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Hemodialysis: History and

Current Perspective
Nadeem A Siddiqui MD
Dallas Nephrology Associates

Hemodialysis:History and Current


Perspective

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

Dialysis
Process by which the solute composition
of a solution A is altered by exposing it
to a second solution B through a semipermeable membrane

Necessary pre-requisites for


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

1773: Nurepuel isolates Urea by boiling


urine in a pan

1828: Wohler
synthesizes Urea and
describes its
molecular structure

Thomas Graham (1805-1869)

1850 Glasgow,
Scotland:
Thomas Graham s
experiment to
demonstrate diffusion
across a semipermeable membrane
(Pergamon paper)

Dialysis Membranes

1750:Advances 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
1957:Helmut Staldiger polymerized Cellulose

1913:The First Hemodialysis


Experiment
90
80
70
60
50
40
30
20
10
0

East
West
North

1st 2nd 3rd 4th


Qtr Qtr Qtr Qtr

1937: William
Thalhimer successfully
lowers BUN by
performing
Hemodialysis in
anephric dogs

1926:The 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

1937:Nils Alwall used


the Alwall Kidney to
perform the first ever
hemodialysis
treatment at the
university of Lund,
Sweden

If I have seen farther it is because I have


stood on the shoulders of Giants
Sir Isaac Newton

Hemodialysis:History and Current


Perspective

History of Dialysis
Principles of Hemodialysis

Mechanisms of Solute transfer

Diffusion
Convection

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

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

Hemodialysis:History and Current


Perspective

History of Dialysis
Principles of Hemodialysis
Practice of Hemodialysis

The Hemodialysis circuit

Dialysis Membranes
Membrane

Hydr.Perm. Examples

Regen.
cellulose

Low flux

cuprophane Poor

Modif.
Cellulose
Synthetic

Low/High
Flux

Cell.acetate Interm.
Cell di-acet.
PAN,PS,PA, Good
PC,PMMC

High/Low
flux

Biocomp.

Dialysis Solution
Component
Na
K
Ca
Mg
Acetate
Chloride
Bicarbonate
Glucose

Concentration
mmol/L
140
2
1.25 (5 mg/dl)
0.5 (1.2 mg/dl)
3.0
108
35
5.6 (100 mg/dl)

Water Purification

Water Treatment System for


Hemodialysis

Vascular Access

Indications for initiating


Hemodialysis

In patients with calculated creatinine clearance <20 ml/min/1.73 m2


the onset of:

*Uremic symptoms
Nausea/emesis
Altered sleep pattern
*Altered mental status
Coma
Stupor
Tremor
Asterixis
Clonus
Seizures

Indications for Hemodialysis


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

Indications for Hemodialysis

Steadily worsening renal function in a


patient with measured 24 hour urinary
creatinine clearance<15 ml/min when
accompanied by worsening azotemia, poor
nutritional status and refractory edema

Equations for estimation of renal


function

Cockcroft and Gault equation


MDRD Formula

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

The MDRD formula

Modification 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.

Measurement of nutritional status

Physical Exam
Skin fold thickness
Mid arm muscle thickness
Protein catabolic rate <1*
Serum Albumin
Serum Cholesterol
Blood Lymphocyte count

Monitoring Dialysis Adequacy

Hemodialysis:History and CURRENT


Perspective

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

Complications of Hemodialysis
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

11.
12.

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

Dialysis Reactions

Management of Intradialytic
Hypotension
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

11.

Assess dry weight frequently


Avoid BP meds before HD
Avoid rapid UF
Use sequential UF and HD
Avoid feeding patients on HD
Use Sodium modeling
Use HCO3 based dialysate
Keep Hct >33
Use non Cellulosic membranes
Keep Dialysate temperature<37 degrees Celsius
Assess cardiac function, r/o pericardial effusion/tamponade

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

Neuromuscular complications

Seizures
Restless legs syndrome
Headache

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

DDS

1.

2.
3.

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

DDS

1.
2.

3.

4.

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

Intradialytic Hemolysis

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

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

Intradialytic Hypoxemia

Treatment : Supplemental oxygen during


Hemodialysis in susceptible patients