal Dialysis:
In nightly peritoneal dialysis, treatment is performed for 8 to 12 hours each night with no
day time dwells.
Complications of Peritoneal Dialysis
Peritonitis
Fluid leakage
Bladder perforation

Back pain
Abdominal hernias
Hyperglycemia

 Hypertriglyceridemia
Respiratory difficulty
Atelectasis
Contra Indications
Hernias
Respiratory problems
Ascites

Pneumonia
Protein depletion

Abdominal surgery
Peritonitis

Work for the students

Nursing care in peritoneal dialysis (Roll No: 11-20)

Comparison of dialysis methods

Hemodialysis
What is
usually
involved

Advantages

Disadvantag
es

Peritoneal dialysis

Before hemodialysis treatments can begin,

there is need to create a site where blood
can flow in and out of body.
Hemodialysis uses a man-made membrane
called a dialyzer to clean your blood.
Patient is connected to the dialyzer by
tubes attached to blood vessels.
Need to go to a hospital or dialysis centre
on a fairly set schedule. Hemodialysis
usually is done 3 days a week and takes 3
to 5 hours a day.
It can also be done at home. Home
hemodialysis requires training of patient
and at least one other person.

It is most often done by trained health

professionals who can watch for any
problems.
It allows patient to be in contact with other
people having dialysis, which may give
them emotional support.
Patient doesnt have to do it by themselves,
as patient do with peritoneal dialysis.
Patient does it for a shorter amount of time
and on fewer days each week than
peritoneal dialysis.
Home
hemodialysis
can
give
more
flexibility in when, where, and how long
patient have dialysis.

It causes patient to feel tired on the day of

the treatments.
It can cause problems such as low blood
pressure and blood clots in the dialysis
access.
It increases patient risk of bloodstream
infections.
Home hemodialysis may require changes to
patient home setup. Patient and assistant
will need to complete training.

Patients
will
have
a
catheter placed in belly
(dialysis access) before
begin dialysis.
Peritoneal dialysis uses the
lining of belly, which is
called
the
peritoneal
membrane, to filter blood.
The
process
of
doing
peritoneal dialysis is called
an exchange. Will usually
complete 4 to 6 exchanges
every day.
Patinet will be taught how
to do treatment at home,
on patient own schedule.
It
gives
patient
more
freedom than hemodialysis.
It can be done at home or
in any clean place. Patient
can do it when patient
travel. Patient may also be
able to do it while sleep.
Patient can do it by
themselves.
It doesn't require as many
food and fluid restrictions
as hemodialysis.
It doesn't use needles.
The procedure may be hard
for some people to do.
It increases patient risk for
an infection of the lining of
the belly, called peritonitis.

KIDNEY/ RENAL TRANSPLANTATION

A kidney transplant involves taking a kidney from the body of one
person and implanting it surgically into the body of someone who has lost
kidney function.
Kidney transplantation means replacement of the failed kidneys with a
working kidney from another person, called a donor. Kidney transplantation
is not a complete cure, although many people who receive a kidney
transplant are able to live much as they did before their kidneys failed.
Indications
Kidney diseases: CKD, ESRD
Genetic diseases: Polycystic kidney disease, inborn errors of metabolism and autoimmune conditions
Other diseases: Malignant hypertension, infections, diabetes mellitus and glomerulonephritis
Sources of Kidneys
Cadaver/deceased donors: A cadaver kidney is removed from an individual who has been declared
as brain dead from non kidney related causes, such as an accident or a stroke.
Living donors: A kidney is given by a healthy living individual, it may be,
Living related donors: Very close relatives-parents, siblings, children, grandparents may donate a
kidney to a near relative.
Emotionally related donors: in the situation where cadaver donor and living related donors are
not found/ unfit, emotionally related kidney donors like spouse, cousins, uncles, aunts, in-laws may
donate a kidney.
Unrelated kidney donors: If all of the above are found unfit, then unrelated donors kidney
transplantation can be considered.
Criteria of donation
Eligibility:
Should have compatible blood group
Age above 18 years and preferably below 6065 years
Should not have any major diseases
Willing to donate
Matching:

Donor and recipient matching can be divided into three distinct areas. Each of these is an
important aspect of donor and recipient matching and applies to living and deceased kidney donation.
1. Blood group: in the case of a deceased donor, the ordinary blood groups (A, B, AB, and O) match
the red blood cells of donor and recipient and must be compatible, as for blood transfusion. In
the case of a live donor, some ABO incompatible transplants are possible.
2. Tissue typing: this involves matching of a type of white blood cell called lymphocytes
HLA(Human Leukocyte Antigens).
3. Cross match: it is done in order to determine if the donor's blood is compatible with the blood of
an intended recipient.
Preparation
Cessation of smoking, drugs and alcohol
Dental care
Dialysis
Weight
Blood pressure
Exercise
General health condition
Procedure
The transplantation operation takes around 3- hours. The transplanted kidney is placed on the
right or left side of the lower abdomen, below the navel. In most cases the barely functioning existing
kidneys are not removed, as this has been shown to increase the rates of surgical morbidities and left
to continue whatever small amount of function they may still have. However, if the failed kidneys must
be removed, a separate operation is necessary prior to transplantation. This is only rarely required e.g.
in the case of chronic infection or very large kidneys. Therefore, the kidney is usually placed in a
location different from the original kidney, often in the iliac fossa, so it is often necessary to use a
different blood supply:
The renal artery of the kidney, previously branching from the abdominal aorta in the donor, is
often connected to the external iliac artery in the recipient.
The renal vein of the new kidney, previously draining to the inferior vena cava in the donor, is
often connected to the external iliac vein in the recipient
Final step is to connect kidney of donor to the recipients bladder
Post operative
After surgery, there is usually some pain around the operation site, which will be relieved by
medication. A bladder catheter and drainage tubes from the wound are needed for about a week to
assist healing. Depending on its quality, the new kidney usually begins functioning immediately. Living
donor kidneys normally require 35 days to reach normal functioning levels, while cadaveric donations
stretch that interval to 715 days. Hospital stay is typically for 47 days. If complications arise,
additional medications (diuretics) may be administered to help the kidney produce urine. The amount
of urine produced by the new kidney is very closely monitored and measured.
The most critical part of kidney transplantation is preventing rejection of the graft kidney. Certain drug
combinations are used to fight rejection of a transplanted kidney. The drugs work by suppressing
immune system, which is programmed to reject anything foreign such as a new organ.
Some of the most common immune-suppressing drugs used in transplantation are
o Cyclosporine
o Corticosteroids
o Azathioprine
o The most common medication regimen today is a mixture of tacrolimus, mycophenolate,
and prednisone.
Complications
Rejection: the body resists the presence of foreign cells o tissue of a donor kidney in much the
same way that it fights off bacteria and viruses which cause illness. The rejection process occurs
when the patients white blood cells reduce or stop the function of the transplanted kidney.
There are three types of rejection
1. Hyper acute rejection: can occur in minutes or hours after the transplant. This type of rejection is
very rare. It is untreatable and the kidney is removed.

2. Acute rejection: can occur at any time form a week to a year after transplant. This form of
rejection is experienced by most transplant patients and is usually treatable. It is certainly likely
to occur if the drug treatments prescribed are not taken regularly.
3. Chronic rejection: occurs slowly over a long period of time and there may be no obvious
symptoms. Chronic rejection is also difficult to treat. If the transplanted kidney eventually stops
working, the patient will require dialysis. Another transplant is possible.
Infection: because the drugs used to prevent and control rejection also weaken the bodys
defences, patients are more prone to infection after transplant. Risk of infection commonly in
the wound site, mouth urinary tract and lungs is highest in the first few months after transplant
because drug dosage is highest. This is the reason for strict infection control in the transplant
ward. Whilst some infections can be very serious, most are controlled by antibiotics and/ or
reducing doses of anti-rejection drugs. Most units prescribe medications to prevent particular
high risk infections after transplantation.
Post-transplant lymphoproliferative disorder (a form of lymphoma due to the immune
suppressants).
Imbalances in electrolytes including calcium and phosphate which can lead to bone problems
among other things.
Emotional changes.

Work for the students

Nursing care in kidney transplantation (Roll No: 21-30)