Hemodialysis: History and
Current Perspective
Nadeem A Siddiqui MD
Dallas Nephrology Associates
Hemodialysis:History and Current
Perspective
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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
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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
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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
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History of Dialysis
Principles of Hemodialysis
Mechanisms of Solute transfer
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Diffusion
Convection
Diffusive Clearance
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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
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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
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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
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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
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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
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Cockcroft and Gault equation
MDRD Formula
The Cockcroft-Gault equation
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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
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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
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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
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History of Dialysis
Principles of Hemodialysis
Practice of Hemodialysis
Complications of Hemodialysis
Complications of Hemodialysis
1.
2.
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6.
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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.
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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
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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
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Seizures
Restless legs syndrome
Headache
Dialysis Disequilibrium Syndrome
(DDS)
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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
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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
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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
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Uncommon
From contamination of dialysate with
Chloramine or Copper (deionization
failure)
From Methemoglobinemia from nitrate
contamination
Intradialytic Hypoxemia
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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
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Treatment : Supplemental oxygen during
Hemodialysis in susceptible patients