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DIALYSIS- HEMODIALYSIS AND PERITONEAL DIALYSIS, INDICATIONS, PRINCIPLES & COMPLICATIONS
The document discusses dialysis, a treatment for kidney failure that removes toxins from the blood through hemodialysis and peritoneal dialysis. Hemodialysis involves filtering blood through a machine, while peritoneal dialysis uses the peritoneum as a membrane for substance exchange. Both methods have specific complications and considerations, with hemodialysis typically requiring more frequent treatments, whereas peritoneal dialysis allows for slower, home-based management.
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DIALYSIS- HEMODIALYSIS AND PERITONEAL DIALYSIS, INDICATIONS, PRINCIPLES & COMPLICATIONS
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- 2. DIALYSIS Dialysis is atreatment that removes excess fluid, waste products, and toxins from the blood when the kidneys are no longer functioning properly
- 3. TYPES DIALYSIS • TheTWO main types of dialysis are: • Hemodialysis: Blood is diverted into a machine that filters it, then returned to the body. This type of dialysis is usually done in a dialysis center 3–5 times a week. • Peritoneal dialysis: A dialysis fluid is pumped into the abdomen to draw waste products from the blood. This type of dialysis can be done at home daily
- 4. Hemodialysis • Hemodialysis isused for patients who are acutely ill and require short- term dialysis (days to weeks) and for patients with advanced CKD and ESRD who require long-term or permanent renal replacement therapy. • Hemodialysis prevents death but does not cure renal disease and does not compensate for the loss of endocrine or metabolic activities of the kidneys. • More than 90% of patients requiring long-term renal replacement therapy are on chronic hemodialysis • Most patients receive intermittent hemodialysis that involves treatments three times a week with the average treatment duration of 3 to 4 hours in an outpatient setting. • Hemodialysis can also be performed at home by the patient and a caregiver. With home dialysis, treatment time and frequency can be adjusted to meet optimal patient needs.
- 5. Objectives & Principalsof Hemodialysis • The objectives of hemodialysis are to extract toxic nitrogenous substances from the blood and to remove excess water. • A dialyzer (also referred to as an artificial kidney) serves as a synthetic semipermeable membrane, replacing the renal glomeruli and tubules as the filter for the impaired kidneys. In hemodialysis, the blood, laden with toxins and nitrogenous wastes, is diverted from the patient to a machine, a dialyzer, where toxins are filtered out and removed and the blood is returned to the patient. • Diffusion, osmosis, and ultrafiltration are the principles on which hemodialysis is based. • The toxins and wastes in the blood are removed by diffusion—that is, they move from an area of higher concentration in the blood to an area of lower concentration in the dialysate. • The dialysate is a solution made up of all the important electrolytes in their ideal extracellular concentrations. The electrolyte level in the patient’s blood can be brought under control by properly adjusting the dialysate bath. The semipermeable membrane impedes the diffusion of large molecules, such as RBCs and proteins
- 6. Cont… • Excess wateris removed from the blood by osmosis, in which water moves from an area of low concentration potential (the blood) to an area of high concentration potential (the dialysate bath). • In ultrafiltration, water moves under high pressure to an area of lower pressure. This process is much more efficient than osmosis at water removal and is accomplished by applying negative pressure or a suctioning force to the dialysis membrane. Because patients with renal disease usually cannot excrete water, this force is necessary to remove fluid to achieve fluid balance.
- 7. Cont… • The body’sbuffer system is maintained using a dialysate bath made up of bicarbonate (most common) or acetate, which is metabolized to form bicarbonate. • The anticoagulant heparin is administered to keep blood from clotting in the dialysis circuit. Cleansed blood is returned to the body. • By the end of the dialysis treatment, many waste products have been removed, the electrolyte balance has been restored to normal, and the buffer system has been replenished.
- 8. dialyser • Dialyzers arehollow-fiber devices containing thousands of tiny strawlike tubes that carry the blood through the dialyzer. The tubes are porous and act as a semipermeable membrane allowing toxins, fluid, and electrolytes to pass through. • The constant flow of the solution maintains the concentration gradient to facilitate the exchange of wastes from the blood through the semipermeable membrane into the dialysate solution, where they are removed and discarded.
- 11. Vascular assess • Accessto the patient’s vascular system must be established to allow blood to be removed, cleansed, and returned to the patient’s vascular system at rates between 300 and 800 mL/min. Several types of access are available.
- 12. Vascular assess device •Immediate access to the patient’s circulation for acute hemodialysis is achieved by inserting a double- lumen, noncuffed, large-bore catheter into the subclavian, internal jugular, or femoral vein by the physician. • This method of vascular access involves some risk (eg, hematoma, pneumothorax, infection, thrombosis of the subclavian vein, inadequate flow). The catheter is removed when no longer needed (eg, because the patient’s condition has improved or another type of access has been established).
- 13. Arteriovenous fistula • Thepreferred method of permanent access is an arteriovenous fistula (AVF) that is created surgically (usually in the forearm) by joining (anastomosing) an artery to a vein, either side to side or end to side. • Needles are inserted into the vessel to obtain blood flow adequate to pass through the dialyzer. The arterial segment of the fistula is used for arterial flow to the dialyzer and the venous segment for reinfusion of the dialyzed blood. This allowing toxins, fluid, and electrolytes to pass through.
- 15. Artivenous graft • Anarteriovenous graft can be created by subcutaneously interposing a biologic, semibiologic, or synthetic graft material between an artery and vein. Usually a graft is created when the patient’s vessels are not suitable for creation of an AV fistula. • Patients with compromised vascular systems (eg, from diabetes) will require a graft because their native vessels are not suitable for creation of an AV Fistula. • Grafts are usually placed in the arm but may be placed in the thigh or chest area. Stenosis, infection, and thrombosis are the most common complications that result in loss of this access. It is not at all uncommon to see a dialysis patient with numerous “old” or “nonfunctioning” accesses present on their arms. The patient is asked to identify which is the current access in use and it is checked carefully for the presence of a bruit and thrill.
- 17. Complications • While hemodialysiscan prolong life indefinitely, it does not alter the natural course of the underlying CKD, nor does it completely replace kidney function. The CKD complications With the initiation of dialysis, disturbances of lipid metabolism (hypertriglyceridemia) are accentuated and contribute to cardiovascular complications. • Heart failure, • coronary heart disease, • angina, • stroke, • peripheral vascular insufficiency may occur Cardiovascular disease remains the leading cause of death in patients receiving dialysis
- 18. Complications • Anemia iscompounded by blood loss during hemodialysis. • Gastric ulcers may result from the physiologic stress of chronic illness, medication, and preexisting medical conditions • Patients with uremia report a metallic taste and nausea when they require dialysis. • Vomiting may occur during the hemodialysis treatment when rapid fluid shifts and hypotension occur. • These contribute to malnutrition seen in patients on dialysis. • Worsening calcium metabolism and renal osteodystrophy can result in bone pain and fractures, interfering with mobility. • As time on dialysis continues, calcification of major blood vessels has been reported and linked to hypertension and other vascular complications. • Phosphorus deposits in the skin can occur and cause itching.
- 19. Complications Other complications ofdialysis treatment may include the following: • Episodes of shortness of breath often occur as fluid accumulates between dialysis treatments. • Hypotension may occur during the treatment as fluid is removed. Nausea and vomiting, diaphoresis, tachycardia, and dizziness are common signs of hypotension. • Painful muscle cramping may occur, usually late in dialysis as fluid and electrolytes rapidly leave the extracellular space. • Exsanguination may occur if bloodlines separate or dialysis needles become dislodged. • Dysrhythmias may result from electrolyte and pH changes or from removal of antiarrhythmic medications during dialysis. • Air embolism is rare but can occur if air enters the vascular system. • Chest pain may occur in patients with anemia or arteriosclerotic heart disease.
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- 21. PERITONEAL DIALYSIS • Thegoals of PD are to remove toxic substances and metabolic wastes and to reestablish normal fluid and electrolyte balance. • PD may be the treatment of choice for patients with renal failure who are unable or unwilling to undergo hemodialysis or renal transplantation. • Susceptible patients to the rapid fluid, electrolyte, and metabolic changes that occur during hemodialysis experience fewer of these problems with a slower rate of PD. Therefore, patients with diabetes or cardiovascular disease, many older patients, and those who may be at risk for adverse effects of systemic heparin are likely candidates for PD. • Additionally, severe hypertension, heart failure, and pulmonary edema not responsive to usual treatment regimens have been successfully treated with PD.
- 22. Cont… • In PD,the peritoneal membrane that covers the abdominal organs and lines the abdominal wall serves as the semipermeable membrane. • Sterile dialysate fluid is introduced into the peritoneal cavity through an abdominal catheter at intervals. • Once the sterile solution is in the peritoneal cavity, uremic toxins such as urea and creatinine begin to be cleared from the blood. Diffusion and osmosis occur as waste products move from an area of higher concentration (the bloodstream) to an area of lesser membrane (the peritoneum). • This movement of solute from the blood into the dialysate fluid is called clearance. Since substances cross the peritoneal membrane at different rates, adjustments in dwell time and amount of fluid used are made to facilitate the process. Ultrafiltration (water removal) occurs in PD through an osmotic gradient created by using a dialysate fluid with a higher glucose concentration. • PD usually takes 36 to 48 hours to achieve what hemodialysis accomplishes in 6 to 8 hours.
- 23. Complications • Most complicationsof PD are minor, but several, if unattended, can have serious consequences Acute Complications • Peritonitis • Leakage • Bleeding Long-Term Complications • Other complications that may occur with long-term PD include abdominal hernias (incisional, inguinal, diaphragmatic, and umbilical), probably resulting from continuously increased intra- abdominal pressure. The persistently elevated intra-abdominal pressure also aggravates symptoms of hiatal hernia and hemorrhoids. • Low back pain and anorexia from fluid in the abdomen and a constant sweet taste related to glucose absorption may also occur. Mechanical problems occasionally occur and may interfere with the instillation or drainage of the dialysate. The formation of clots in the peritoneal catheter and constipation are factors that may contribute to these problems.