Dialysis: Treatment in

End-Stage Renal Disease

 Dialysis
 From Greek "dialusis”-dissolution, "dia"-through, and
"lysis”-loosening.

 Dialysis is primarily used to provide an artificial

replacement for lost kidney function in people with renal
failure.

 Most patients begin dialysis when their kidneys

have lost 85%-90% of their ability.

 Dialysis will continue for the rest of

their lives /until kidney transplant is done.
The main functions of dialysis are to:
 Remove waste products such as BUN, Uric Acid,
Excess electrolytes, Excess fluid from the blood to
prevent build-up.

 Treat patient with edema that does not respond to

treatment.

Patient’s with hepatic coma, hyperkalemia, HPN &

uremia

 It may also be used to remove certain medication or

other toxins(poisoning or medication overdose) in the
blood
Types of Dialysis
 A. Hemodialysis
• Most common and efficient method of
dialysis.

• Used for acute ill patient

& require short term dialysis and for
patients with ESRD who require long
term, permanent therapy or until
kidney transplant is done.
• The blood travels from the body to the
machine through tubes inserted into a
vein in your arm, leg, or neck through
the artificial kidney called “dialyzer” to
excrete waste products and regulate
electrolytes.

• Treatments are usually 3x a week for

at least 3-4 hours per permanent
treatment.
 Principles of Hemodialysis

A. Diffusion- toxins &

wastes in the blood tend
to move from an area of
concentration to an area
of concentration in the
dialysate.
B. Osmosis- Excess water is
removed by osmosis in which
water moves from an area of
solute concentration(blood) to an
area of concentration (dialysate
bath)
C. Ultrafiltration- water
moving under pressure
to an area of pressure.
The force is necessary
to remove fluid to
achieve fluid balance.
Equipment for Hemodialysis
1. Hemodialysis Machine
Hemodialysis machine is required
to pump the blood at requisite flow.
The machine also monitors the
flow parameters and the pressures in
the circuit.
The amount of ultrafiltration
( removal of excess fluid from the
body) can be programmed into the
machine and current day machines
will precisely remove the fluid to the
last milliliter
2. Dialyzer or the artificial kidney which
acts as the semipermiable membrane.
Blood is pulled from the patient and
carried into the filter.
Once inside, the blood travels through
many tiny tubules called hollow fibers.
Water and solutes can pass across the
semi-permeable membrane between the
blood and the fluid that surrounds the
hollow fibers. Any fluid or solutes that
enters the filter canister will be drained
out as waste.
• Note how the dialysis filter has structural
similarities to the nephron unit. Blood
arrives at the filter via the access tubing
(afferent arteriole). Blood enters the small
hollow fibers within the filter (glomerulus).
Water and solutes diffuse across the semi-
permeable membrane of the hollow fibers
and collect in the canister (Bowman's
Capsule). Collected fluid (filtrate or
effluent) is then removed via the drainage
tubing(collecting tubule). Blood that
remains in the hollow fibers is returned to
the patient via the return side of the filter
(efferent arterial)
 Semi permeable membrane
Dialysate out Dialysate
in

Blood in Blood out

Urea, Creatinine, Water removed by dialysis

and ultrafiltration
• Although they have similarities
between nephron and dialyzer, they
also have difference like the some
electrolytes and water are not
reabsorbed.
• Any filtrate that enter the dialyzer will
be removed via drainage tubule.
• This would only be controlled by
adjusting the dialysis solution and
ultrafiltration rates.
 Artificial Kidneys/
Normal Kidneys Dialyzer
Urine Formation X
Excretion of waste products 

Regulation of electrolytes 
Regulation of acid-base balance X

Control of water balance 

Renal Clearance 
Regulation of Red Blood Cell X

Synthesis of Vitamin D to active X

form
Secretion of Prostaglandin X
(PGE & Prostacyclin) - VD
Auto Regulation of Blood X
Pressure
3. Dialysate bath is a
solution that is composed
of electrolytes, buffer
such as lactate and
acetate, and the most
common is bicarbonate.
4. Blood Tubing Sets and
Needle
5. Vascular Access which allow
blood to be removed,
cleansed, and returned to the
patient’s vascular system at
rates between 200-800ml/min.
 Types of vascular Access:

A. Subclavian, Internal Jugular and

Femoral Catheters- non
permanent and is usually used
for immediate hemodialysis. It is
also used if the AV Fistula or
Graft are not yet matured.
Subclavian catheter internal jugular catheter.
B. Atriovenous Fistula- it is a permanent site which is
surgically done by anastomosing the artery to
vein. Fistulas may need as long as 2 to 3 months
to fully heal before they can be used.
C. AV Graft- subcuneously interpositioning a
biologic, semibiologic or synthetic graft
Nursing Management
For Hemodialysis
Before Hemodialysis:

o There is increase in BUN, creatinin, serum

phosphorus, potassium, and low levels of hemoglobin,
hct, Ca and Na. (MUST HAVE lab exam)

o Weight and blood pressure (NOT on the site of AV

Fistula/graft), of the patient are taken. Dry Weight is
also must be identify.
o Wash hands and use clean or sterile gloves(depends
on the hospital protocol).

o Topical anesthetic is applied for needle insertion.

 During Hemodialysis
• Monitor VS especially closely monitor BP
every 30 mins
• Administration of Heparin to prevent blood
clot. Contact of patient's blood with the dialysis
membrane and the tubing leads to activation of the
coagulation cascade.
• BT may be done as ordered.
• Watch for major complications such as:
 Atherosclerotic CVD
 Heart Failure : Coronary Heart Disease,
Anginal pain, Stroke.
 Anemia and Fatigue.
Before Hemodialysis:

o There is increase in BUN, creatinin, serum phosphorus,

potassium, and low levels of hemoglobin, hct, Ca and
Na. (MUST HAVE lab exam)

o Weight, blood pressure(NOT on the site of AV

Fistula/graft), are taken. Dry Weight is also must be
identify.
o Wash hands and use clean gloves.

o Topical anesthetic is applied for needle insertion.

 Other complications
• Hypotension- may occur because fluid is removed.
Nausea, Vomiting, diaphoresis, Tachycardia and
dizziness are common signs of hypotension.
• Painful muscle cramping- rapid electrolyte
excretion
• Exsanguination- dialysis needles are dislodge.
• Dysrhythmias- electrolyte & ph changes
• Air embolism
• Dialysis Disequilibrium results from cerebral fluid
shifts of urea nitrogen in the blood rapidly.
Nausea, Vomiting, decreased LOC.
 Assessment
• Assess venous site for swelling or
redness.

• Check for audible bruit sign and

palpable thrill in the AV fistula and
graft.

• Assess client knowledge regarding

hemodialysis
 Protect the Vascular acess

• Protect from damage

• Assess for patency
• Do not use extremity for BP
taking or venopuncture
• Instruct to avoid tight dressing,
restraints or jewelry over vascular
access
• Clean with soap and water
ALERT: Failure of the permanent vascular access accounts for most
hospital admissions of patients undergoing chronic hemodialysis. Thus,
protection of the access is the highest priority
 After Hemodialysis

• Monitor VS especially BP

• Weight patient

• Must obtain Lab Examination

and serum electrolytes.
 Diet
Goals
Maintain body weight (age, height, build)
Maintain serum lab values within safe limits
Comply with dietary regimen

• Low soduim, Protein, K,

phosporus
• High in calcuim
 Pharmacologic Treatment
• Protamine Sulfate- antidote for heparin.
• Epogen/ Synthetic erythropoietin
• Blood pressure medications
• Calcium supplements or multivitamins
• Phosphorus binders—to lower phosphorus levels in the
blood
• Diuretics—to remove excess fluid
• Stool softeners or laxatives—to prevent or treat
constipation, which can be caused by decreased fluid
intake
• Iron supplements—to increase iron intake, which is
important for production of red blood cells
 B. Peritoneal Dialysis

• a sterile solution containing glucose

is run through a tube into the
peritoneal cavity, the abdominal
body cavity around the intestine,
where the peritoneal membrane acts
as a semipermiable membrane.
• Peritoneal dialysis is primarily
performed at home by patients and
their family members.
• Used if unable or unwilling to
receive hemodialysis
• Has slower rate of fluid electrolyte
and metabolic changes
 Types of PD
• Continuous Ambulatory (CAPD)- is the most common type
of peritoneal dialysis. A bag of dialysate is infused into the
abdomen through a catheter. It remains there for 3-6 hours and
is drained. The abdomen is refilled with fresh solution. This
way your blood is always being cleaned. No machine is
needed.
• Continuous Cyclic (CCPD) is done by machine. It is done
at night while sleeping.
• Nocturnal Intermittent (NIPD) uses the same type of
machine as CCPD. This requires assistance and is usually
done at a hospital or center. It often takes longer than CCPD.
Type Length of Frequency of
procedure procedure
CAPD 3-6 hours, 4 times/day
plus
30
minutes to
drain
CCPD 9-12 Every night
hours
NIPD 12 + 36-42
hours hours/week
 Principles

• Diffusion
• Osmosis
As waste product moves from higher
concentration(peritoneal blood) to
lower concentration (peritoneal
cavity) across a semipermiable
membrane(peritoneal membrane)
 Peritoneal Catheter
• Before the first treatment, the physician
places a small, soft tube (approximately 24
inches long) in the lower abdomen 3-5 cm
below umbilicus.
• Trocar is used to puncture the peritoneum
• This tube will remain there permanently. A
portion of the tube remains outside the body
for use in the process.
 Prepare the client
• Assess patient’s anxiety and provide
support and instruction
• Obtain VS, weight, serum
electrolytes are recorded.
• EMPTY bladder and bowel to reduce
risk of puncturing internal organs.
• It is important to keep this access
clean and dry to prevent infection.
 Preparing Equipment
• Warmed concentration of dialysate- dry
heating(heating cabinet, incubator, heating
pad) is recommended
• Heparin is also used
• Potassium Chloride is also prescribed to
prevent hypokalemia.
• Antibiotics may be added to treat peritonitis
• Insulin may also be added for diabetic pt.-
larger than normal dose because 10% of
Insulin binds to dialysate container
 Performing the Exchange
An Exchange is defined as the
infusion, dwell and drainage of the
dialysate.
The dialysate is infused by gravity. A
period of about 5-10 mins is usually
required to infuse 2L of fluid.
The prescribed dwell or equilibrium,
time allows diffusion osmosis to
occur.
Diffusion of small molecules such
as urea and creatinine, peaks in
1st 5-10 mins of the dwell time.
At the end of the dwell time,
drainage portion of the
exchange begins.
The tube is unclamped and the
solution drains from the peritoneal
cavity by gravity through a closed
system.
 Drainage is usually completed in 10
– 30 mins.
 Drainage fluid is normally colorless
or straw colored and should NOT
be cloudy.
 Bloody drainage may be seen in the
first few exchanges after the new
insertion of catheter but should NOT
occur AFTER that time.
 Entire Exchange (infusion, dwell
time, drainage) takes 1-4 hours
depending on the prescribed dwell
time.
The removal of excess water
during PD is achieved by using a
hypertonic dialysate with a high
dextrose concentration that creates
an osmotic agent.
 Complications
• Peritonitis
• Leakage
• Bleeding
• Long term complications:
Hypertriglyceridemia,
Abdominal hernia due to intra
abdominal pressure
Low back pain and anorexia
from fluid in the abdomen
 Health Teachings
Patient education must include:
instruction on aseptic measures to
prevent infection
timing and number of exchanges to be
performed
appropriate dwell times
use of the cycler if automated dialysis is
chosen
obtaining the proper dialysate solutions
storage of solutions and equipment.
CLINICAL DO'S & DON'T
DO
 Use strict aseptic technique, including wearing a surgical
mask and having the patient wear one when changing the PD
catheter dressings, manipulating the PD catheter, or opening
the PD system.
Obtain the prescribed concentration and amount of dialysate.
Warm it to body temperature.
After attaching the primed dialysate connecting tubing to the
PD catheter, open the infusion clamp. Allow the dialysate to
enter the patient's peritoneal cavity by gravity for the
prescribed time-usually 5 to 10 minutes. Close the clamp once
the dialysate solution has infused.
Let the dialysate dwell in his abdomen for the prescribed time,
which will differ depending on the type of PD.
When the dwell time is complete, open the drain
clamp and let the fluid drain by gravity into the
drainage bag. Observe and document the
characteristics and amount of outflow (effluent).
Monitor your patient's vital signs as prescribed,
especially during outflow.
When drainage is complete, attach a new bag of
dialysate and repeat as ordered.
Monitor and document your patients total fluid intake
and output, and record positive and negative balances
after each PD exchange. Weigh at the same time
every day.
Monitor serum electrolyte, glucose, and lipid levels as
ordered.
DON'T
 Don't use expired or cloudy dialysate
solution.
 Don't warm the dialysate in a microwave
oven because the temperature is
unpredictable.
Don't proceed with the infusion if the
patient has signs and symptoms of
peritonitis or infection at the insertion site.
Don't break sterile technique; peritonitis is
the most common complication of PD.