Module No: _02__

Module Title: PRINCIPLES OF HEMODIALYSIS

Learning Outcomes:
1. Define hemodialysis.

2. Distinguish the functions of a normal kidney that can be replaced through dialysis.

3. List the different treatment modes in hemodialysis.

4. Learn the different principles behind clearance and ultrafiltration in Hemodialysis

Outline
1. Normal Kidney functions vs Dialysis

2. Dialysis Principles

3. Dialysis Components

4. Dialysis Treatment Modes

What is Hemodialysis?
- Is an extracorporeal therapy that utilizes a man – made membrane (dialyzer) to
remove wastes from the blood, restore the proper balance of electrolytes and
eliminate extra fluid from the body.

BASIC FUNCTIONS OF THE KIDNEYS (Review)

1. Removal of waste products
– Urea – end product of protein breakdown
– Creatinine – end product of creatine metabolism primarily from skeletal and
muscle breakdown.
2. Regulation of
– Fluid balance
– Electrolyte balance
• Sodium, Potasium, Calcium, Phosphate, Magnesium
– Acid – Base balance
3. Endocrine
– Production of RENIN
– Erythropoietin formation
– Vitamin D conversion to active form (1,25 dihydroxy vitamin D3)
–
Functions of Kidneys that can be replaced by dialysis
1. Removal of waste products
2. Regulation of fluid balance
3. Regulation of electrolyte
4. Regulation of acid and base balance in the blood

DEFINITION OF TERMS
• SOLUTION – mixture of solute and solvent
• DIALYSATE – solution used during dialysis
• SOLUTES – electrolytes
• TOXINS – end products of metabolism (creatinine, urea etc.)
• SEMI PERMEABLE MEMBRANE – thin, flexible filter, a barrier that allows certain size of
particles to pass thru it.
TRANSPORT MECHANISMS USED IN DIALYSIS
1. Osmosis
Movement of FLUID across a semipermeable membrane from an area of LOWER solute
concentration to an area of HIGHER solute concentration.

2. Diffusion
Movement of dissolved particles (solutes) across a semipermeable membrane from an
area of HIGHER solute concentration to an area of LOWER solute concentration.
FACTORS AFFECTING THE RATE OF DIFFUSION
1. Molecular Size
– Small molecules are cleared faster than larger molecules
2. Membrane Permeability
– Pore size: the larger the pore size, the faster the diffusion
– Number of pores: the higher the number of pores, the faster the diffusion
– Thickness: Thin membranes facilitates better diffusion
– Design
3. Surface Area
– The greater the surface area of the semi-permeable membrane, the more rapidly
diffusion occurs.
4. Temperature
– Molecules moves faster than larger molecules in higher temperature
5. Concentration Gradient
– Difference in the concentration of solutes of the two different fluids
– The higher the concentration gradient, the faster the diffusion occurs
6. Flow Geometry
– Direction of blood flow in relation to the direction of dialysate flow.
Two flow geometries in dialysis:
• Concurrent flow
– Blood flows in same direction with the dialysate.
• Counter-Current flow
– Blood flows in a direction opposite to dialysate flow.
3. Convection
- Transfer of heat and solutes by physical circulation or movement of the parts of a
liquid or gas.
- In dialysis, convective transport (ultrafiltration) leads to SOLVENT DRAG.
- As solvent crosses a semi-permeable membrane, it drags along smaller solutes.

4. Ultrafiltration (UF)
- A convective transport in which solutes move with the solvent
- Water / fluid is driven by either a hydrostatic or osmotic force though the
membrane.
- UF rate is dependent on:
o Total pressure gradient
o Water permeability of membrane (dialyzer)
o Surface area of membrane (dialyzer)
- Can be used to remove water during hemodialysis (HD) sessions, or as means of
solute clearance (by convection) for convective therapies like Hemofiltration(HF) and
Hemodiafiltration (HDF).
DIALYSIS COMPONENTS
1. Dialyzer
- The artificial kidney made of semi – permeable membrane (hollow fibers)
- Two compartments:
Blood
Dialysate
- Compartments are separated by a semi-permeable membrane
- Compartments are enclosed in a clear plastic cylinder which acts a support for the
fibers

- Dialyzers are made of synthetic membranes

Example of membranes: Polysulfone, Polyacrylonitrile (PAN)
- Note: Patients may develop hypersensitivity to synthetic membranes, particularly during first
use of dialyzers (FIRST USE SYNDROME).

DIALYZER MEMBRANE: Flux, Permeability and Efficiency

FLUX
- Movement of water and solutes through a dialysis membrane
- Measure of Ultrafiltration capacity
- Dependent to particle size, pore size, UF rate and surface area
- Can be low flux or high flux based on Ultrafiltration Coefficient (Kuf)
o Low Flux: <20 ml/hr/mmHg
o High Flux: >20 ml/hr/mmHg
PERMEABILITY
- Measure of clearance of the middle molecular weight molecule (eg; β -2
microglobulin)
- Low permeability: β -2 microglobulin clearance <10 ml/min
- High permeability: β -2 microglobulin clearance >20 ml/min
- Correlated to flux

EFFICIENCY
- Measure of urea clearance
- Based on Urea KoA value, where:
o Ko – mass transfer coefficient
o A – surface area
- Low efficiency: KoA <500ml/min
- High efficiency: KoA >600 ml/min

2. Dialysate
- Is the fluid that is pumped into the filter canister, surrounding the hollow fibers.
- The concentration of solutes in the dialysate fluid determines the diffusion gradients.
- Composed of concentrated electrolytes, bicarbonate and treated water / permeate.

TYPES OF DIALYSATE BATH

a. Acetate Bath
o Is a buffer used for acid – base correction in dialysis patients
o Acetate water ratio of 1:34
o Rarely used nowadays
 Conversion of acetate to bicarbonate is dependent to muscle mass
and liver function, thus it is more difficult for patients with reduced
muscle mass or liver dysfunction.

b. Bicarbonate Bath
o Utilizes two concentrate solutions:
 Acid Solution (“A”) – contains most of electrolytes (Na, Ca, Mg, K, Cl)
 Bicarbonate Solution – Contains sodium (Na) and bicarbonate (HCO3)

THE EXTRACORPOREAL BLOOD CIRCUIT

DIFFERENT TREATMENT MODALITIES (MODES)
1. Hemodialysis (Conventional) / HD
- Solutes and water are cleared from the body by movement across a semipermeable
membrane (diffusion).
- Solute clearance is mainly by DIFFUSION through dialysate
- Fluid removal (ultrafiltration)
*** SLED (Slow Low Efficiency Dialysis) – is a hemodialysis characterized by low
dialysate flow rate (low efficiency, DFR ≤ 300 ml/min), low blood flow rate (BFR) and
longer treatment time.
2. Hemofiltration (HF)
- Solutes, toxins and water are cleared from the body by CONVECTION, through
replacement / substitution fluid and ultrafiltration.
- Replacement / substitution fluid can be administered either before the filter (pre –
dilution) or after the filter (post – dilution).
3. Hemodiafiltration (HDF)
- A combination of Hemodialysis + Hemofiltration, where solutes and toxins are
cleared through DIFFUSION (dialysate) and CONVECTION (substitution fluid) while
excess body fluids are removed by ultrafiltration.
- Similar to HF, substitution or replacement fluid can be administered before the filter
(pre-dilution) or after the filter (post-dilution).
 - Can either be Low Volume HDF (<20L substitution fluid) or High Volume HDF (≥20L
substitution fluid).
4. Isolated Ultrafiltration / Sequential therapy (ISO UF)
- A treatment mode where excess fluids are removed (ultrafiltration) with no dialysis
(negligible or no clearance).

ESSENTIAL COMPONENTS OF HEMODIALYSIS PRESCRIPTION

1. Treatment mode
- HD, SLED, HF, HDF (pre or post dilution), ISO UF
2. Duration (average is 4 hours)
3. Blood flow rate (BFR, average is 300-400 ml/min)
4. Dialysate flow rate (DRF, 500 – 800 ml/min; <300ml/min for SLED)
Usually computed through: DFR = BFR x 1.5 or 2.
Example: DFR = 300 x 2
DFR = 600 ml/min
**NKTI Standard DFR = 500ml/min
5. Dialysate bath
6. Anticoagulation / heparinization
7. Target Net Ultrafiltration (UF)
8. Dialyzer type
9. Substitution / replacement volume (for HF and HDF therapies only)
10. Incorporations to Bath (eg, KCl)

REFERENCES
1. Daugirdas J., Handbook of Dialysis, 4th Ed: 2007.
2. Arakama M., Principles of Hemodialysis: Lecture Presentation, 2012.
3. Hemodialysis Training Program for Nurses Course Manual. AESCULAP Academy, B.Braun
Avitum, Philippines Inc.