TYPES OF DIALYZERS

A dialyzer is an artificial kidney designed to provide controllable transfer of solutes and water across a
semi permeable membrane separating flowing blood and dialysate streams. The transfer processes
are diffusion (dialysis) and convection (ultrafiltration). There are three basic dialyzer designs: coil,
parallel plate, and hollow fiber configurations.
Coil dialyzer: An early design in which the blood compartment consisted of one or two long
membrane tubes placed between support screens and then tightly wound around a plastic core. This
design had serious performance limitations, which gradually restricted its use as better designs
evolved. The coil design did not produce uniform dialysate flow distribution across the membrane.
More efficient devices have replaced the coil design.
Parallel Plate Dialyzer: Sheets of membrane are mounted on plastic support screens, and then
stacked in multiple layers ranging from 2 to 20 or more. This design allows multiple parallel blood and
dialysate flow channels with a lower resistance to flow. The physical size of the parallel plate dialyzers
has been greatly reduced since their introduction. There have been major improvements which
provide (1) thinner blood and dialysate channels with uniform dimensions, (2) minimal masking or
blocking of membranes on the support, and (3) minimal stretching or deformation of membranes
across the supports.
Hollow Fiber Dialyzer: This is the most effective design for providing low-volume high efficiency
devices with low resistance to flow. The fibers in the device are termed the fiber bundle. The fibers are
potted in polyurethane at each end of the fiber bundle in the tube sheet, which serves as the
membrane support.
Ultra filtration: All excess fluid must be removed from the bloodstream as the patient's blood flows
through the dialyzer. The process of water removal from the bloodstream is called ultra filtration, and
the amount of fluid removed is the ultra filtrate.
COMPLICATIONS DURING HEMODIALYSIS
Even though the safety of the hemodialytic procedure has improved greatly over the years, the
procedure is not without risks. Common problems are listed below.
Hypotension
A decrease in blood pressure is the most frequent complication reported during hemodialysis. 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. The immediate treatment to hypotension is to discontinue dialysis and place the patient
in a trendelenburg position. This will increase cardiac filling and may increase the blood pressure
promptly.
Cramps
In the majority of hemodialysis patients, cramps occur toward the end of the dialysis procedure after a
significant volume of fluid has been removed by ultrafiltration. The immediate treatment for cramps is
directed at 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.
Febrile reactions
Febrile episodes should be aggressively evaluated with appropriate wound and blood cultures. The
suspicion of infection should be high. Treatment of endotoxin related fever is generally supportive with
antipyretics. Temperatures should be recorded at the initiation and termination of dialysis treatment.
Arrhythmia
Patients on maintenance hemodialysis are at risk of cardiac arrhythmias. They occur predominately in
association with hemodialysis or may occur in the interdialytic period. Both acute and chronic
alterations in fluid, electrolyte, and acid-base homeostasis may be arrhythmogenic in these patients.
Hemolysis
Hemolysis may result from a number of biochemical and toxic insults during the dialysis procedure.
The half-life of red blood cells in renal failure patients is approximately one half to one third of normal
and the cells are particularly susceptible to membrane injury.
Hypoxemia
A fall in arterial PO2 is a frequent complication of hemodialysis that occurs in nearly 90% of patients.
The drop ranges from 5 to 35 mm Hg, and reaches its peak between 30 - 60 minutes after beginning
dialysis. This is obviously undesirable for patients with underlying cardiopulmonary disease. Also,
patients on mechanical ventilators with constant minute volume and inspired oxygen concentration
can still develop hypoxemia during hemodialysis.
HEMODIALYTIC PROCEDURE
When starting a patient on hemodialysis a physician’s order must include the following:
1. Type of dialysis—conventional vs. high-efficiency or high-flux
2. dialyzer
3. blood flow rate
4. dialysate composition—important items to consider are buffer, potassium
concentration, and glucose concentration
5. dialysate flow rate
6. frequency and duration—schedules for patients vary from 2-4 hours, two or
three times a week
7. estimated ideal or dry weight and amount of fluid to remove as well as blood
pressure support
8. nutritional management including fluid intake—the doctor must consult with
the dietician who will suggest an appropriate diet for the patient
9. laboratory tests pre- and postdialysis—these include BUN, electrolytes,
creatinine, calcium, phosphates, glucose, total bilirubin, cholesterol, total protein,
albumin, and total blood count
 10. medication to be given during the treatment including erythropoietin (EPO),
calcitriol, and others
11. any special instructions that may be required to complete the dialysis as
prescribed
Each hospital has different procedures and nursing practices for the initiation of dialysis. These
procedures should begin with stated goals such as:
1. Dialysis is begun with minimal or no complications
2. All written physician orders are evaluated and the pre-assessment is
completed
3. Pre-assessment of the patient is completed prior to initiation of dialysis—vital
signs, weight, evaluation of fluid status, brief interdialytic history, and access
evaluation.
4. Pre-assessment of the machine is completed prior to initiation of dialysis—set-
up, proper dialyzer, and dialysate concentrate.
5. A list of necessary equipment to begin the procedure:
a. Alcohol wipes and/or Betadine swabs
b. Clamps
c. Drapes or barrier
d. Fistula needles or shunt adapter
e. Gauze pads
f. Gloves
g. Heparin
h. Lidocaine
i. Needles and syringes
j. Physician orders
k. Tape
l. Treatment record
m. Tubes for predialysis lab test
VASCULAR ACCESS
Vascular access is the circulatory site that allows the connection between the patient's circulation and
the dialyzer.
The two most common types of chronic access used for hemodialysis are: 1) Arterio-venous (AV) fistula
and 2) Arterio-venous (AV) graft
Arterio-Venous Fistula
This is created internally and is used for prolonged periods of time. This involves a small operation to
join an artery and vein, allowing arterial blood to flow directly into the vein.
The blood vessels of the arm are usually chosen, e.g. at the wrist or at the upper forearm. Due to the
arterial pressure, the vein will increase in size and its walls will thicken. It takes about 3 to 7 weeks for
the fistula vein to mature. It is then easier to put a needle into this vein to allow blood to flow through
the dialyzer using the blood pump on the machine.
Arterio-Venous Graft
The arterio-venous graft (AVG) is an artificial blood vessel used to join artery and vein. It is used when
the patient's own blood vessels are too small for fistula construction. Often, these patients are the
elderly or have pre-existing diabetes mellitus. The graft, which may be either straight or looped, is
close to the surface of the skin for easier needle insertion. The graft may be of an artificial material
such as polytetrafluoroethylene or Gortex, or can be obtained from the patient's own body, e.g. the
vein in the thigh.
Grafts are most commonly placed in the upper arm, lower arm, and thigh. Two to four weeks should
pass before the graft is punctured to allow adequate healing and sufficient growth of tissue to stabilize
the graft.
Temporary Access

These are temporary or immediate accesses created for use in cases where urgent dialysis is needed,
and the patient cannot wait weeks for the AV fistula to be ready for use. These include 1) the
subclavian catheter, 2) internal jugular catheter and 3) arterio-venous shunt.
The subclavian catheter is a tube which is inserted into the subclavian vein near the neck. The internal
jugular catheter is placed in the veins by the side of the neck. It cannot be used beyond a few weeks
as it tends to get blocked by clotting blood or the site of insertion gets infected.
An arterio-venous shunt is surgically created which consists of two pieces of silastic tubing, each with a
Teflon tip on one end. The Teflon tip of one piece of the shunt tubing is placed in an artery and the
Teflon tip of the other is placed in an adjacent vein. The tubing is then brought through two puncture
wounds in the skin and connected. The AV shunt has limited life-span due to clotting or infection and
does not usually work for longer than 6 months whereas an AV fistula can be used for years.
NEED FOR DIALYSIS
When patients have mild kidney failure (serum Creatinine is less than 400 umol/L), they do not require
renal replacement therapy such as dialysis or renal transplant because they still have sufficient
residual renal function to sustain life. However, they require certain medications, such as phosphate
binders, and need to restrict fluid, salt, and protein intake to reduce the risk of further damage to the
kidney. When the serum Creatinine rises to 900 umol/ L, it is considered severe renal failure and they
require dialysis or a kidney transplant. Additionally, it is customary to consider dialysis in any patient
who 1) is symptomatic from uremia, 2) has a complication of renal failure that is unlikely to resolve by
conservative treatment, 3) has a complication that is associated with a definite risk to the patient, or
4) is suffering from an end-stage renal disease (ESRD).
MECHANICAL ASPECTS
Single-patient hemodialysis machines offer nephrologists tremendous flexibility in adjusting dialysis
regimens to address individual patient needs. Almost all single-patient hemodialysis machines use a
single pass system where the dialysate circulates through the dialyzer once and is then discarded.
All systems require the same basic components:
1. a dialysate heater to warm dialysate to body temperature
2. a dialysate pump and flow meter to regulate the rate of dialysate delivery, and
3. sensors and alarms to monitor dialysate pressure, temperature, conductivity,
and air or blood leaks.
MANAGEMENT
Prior to Dialysis
-Weight the client
-Dry Weight – pre-dialysis weightDuring Dialysis
-Watch for the change in LOC
-Monitor VS
-Assess for the patient for complications:1.Dialysis Disequilibrium Syndrome (DDS)2.Acute
Hypertension3.Hypotension4.Nausea & Vomiting5.Headache6.Acute Bleeding7.Fever8.Blood reactions
occasionally occurs due to hypersensitivity in BT9.Muscle cramps10.Cardiac arrhythmias11.Chest
Pain12.Shortness of Breath13.Restlessness14.Depression & hostility

ASSESSMESNT
1.Assess the venous access site for redness or swelling & the dressing for bleeding or other drainage
2.Assess VS
3.Check fro presence of pain & numbness in the extremities where the access is located
4.Check for the presence of audible bruit & palpable thrill in the fistula/ graft
5.Assess the client’s knowledge of access & hemodialysis to determine the need for education6.Client
Education:a.Implement interventions that is, counselling or support groups to deal with
anxietyb.Demonstrate proper techniques for assessment of sites & determination of fistula
patencyc.Communicate teaching plan with health care providersd.Teach the client not to wear
constricting clothing on the extremity with the permanent shunt.

NURSING MANAGEMENT OF DIALYSIS PATIENT

1.Protect Vascular access
a.Protect from damageb.Assess from patencyc.Do not use extremity for BP taking &
venipunctured.Avoid tight dressing, restraints or jewellery over the vascular access
2.Take Precautions during IVT
a.Rate of administration must be slow (rapid or slow administration of IVF can lead to PE)b.I&O
3.Monitor Symptoms for uremia
Uremia
=Build-up of waste products in the blood due to the inability of the kidneys to excrete them Nausea
Vomiting Headache Loss of energy Sore mouth Drowsiness Muscle twitches Muscle cramps
Abnormal skin sensations Skin discoloration Skin itch
4.Detect cardiac & respiratory complications
a.Fluid overload, HF, PE
b.Pericarditis (may result from accumulation & uremic toxins, may progress to pericardial effusion
[fluid around the heart/ abnormal accumulation of fluid in the pericardial cavity] & cardiac
temponade[fluid accumulates in the pericardium/ the sac in which the heart is enclosed])

5.Control electrolyte level & diet

a.Evaluate all IV solution & medications to be administered for electrolyte contents
b.Assess serum lab values
c.Monitor dietary intake

6.Manage discomfort & pain

a.Antihistamine (benadryl)
b.Analgesicsc.Keep skin clean & moisturized

7.Monitor BP
a.Antihypertensive therapy
b.Dietary salt restriction

8.Prevent Infection
a.Infection of vascular access site & pneumonia
9.Care of Catheter site
a.Soap & H2O

10.Administer Medications
a.Avoid meds toxic to the Kidney

11.Provide Psychological Support

RNs working in a hemodialysis center plan and manage the care patients receive. The
nurses responsibilities include:
• checking the patients' vital signs and talking with them to assess their condition
 • teaching patients about their disease and its treatment and answering any questions
• overseeing the dialysis treatment from start to finish
• making sure patients are given the correct medications ordered by their doctors
• evaluating patients' reaction to the dialysis treatment and medications
• reviewing the patients' lab work, home medications and activities and letting the doctors know
about changes in their patients' conditions
• helping patients follow-up with their transplant center
• supporting the entire care team in delivering quality care in a considerate, respectful manner

Complications of Renal Replacement Therapy

Complication Hemodialysis Peritoneal Dialysis

Cardiovascular Air embolism Arrhythmia

Angina Hypotension

Arrhythmia Pulmonary edema

Cardiac tamponade

Hypotension *

Infectious Bacteremia Catheter exit site infection*

Colonization of temporary central venous catheters Peritonitis*

Endocarditis

Meningitis

Osteomyelitis

Sepsis

Vascular access cellulitis or abscess

Mechanical Obstruction of the arteriovenous fistula due to Catheter obstruction by clots, fibrin,

thrombosis or infection omentum, or fibrous encasement

Stenosis or thrombosis of the subclavian vein or Dialysate leakage around the catheter

superior vena cava due to recurrent use of Dissection of fluid into the abdominal wall

subclavian and internal jugular vein catheters Hematoma in the pericatheter tract

Perforation of a viscus by the catheter

Metabolic Hypoglycemia in diabetics who use insulin Hypoalbuminemia

Hypokalemia Hyperglycemia

Hyponatremia and hypernatremia Hypertriglyceridemia

Obesity

Pulmonary Dyspnea due to anaphylactic reaction to Atelectasis

hemodialysis membrane Pleural effusion

Hypoxia when acetate buffered dialysate is used Pneumonia

Miscellaneous Amyloid deposits Abdominal and inguinal hernias

Catheter-related hemorrhage Catheter-related intra-abdominal bleeding

Fever due to bacteremia, pyrogens, or overheated Hypothermia

dialysate Peritoneal sclerosis

Hemorrhage (GI, intracranial, retroperitoneal, Seizures

intraocular)

Insomnia

Muscle cramps

Pruritus

Restlessness

Seizures

*Most common complications overall.