1|Page

NORMAL KIDNEY FUNCTION LEFT KIDNEY IS HIGHER THAN THE RIGHT KIDNEY DARK REDDISH IN COLOR O.5% OF TOTAL BODY WEIGHT 2 3 WIDE; ABOUT THE SIZE OF THE FIST OR BAR OF SOAP 1 THICK; 4 5 LONG 135 150 GRAMS IN WEIGHT LOCATED AT MID. BACK OF THE BODY, JUST ABOVE THE WAIST POSTERIOR WALL OF THE ABDOMEN INSIDE THE RIB CAGE; PROTECTED WITH PADS OF FAT LAST THRORACIC AND THIRD LUMBAR VERTIBRAE >20% OF BLOOD GOES TO THE KIDNEY FOR FILTRATION 190 LITERS OF BLOOD (335 PINTS) PER DAY; 1200 ml/min

NEPHRON EACH KIDNEY HAS ONE MILLION NEPHRONS CORTEX THE GLOMERULUS IS LOCATED MEDULLA THE TUBULES ARE SITUATED GLOMERULUS MAIN FILTER, LOCATED INSIDE THE BOWMANS CAPSULE IT IS WHERE THE PLASMA IS FILTERED IT IS A TANGLED BALL OF CAPILLARIES AFFERENT ATERIOLE - BLOOD GOES IN EFFERENT ATERIOLE BLOOD GOES OUT HAS FENESTRATION ACTS AS A SIEVE ALLOWING WATER AND MOST SOLUTES IN THE BLOOD PLASMA TO PASS THROUGH PASSIVE TRANSPORT - PERITUBULAR CAPILLARY ACTIVE TRANSPORT RENAL TUBULES (USING ATP)

2|Page SOLUTES CREATININE WATER PROTEIN SODIUM (Na+) CHLORIDE (Cl-) BICARBONATE (HCO3) GLUCOSE UREA POTASSIUM (K+) URIC ACID FILTERED 1.7 GRAM 180 LITERS 2.0 GRAMS 579 GRAMS 640 GRAMS 275 GRAMS 162 GRAMS 54 GRAMS 29.6 GRAMS 8.5 GRAMS REABSORBED 0 GRAM 178 179 LITERS 1.9 GRAM 575 GRAMS 633.7 GRAMS 275 GRAMS 162 GRAMS 24 GRAMS 29.6 GRAMS 7.7 GRAMS URINE 1.7 GRAM 1 2 LITERS 0.1 GRAM 4 GRAMS 6.3 GRAMS 0.03 GRAM 0 GRAM 30 GRAMS 2.0 GRAMS 0.8 GRAM

NOTE: HCO3 - 0.03 GRAM COMES FROM THE LIVER

HOMEOSTASIS BICARBONATE ACTS A BUFFER ACID BASE HOMEOSTASIS NORMAL BLOOD pH (7.35 7.45) ACIDOSIS (EXCESS H+) ACIDEMIA (pH IS LESS THAN 7.35 ) ALKALOSIS (EXCESS HCO3-)

ALKALEMIA (pH IS >7.45) KIDNEY ELIMINATES H+ ACIDOSIS BICARBONATE IS ADDED TO THE BLOOD PLASMA BY TUBULAR CELLS TUBULAR CELLS REABSORBS HCO3

COLLECTING DUCT CELLS SECRETE H+ AND CONCRETE HCO3 ALKALOSIS EXCRETE HCO3 DECREASE H+; CAUSED BY LOWERED RATE OF GLUTAMATE METABOLISM AND AMMONIA EXCRETION

3|Page

SALT HOMEOSTASIS ALDOSTERONE INFLUENCES THE REABSORPTION OF Na AND KEEPSTHE LEVELS OF SALT IN THE EXTRACELLULAR FLUID AND THE BLOODSTREAM CONSTANT

FLUID AND SODIUM IS REABSORBED IN THE DISTAL TUBULES WATER HOMEOSTASIS INFLUENCED BY ANTI-DIURETIC HORMONE (ADH) REABSORBED BY THE PROXIMAL CONVULATED TUBULE, IN THE LOOP OF HENLI

FUNCTIONS OF KIDNEY FILTRATION, REABSORPTION, EXCRETION, BP CONTROL HORMONE D, SECRETION OF WATES RENIN ANGIOTENSIN ALDOSTERONE SYSTEM ERYTHROPOIETIN PRODUCTION BONE MINERAL HOMEOSTASIS AND BONE HEALTH CONSISTENCY OF CHEMISTRY IN THE BODY (SALTS/ELECTROLYTES)

URINE FORMATION GLOMERULAR FILTRATION - FIRST STEP OF URINE FORMATION TUBULAR REABSORPTION RETURNING THE WATER AND MANY FILTERED SOLUTES TO BLOODSTREAM; ABOUT 99% OF BLOOD IS FILTERED TUBULAR SECRETION TRANSFER OF MATERIAL FROM BLOOD AND TUBULE CELLS INTO THE TUBULAR FLUID SECRETION OF H+, HELPS CONTROL BLOOD pH SECRETION OF OTHER SUBSTANCES AND HELPS ELIMINATE THEM FROM THE BODY

4|Page

NEPHRON

GLOMERULAR FILTRATION (GLOMERULUS)

PROXIMAL TUBULES (REABSORPTION AND TUBULAR REABSORPTION)

DISTAL TUBULES (TUBULAR SECRETION AND FINE TUNING IS DONE)

COLLECTING DUCT (URINE COLLECTION)

RENAL PELVIS (URINE GATHERED)

URETERS (URINE PASSAGE)

BLADDER (URINE STORAGE)

URETHRA (URINE OUT)

URINE

5|Page RENIN ANGIOTENSIN ALDOSTERONE SYSTEM RESPONSIBLE FOR BLOOD PRESSURE CONTROL EFFECTS OF ANGIOTENSION SYMPATHETIC ACTIVITY PITUITARY GLAND (POSTERIOR LOBE); RELEASES ADH AND ACTS ON THE COLLECTING DUCT TO REABSORP WATER VASOCONSTRICTION ALDOSTERONE; RELEASED IN THE ADRENAL CORTEX ALDOSTERONE REABSORBS Na+, Cl+, AND K+ EXCRETION AND WATER RETENTION

KINDEY (DECREASE JGA PERFUSION)

RENIN

ADRENAL CORTEX

LUNGS RELEASE ACE (ANGIOTENSIN CONVERTING ENZYME)

LIVER CONVERTS ANGIOTENSIN TO ANGIOTENSIN 1

ANGIOTENSIN

ACE CONVERTS ANGIOTENSIN 1 TO ANGIOTENSIN 2

ANGIOTENSIN 2

INCREASE WATER, INCREASE ACID EXCRETION AND NaCl CONCENTRATION

INCREASE JGA PERFUSION

6|Page ERYTHROPOIESIS MAKING OF RED BLOOD CELLS SYNTHESIS IN THE RENAL CELLS IN RESPONSE OF HYPOXIA ERYTHROPOIETIN GLYCOPROTIEN ~30,000 DALTON HiF DIRECT STIMULUS TO EPO PRODUCTION ACTIVATES BONE MARROW INCREASES ERYTHROPOIESIS

HYPOXIA 10 SIGNAL

INCREASE INDUCIBLE FACTOR (HiF)

INCREASE ERYTHROPOIETIN (KIDNEY)

INCREASE ERYTHROPOIESIS (BONE MARROW)

INCREASE RED BLOOD CELLS AND INCREASES OXYGEN

7|Page HORMONE VITAMIN D LACK OF VITAMIN D CAUSES RICKETS OR OSTEOMALACIA BONE DEFORMITY VITAMIN D SUPPLEMENTS CALCIJEX ZEMPLAR HECTOROL

DIET AND UV LIGHT ON SKIN CELLS VITAMIN D3 (CHOLECALCIFEROL) LIVER (25 - HYDROXY - D3 CALCIFEROL) KIDNEY CONVERTS CHOLECACIFEROL ACTIVE VITAMIN D3 (1, 25 DIHYDROXY - D3 CALCIFEROL) HELPS ABSORBS Ca

BONES ACTIVE VITAMIN D3 GIT

BONE MINERALIZATION

INCREASE ABSORPTION OF CALCIUM

8|Page CONTROLLING EXTRACELLULAR WATER OSMOLALITY ANTI DIURETIC HORMONE ECW EXTRACELLULAR WATER

KIDNEY EXCRETION DECREASE FREE EXCRETION THIRST VASOPRESSIN INCREASE FREE WATER

THIS WILL THEN CAUSE DECREASE IN PLASMA OSMOLALITY IS THE CONCENTRATION OF PLASMA OSMOLALITY IS CONCENTRATED PARATHYROID HORMONE INCREASE PHOSPHATE PARATHYROID HORMONE IS SECRETED IF THERE IS AN INCREASE Ca+

DECREASE Ca+
PARATHORMONE KIDNEY

BONE RELEASE /
DEMINERALIZATION

ACTIVE VITAMIN D

9|Page CHRONIC KIDNEY DISEASE CKD ACUTE RENAL INJURY MOSTLY CAUSED BY DIABETES PERSONAL EFFECTS ON THE PATIENT COST OF IMPACT WELLNESS ILLNESS CONTINUUM QUALITY OF LIFE (QoL)

FAMILY IMPACT WEBSITE LINK ABOUT CKD; KDOQI http://www.kidney.org/professional/KDOQI/guidelines_ckd/toc.html COMMON CAUSES DISEASE OF GLOMERULI DISEASE OF TUBULAR SYSTEM

DISEASE OF URINE DRAINAGE SYSTEMIC DISEASE TARGETING KIDNEY DISEASE DIABETES MELLITUS HYPERTENSION

GENERALIZED VASCULAR DISEASE (VASCULITIDES) RISK FACTORS WHY ARE THE KIDNEYS AT RISK? 20% OF CARDIAC OUTPUT GOES TO THE KIDNEY KIDNEY IS EXPOSED TO NEPHROTOXIC CHEMICALS DUE TO AGING PROCESS

HOW ARE THE KIDNEYS AFFECTED? INCREASE WORKLOAD ACHIEVING GFR (NORMAL 90 - 120) TRADE OFF (PARATHYROID HORMONE) CONSEQUENCES DECREASE FLUID AND SALT HOMEOSTASIS INCREASE iPTH ACIDOSIS MALNUTRITION / POOR APPETITE

10 | P a g e DIAGNOSIS KIDNEY DAMAGE FOR LESS THAN OR EQUAL TO 3 MONTHS, STRUCTURAL AND FUNCTIONAL ABNORMALITIES OF THE KIDNEY, WITH OR WITHOUT DECREASE IN GFR PATHOLOGICAL ABNORMALITIES ARE THE MARKERS OF KIDNEY DAMAGE GFR <60 ml / 1.73m2 FOR LESS THAN OR EQUAL TO 3 MONTHS WITH OR WITHOUT KIDNEY DAMAGE

STAGES

STAGES STAGE 1 STAGE 2 STAGE 3 STAGE 4 STAGE 5

GFR (ml / min / 1.73 m2) LESS THAN OR EQUAL 90 60 90 30 - 59 15 - 29 < 15 / DIALYSIS

CKD IS USUALLY DETECTED AT STAGE 3 WHEN ITS ON STAGE 3 ITS ALREADY TOO LATE STAGE 1 SYMPTOMS ARE VERY RARE MICROPROTENURIA HYPERTENSION STAGE 2 MICROPROTENURIA ANEMIA INCREASE BLOOD VALUES STAGE 3 4 MULTI SYSTEM SYMPTOMS HYPERTENSION, MACROPROTENURIA HYPERVOLEMIA INCREASE PTH DYSLIPIDEMIA VASCULAR CALCIFICATION DECREASE CALCITRIOL

11 | P a g e INCREASE INSULIN RESISTANCE OSTEODYSTROPHY STAGE 5 HYPERURECEMIA ANEMIA SYMPTOMS NOCTURIA LETHARGY EDEMA LOSS OF CONCENTRATION LOSS OF APPETITE SHORTNESS OF BREATH DRY ITCHY SKIN TROUBLE SLEEPING SPECIFIC SYMPTOMS CARDIOVASCULAR o HYPERTENSION o CARDIOMYOPATHY INTEGUMENTARY o PALLOR o ITCHINESS GASTROINTESTINAL o NAUSEA / VOMITING o DECREASE APPETITE HEMATOLOGICAL o ANEMIA o INCREASE RISK FOR INFECTION INCREASE CREATININE AND URIC ACID ANEMIA DECREASE CALCIUM HYPERTENSION

SIGNS

PROTENURIA MANAGE MENT PRINCIPLES DELAY THE PROGRESSION OF CKD TREAT UNDERLYING CONDITION CONTROL BLOOD PRESSURE USE ACE INHIBITOR

12 | P a g e CONTROL DIABETES (HbAlC < 65 %) TREAT HYPERLIPIDEMIA AVOID NEPHROTOXIC MEDICATIONS TREAT THE SECONDARY EFFECTS OF CKD ANEMIA HYPOCALCEMIA HYPERPARATHYROIDISM VOLUME OVERLOAD ACIDOSIS POOR NUTRITION

MONITOR AND PREPARATION OF ESRD TREATMENT PREVENTION EARLY DETECTION COMMUNITY EDUCATION POPULATION SCREENING BLOOD PRESSURE MONITORING URINALYSIS (HEMATURIA AND PROTENURIA) PATIENT EDUCATION AND MONITORING ADHERENCE TO THERAPY FREQUENCY OF MONITORING DELAYING THE NEED FOR DIALYSIS COMPETING WITH PATIENTS WELL BEING

DETERMINING THE POPULATION AT RISK DIABETIC PATIENTS AGING POPULATION (>50 YEARS OLD) ANEMIA IN CKD NORMAL ERYTHROPOIETIN FLOW

RBC PRODCUTION ERYTHROPOIESIS BONE MARROW ERYTHROPOIETIN KIDNEY

13 | P a g e IRON STORES FERRITIN >100 - <500 TS% Hbt 11 12 GRAMS / dl IRON SHOULD BE TAKEN WITH MEALS ERYTHROPOIESIS RESISTANCE CHEMOTHERAPY DRUGS FACTOR DEFICIENCES (FD) UREMIC TOXINS (UT) CHRONIC INFLAMMATION ALUMINUM NEPHROTOXIC DRUGS

ERYTHROPOIESIS

ERYTHROPOIESIS RESISTANCE

RED BLOOD CELLS

OXIDANTS, CHLORAMINES, DRUGS, FD AND UT

HEMODIALYSIS

RED BLOOD CELL DEATH

PARATHYROID HORMONE ACTS AS THE TRADE OFF IN CKD, CAN CAUSE SECONDARY HYPERPARATHYROIDISM RELEASES PARATHORMONE ; UREMIC TOXIN INCREASE IN iPTH CAUSES WEAKNESS AND BONE DEFORMITY MANAGEMENT PARATHYROIDECTOMY TAKING OUT THE PARATHYROID TO STOP THE PRODUCTION OF THE HORMONE PARATHORMONE AS UREMIC TOXIN NEUROTOXIC EFFECTS CARDIOTOXIC EFFECTS VASCULAR CALCIFICATION DYSMETABOLISM

14 | P a g e NORMAL BONE REGENERATION OSTEOCLAST 10 20 DAYS BONE REABSORPTION ABNORMAL BONE REGENERATION OSTEOBLAST 3 6 MONTHS COLLAGEN FORMATION VITAMIN D DEFICIENCY

NOTE: SOLUTES CANNOT BE REMOVED WHEN SOLUTE BINDS WITH THE PROTEIN

ADYNAMIC BONE DISEASE OCCURS AFTER THE PARATHYROID GLAND WAS TAKEN OUT

ADYNAMIC BONE DISEASE

HYPERPARATHRYROID BONE LESION

OSTEOMALACIC BONE LESION

MIXED RENAL OSTEODYSTROPHY

15 | P a g e TREATMENT ADEQUATE DIALYSIS HIGH DIALYSATE Ca Ca BASED MEDICATIONS AND PHOSPHATE BINDERS POTENT VITAMIN D ANALOUGS

CASE MIX CHANGE (MIXTURE OF TREATMENTS) HYPERTENSION MAIN CAUSE OF END STAGE RENAL DISEASE (ESRD) DEATH IS HPN HYDRAULIC SYSTEM FLOW (Q ) VOLUME TRANSIT PER MINUTE RESISTANCE (R) RESISTANCE TO FLOW

P QXR CARDIOVASCULAR SYSTEM FLOW (CARDIAC OUTPUT : L / min) RESISTANCE TO FLOW (PERIPHERAL VASCULAR RESISTANCE) HYPERTENSION THERAPY DRUG THERAPY MANDATORY PRE-DIALYSIS MAP >

106 mmHg PRE-DIALYSIS MAP 98 -106 mmHg AND PATIENT IS ANEMIC

EPO OR PATIENT HAS LVH DRUG THERAPY RECOMMENDED MAP 98 106 mmHg AND PATIENT IS ALREADY ON EPO, NOT ANEMIC AND NO LVH HYPERTENSIVE DRUGS ANGIOTENSIN RECEPTOR BLOCKER (ARB) ACE INHIBITOR VASODILATOR o MONO VS POLYPHARMACY o ASSESSMENT APPROACHES o MANAGEMENT OF HYPERTENSIVE CONDITIONS o TARGET BLOOD PRESSURE IS 130 140 / 80 -90 (PRE DIALYSIS)

16 | P a g e NOTE: BLOOD PRESSURE VARIES PER PERSON NOTE: DALTONS MOLECULAR WEIGHT PATIENTS WITH CKD SHOULD AVOID FOODS RICH IN PHOSPHATE STAGE 1 3 PATIENT IS ADVICED TO DECREASE PROTEIN INTAKE STAGE 4 5 PATIENT IS ENCOURAGED TO INCREASE PROTEIN TO INCREASE HEMOGLOBIN PRODUCTION BETA 2 MICROGLOBULIN 1,818 DALTONS - TOXINS THAT CAUSES BONE DEGENERATION LEPTIN HORMONE THAT SUPRESSES APPETITE; 16, 000 DALTONS CKD IS A TOTAL BODY DISEASE RATE OF DETERIORATION OF RENAL FUNCTION RISK FOR OCCLUSIVE VASCULAR EVENTS ATHEROSCLEROSIS MYOCARDIAL INFARCTION (MI) LEFT VENTRICULAR HYPERTROPHY

FREE RADICALS AND OXIDATIVE STRESS

ATMOSPHERIC OXYGEN INSPIRED BY THE LUNGS

Hb - O2 IS TRANSPORTED IN THE BLOOD

RADICAL OXYGEN SPECIES (ROS)

BODY CELLS (CONSTANT LOW LEAK RISE WITH METABOLISM)

17 | P a g e

LEUKOCYTE; HOST DEFENSE INTENSE GENERATION AND RELEASE ANTIOXIDANTS BODY CELLS

RADICAL OXYGEN SPECIES

UREMIC TOXINS LIPID OXIDATION PRODUCTS (CAN BE INTERMEDIATE OR ADVANCE) ROS; TRANSIENT FREE RADICALS UREMIC TOXIN EXAMPLES ARE: HOMOCYSTEINE ADMA AGE

OXIDATIVE STRESS PRODUCTION HOMOCYSTEINE CAUSES CKD DUE TO ACCUMILATION TOXICITY ACTIVATE / INHIBIT METABOLIC PATHWAYS INCREASE / DECREASE CELL PROLIFERATION ACTIVATE / INHIBIT MEMBRANE CHANNELS INDUCE CELLS DEATH AS NECROSIS

18 | P a g e

UREMIA EXCESSIVE UREA IN THE BLOODSTREAM BUILD UP UREA IN THE BLOOD STREAM DUE TO POOR KIDNEY FUNCTION ACCUMILATION OF TOXINS IN THE BLOOD DUE TO SEVERE KIDNEY DISEASE PERSON GETS SICK FROM WASTES PRODUCTS IN THE BLOOD DUE TO INABILITY OF THE KIDNEYS TO EXCRETE THEM

UREA ORGANIC COMPOUND OF CARBON, NITROGEN, OXYGEN, AND HYDROGEN CON2H4 OR (NH2)2 CO MOLECULAR WEIGHT : 60 DALTONS MOST ABUNDANT SOLUTE REMOVED BY THE KIDNEY USED AS A MARKER IN THE ADEQUACY OF THE DIALYSIS END PRODUCT OF N BALANCE THAT QUANTITAVLY ACCOUNTS FOR NEARLY ALL NITROGEN METABOLISM A CHEAP STANDARD PARAMETER FOR CLINICAL LABORATORY TRANSPORTED RAPIDLY ACROSS ERYTHROCYTE IF THERE IS AN INCREASE IN WATER CONTENT THERE IS AN INCREASE IN UREA LEVELS UREA IS K SOLUTE ONLY THE DIFFUSIVE REMOVAL FROM THE DIALYZER IS THE ONLY FACTOR AFFECTING CHANGE IN UREA CONCENTRATION UREA STILL CONTINUES TO GENERATE DURING DIALYSIS

19 | P a g e UREA AND CARBAMYLATION

UREA

CYANATE
CYANIDE (LEADS TO CYANIDE POISONING)

UREA AND CYANATE

CARBAMYLATION

CARBAMOYL PROTEINS (TOXIC TO THE BODY)

EFFECTS OF CARBOMOYL ALTERS THE FUNCTIONS OF: o ENZYME o HORMONES o RECEPTORS o TRANSPORTS

ADDRESING THE RISK FOR UREA CLEARANCE OF THE SOLUTES RETAINED IN CKD REDUCE BIOINCOMPATIBILITY CLEARANCE AND / OR INFLAMMATORY SOLUTES FLUID MANAGEMENT BLOOD pH AND DIALYSATE HCO3 ENCOURAGE PHYSICAL ACTIVITY

20 | P a g e TOXICOLOGY COMPARED TO PHARMACOLOGY

TOXICOLOGY (AGENT = TOXIN)

PHARMACOLOGY (AGENT = DRUG )

ROUTE OF ACCESS (EXOGENOUS AND ENDOGENOUS)

DOSOLGY (DOSAGE, CONCENTRATION DEPENDENT EFFECT)

KINETICS (ABSORPTION, BIOAVAILABILITY, DISTRIBUTION, DISTRIBUTION VOLUME, ELIMINATION AND CLEARANCE)

EFFECT (SINGLE, MULTIPLE, SPECIFIC, NON - SPECIFIC)

ANTIDOTE POTENTIAL

DOSE OF TOXIN URIC ACID SMALL AMOUNT CAN BE TOXIC UREA LESS THAN 10 TOXINS OF INTEREST CYTOKINES ADIPOKINES (PRODUCE IN THE FAT TISSUE) P CRESOL HOMOCYSTEINE

21 | P a g e INFLAMMATION STATE OF ACTIVATION OF ONE OR MORE HORMONAL (CHEMICAL) AND CELLULAR ELEMENTS OF THE IMMUNE (HOST DEFENSE) SYSTEM A NORMAL RESPONSE TO TISSUE INJURY OR PRESENCE OF FOREIGN (NON - SELF) MATERIAL NORMALLY PRO INFLAMMATORY AGENTS IS CONTROLLED BY ANTI INFLAMMATORY INHIBITORS CHRONIC KIDNEY DISEASE IS ASSOCIATED WITH: INCREASE PROINFLAMMATORY CYTOKINES (INTER LEUKIN 6) PROINFLAMMATORY MEDIATORS ARE: o CYTOKINES o UREMIA DECREASE LEVELS OF ANTI INFLAMMATORY (INTER LEUKIN 10) INCREASE LEVELS OF ACUTE PHASE PROTEINS (C REACTIVE PROTEIN) DECREASE LEVELS OF REVERSE APR (ALBUMIN)

INFLAMMATION

OXIDATIVE STRESS

GLYCOXIDATION

DIALYSIS OVERVIEW AIMS : CHRONIC HEMODIALYSIS THERAPY INCREASE SURVIVAL REDUCE MORTALITY REDUCE ILLNESS REDUCE THE BURDEN OF THE DISEASE IMPROVE THE QUALITY OF THE TREATMENT

22 | P a g e REDUCE THE COMPLICATIONS / SIDE EFFECTS OF THE TREATMENT INCREASE THE QUALITY OF LIFE CLEARANCE OF UREMIC TOXINS SMALL AND MIDDLE MOLECULAR WEIGHT CORRECTION OF FLUID BALANCE K+, Na, BICARBONATE, Ca CORRECTION OF FLUID BALANCE CARDIOVASCULAR PROTECTION REDUCE MORTALITY INCREASE SOLUTE CLEARANCE BIOCOMPATIBILITY ULTRAPURE DIALYSATE FLUID AND SALT CLEARANCE o BLOOD PRESSURE o INITIAL WEIGHT DETERMINATE o CONTROL SALT INTAKE REDUCE MORBIDITY DECREASE HOSPITALIZATION DECREASE INTRADIALYTIC ADVERSE EVENTS IMPROVE THE QUALITY OF LIFE OF DIALYSIS PATIENT INCREASE WELL BEING OF PATIENT

NOTE: DIALYSISTHERAPY WILL HELP THE SURVIVAL RATE OF A PATIENT TO 5

YEARS (72 % SURVIVAL RATE)

NOTE:

4 % WEIGHT GAIN IS ALLOWED >8% WILL NOT BE ALLOWED TO BE DIALYSED

HYPOTENSION o TOO MUCH FLUID IS REMOVED o EATING LARGE MEALS o ADVISED PATIENT TO EAT TWO HOURS BEFORE THE TREATMENT STARTS UREMIC TOXIN DOSAGE IS ACCORDING IN SIZE IF THERE IS A DECREASE IN PULSE o LET THE PATIENT DRINK ORANGE JUICE BECAUSE IT IS POTASSIUM RICH

23 | P a g e HOW TO ENSURE ADEQUACY OF DIALYSIS? CONSIDERATION SOLUTE TO MEASURE MOLECULAR WEIGHT OF SOLUTE PROTEIN BINDING SOLUTES COMPARTMENT LOCATION AND CONCENTRATION OF SOLUTE CLINICAL APPLICATION HIGH FLUX MEMBRANES LENGTH OF DIALYSIS TIME MONITOR PATIENTS UREMIC SYMPTOMS FREQUENTLY SYNTHETIC MEMBRANES (SHOULD BE POLYSULFONE BECAUSE ITS BIOCOMPATIBLE) o OTHER BIOCOMPATIBLE SUBSTANCES ARE WATER AND DIALYSATE

CARDIOVASULAR COMPLICATIONS MAJOR RISK ESRD PATIENTS DIE FROM CARDIOVASCULAR EVENTS NOT UREMIA CONTRIBUTING FACTORS INFLAMMATORY STATE OF UREMIA Ca PHOSPHATE IMBALANCE ANEMIA FLUID IMBALANCE SALT IMBALANCE HYPERTENSION

DYSMETABOLISM IR, HYPERLIPIDEMIA, ADIPOCYTOKINES IMPLICATION SOLUTE CLEARANCE UREMIC TOXINS SMALL MOLECULAR WEIGHT, MIDDLE TO LARGE MOLECULAR WEIGHT DIALYSIS MODALITY FREQUENCY OF DIALYSIS

24 | P a g e FLUID AND SALT MANAGEMENT INTERDIALYTIC FLUID GAINS IDEAL WEIGHT SSHOULD BE MAINTAINED BLOOD PRESSURE FREQUENCY OF DIALYSIS

INTRADIALYTIC EFFECTS HYPOOTENSION CRAMPS ACID BASE AND POTASSIUM BALANCE BICARBONATE ACTS AS THE BUFFER FREQUENCY OF DIALYSIS SESSION NUTRITION DIALYSATE MANAGEMENT AND MONITORING ANEMIA MANAGEMENT HEMOGLOBIN - > 11 12 g / dl TS % - > 22 50 FERRITIN - > 200 - <800 BONE MANAGEMENT CALCIUM PHOSPHATE IPTH ALP

25 | P a g e CORE INDICATORS FOR SUCCESSFUL OUTCOMES (LONG TERM)

INCREASE SURVIVAL

EXCERCISE AND PHYSICAL FITNESS

QUALITY OF LIFE

INDICATORS OF OUTCOMES DIALYSIS ADEQUACY WEEKLY kt/v TARGET: 4.2 80% MEET TARGET VOLUME MANAGEMENT <4% INTERDIALYTIC FLUID GAIN >80% MEET TARGET PHOSPHATE <5.5 mg / dl PER DIALYSIS ANEMIA >110 g / L <12 (13) gm / dl USE ESA NUTRITION >38 g / L ALBUMIN DIABETIC S DECREASE MORBIDITY DECREASE MORTALITY INTRADIALYTIC COMPLICATIONS HYPOTENSION EVENT SHOULD BE <10%

26 | P a g e DIALYSIS TREATMENT OPTIONS PERITONIAL DIALYSIS CAPD OR APD (HOME THERAPY) HEMODIALYSIS HOME, SATELLITE, SELF CARE, IN - CENTER

PRINCIPLES OF HEMODIALYSIS BASIC OVERVIEW HYDROSTATIC PRESSURE IS WATER MOVEMENT

BLOOD SIDE CHANNEL

TOXIC SOLUTES DIFFUSSION CONVECTION (HI - FLUX)

DIALYSATE SIDE CHANNEL

DIFFUSION CONVECTION

BUFFER

(HCO3)

CONTAMINANTS DIFFUSION HYDROSTATIC PRESSURE WATER HYDROSTATIC PRESSURE

WATER

MEMBRANE

DIALYSIS MODALITIES HEMODIALYSIS UREA HEMOFILTRATION MORE DIFFUSION HEMODIAFILTRATION MORE ON CONVECTION

NOTE: DIFFUSION MORE SOLUTES ULTRAFILTRATION MORE ON WATER

27 | P a g e HEMODIALYSIS

BLOOD

BLOOD PUMP

ANTICOAGULANT

DIALYSER

USED DIALYSATE

FRESH DIALYSATE

DEPENDENT ON WATER QUALITY BLOOD FLOW RATE DIALYSATE FLOW RATE (COUNTERFLOW) CONCENTRATION GRADIENTS BETWEEN BLOOD HEMODIAFILTRATION COMBINES DIFFUSION AND CONVECTION WITH SUBSTITUTION FLUID

NOTE: TO PREVENT HYPOTENSION AN EXACT BALANCING OF INFUSED AND UNLTRAFILTERED VOLUME IS MANDATORY WHEN USING HEMOFILTRATION MODALITIES HEMODIALYSIS (HD) HEMOFILTRATION (HF) HEMODIAFILTRATION (HDF) PRINCIPLES DIFFUSION OSMOSIS REVERSE OSMOSIS

28 | P a g e IMPORTANCE OF TIME ALLOWING SOLUTES AND FLUID TO MOVE BETWEEN COMPARTMENTS WE ACCESS THE VASCULAR COMPARTMENT ONLY DIFFUSIN PRINCIPLES CONCENTRATION GRADIENT Qb COUNTER CURRENT FLOW o FROM HIGHER CONCENTRATION o FOR EFFECTIVE CONCENTRATION UREA PHOSPHATE WHICH IS LOCATED IN THE INTRACELLULAR SPACE ULTRAFILTRATION THE MOVEMENT OF FLUID ACROSS A SEMI PERMIABLE MEMBRANE CAUSED BY THE PRESSURE GRADIENT PRESSURE GRADIENT POSITIVE PRESSURE (PUSH) NEGATIVE PRESSURE (SUCK) OSMOSIS MOVEMENT OF WATER OSMOSIS MOVEMENT OF WATER FROM AN AREA OF HIGH CONCENTRATION TO LOW CONCENTRATION DISSOLVED PARTICLES CANNOT PASS THROUGH THE MEMBRANE IN PERITONIAL DIALYSIS OSMOTIC AGENTS ARE GLUCOSE AND SALT ULTRAFILTRATION VOLUMETRIC CONTROLS KUF DIALYZER; SURFACE AREA HIGH FLUX OR LOW FLUX REVERSE OSMOSIS PRESSURE IS APPLIED TO ONE SIDE OF THE MEMBRANE PRODUCT WATER / PERMEATE REJECTS MOST ORGANICS AND ELECTROLYTES REJECTS SOLUTES >200 DALTONS MAY BE A SITE FOR BACTERIAL COLONIZATION

29 | P a g e VASCULAR REFILLING (CRR) FACTORS AFFECTING VASCULAR REFILLING UFR SURFACE AREA OF CAPILLARY NETWORK

DECREASE SERUM ALBUMIN LEVEL TYPES NORMOHYDRATED SLOW REFILLING OVERHYDRATED - EDEMA; RAPID REFILLING DEHYDRATED SLOW REFILLING, PROBABLY FORCED AND WILL LIKELY TO CAUSE HYPOTENSION

HYPOTENSION MANAGEMENT CHECK BLOOD PRESSURE TURN OFF UF POSITION THE PATIENT MODIFIED TRENDELENBURG CHECK THE BP AGAIN IF THE PATIENTS BP IS STILL DOWN, START SALINE DDRIP

DIALYSIS MACHINE MEANS FOR REMOVING WATER FROM BLOOD (ULTRAFILTRATION) CIRCULATE BLOOD THROUGH THE DIALYZER (THE ARTIFICIAL KIDNEY) GENERATE FROM WATER AND CONCENTRATES OF ELECTROLYTE SALTS INFUSES ANTI COAGULANT ON THE BLOOD CIRCULATE DIALYSATE THROUGH THE DIALYZER NEGATIVE PRESSURE ARTERIAL PRESSURE: - 200 0 mmHg AN INCREASE ARTERIAL PRESSURE MEANS THERE IS: NO BLOOD SUCKED INCREASE TEMPERATURE

30 | P a g e VENOUS NEEDLE HAS PRESSURE TRANSDUCER BARRIER VENOUS CHAMBER DRIP SHOULD BE FULL SO THAT THE AIR DETECT ALARM WILL NOT BE TRIGGERED CONDUCTIVITY REVERSE OSMOSIS WATER SHOULD BE ACID WASH / CONCENTRATE A IS

32.775

BICARBONATE / CONCENTRATE B IS 1.225 TOTAL DIALYSATE MIXTURE IS 35

IF THERE A INCREASE IN TEMPERATURE OR CONDUCTIVITY INCREASES THE DIALYSIS MACHINE WILL BYPASS THE SOLUTION AND THE DIALYSATE MIXTURE WILL GO TO THE DRAIN UF PUMP WATER PUMP REMOVES EXCESS WATER; 1 ml / minute

BLOOD LEAK DETECTOR DETECTS BLOOD COMING OUT OF THE DIALYZER FOR BLOOD LEAK TURN OFF THE MACHINE CHECK THE LEAK IF THERES ARE BUBBLES FOR MINOR BLOOD LEAK THE BLOOD SHOULD BE RETURNED FOR MAJOR BLOOD LEAK DO NOT RETURN THE BLOOD NOT UNLESS THE SITUATION CALLS FOR IT

WATER TREATMENT REVERSE OSMOSIS WATER (RO WATER); TREATED WATER PROTECT THE PATIENT AGAINST EXPOSURE TO PATHOGENS / BACTERIA PROTECT THE MEMBRANES OF THE DIALYZER AGAINST DETERIORATION DUE TO WATER BORNE CHEMICALS NORMAL PERSON CONSUMES 3 LITERS OF WATER PER DAY THATS ABOUT 1,000 LITERS PER YEAR STANDARD HEMODIALYSIS CONSUMES 120 LITERS PER HEMODIALYSIS TREATMENT OR 18,000 LITERS PER YEAR

31 | P a g e NOCTURNAL HEMODIALYSIS CONSUMES 144 LITERS PER TREATMENT OR 45, 000 LITERS PER YEAR ORGANIC CHEMICALS AND SIDE EFFECTS CHLORINE HEMOLYSIS AND EMBOLISM ALUMINUM BONE DISEASE AND ANEMIA CALCIUM / MAGNESIUM HARD WATER AND HYPERTENSION CHLORAMINES HEMOLYSIS, ANEMIA, METHEMOGLOBINEMIA COPPER HEMOLYSIS, HEPATITIS FLOURIDE BONE DISEASE, OSTEOMALACIA NITRATES CYANOSIS, HYPERTENSION SULFATES METABOLIC ACIDOSIS

MICROBIAL CONTAMINANTS PYROGENIC REACTION, HYPOTENSION, CHRONIC SEVERE INFLAMMATORY REACTION TREATED WATER STORAGE AVAILABLE IN THE EVENT OF A BREAKDOWN OF ONE OR MORE COMPONENTS OF WATER TREATED STATION FILTERS MEDIA FILTER SILT DENSITY INDEX TO CHECK THE FUNCTION REMOVAL OF LARGE MATTER (>10 MILLION DALTONS) WATER SOFTENER ION EXCHANGE RESIN REMOVES HARD IOS LIKE Ca AND Mg FUNCTION TEST : WATER HARDNESS TEST CARBON FILTER CHARCOAL REMOVES CHLORINE AND CHLORAMINE FUNCTION TEST : CHLORINE OR TOTAL CHLORINE TEST ADSORP CHLORINE SCREEN FILTER FIBER SCREEN MESH REMOVES FINE PARTICULATES FUNCTION TEST : PRESSURE DROP TEST

32 | P a g e REVERSE OSMOSIS MOVEMENT OF FLUID FROM AN AREA OF GREATER CONCENTRATION TO AN AREA OF LOW CONCENTRATIONWITH THE USE OF PRESSURE GRADIENT 90 99 % OF SOLUTES ARE REJECTED CONDUCTIVITY IS 13 13.5

FEED

M E M B R A N E

PERMEATE

REJECT WATER PIPEPING

DISTRIBUTION SHOULD BE CONTINUES NO LOOP SHOULD BE ALLOWED STAGNATION CAN CAUSE BIOFILM WHICH ADHERES TO THE PIPE ONCE BIOFILM HAS COATED THE PIPE IT WOULD BE VERY DIFFICULT TO ERADICATE

33 | P a g e

DIALYSATE COMBINATION OF ACID WATER AND BICARBONATE DIALYSIS FLUID ANIONS (147) HCO3 (34) ACETATE (3) CATION + (147) Na+ (140) K+ (2) Ca2+ (3) Mg2+ (2)

BLOOD FLUID

ANIONS (53) HCO3 (27) ORGANIC IONS (9) PROTEIN (CHON) (16)

CATION + (153) Na+ (142) K+ (4) Ca2+ (5) Mg2+ (2)

34 | P a g e NOTE: ACETATE IN THE DIALYSIS FLUID GOES TO THE LIVER TO BE CONVERTED TO HCO3 DURING PERIODS OF NO DIALYSIS

BICARBONATE KREB'S CYCLE ACETATE

CONCENTRATE PROPORTIONING CONDUCTIVITY IS 13.5 - 14.5

-34 ml RO WATER

35 ml DIALYSATE

1 ml (210 mg) CONCENTRATES

GLUCOSE IS ADDED TO THE DIALYSATE FOR DIABETICS; IT MAY VARY AS PER DOCTORS ORDER ARGUEMENT FOR: SOURCE FOR CALORIE / ENERGY OSMOLALITY GLYCEMIA MANAGEMENT ARGUMENT AGAINST: MAY CAUSE BACTERIAL CONTAMINATION OF DIALYSATE OR HYDRAULICS

35 | P a g e MAY CAUSE CARAMELIZATION WITHIN THE HYDRAULICS ULTRAPURE DIALYSATE RO WATER HEAT OR CHEMICAL STERILIZATION

UV IRRADITION
ULTRAFILTRATION ULTRAPURE DIALYSATE

DIALYZER FUNCTIONS AND PERFORMANCE

REMOVAL OF RETAINED FLUID FROM EXTRACELLULAR SYSTEM (ECS) THIS IS DONE THROUGH ULTRAFILTRATION DEPENDENT ON WATER PERMIABILITY OF MEMBRANE AND PRESSURE DIFFERENCE ACROSS THE MEMBRANE DELIVERY OF SOLUTE FROM DIALYSATE TO PATIENT DONE THROUGH DIALYSANCE DEPENDENT ON SOLUTE CONCENTRATION GRADIENT AND SOLUTE DIFFUSIVITY IN THE MEMBRANE REMOVAL OF SOLUTE FROM PATIENT DIALYSATE CLEARANCE AND DIALYSANCE SOLUTE CONCENTRATION GRADIENT AND SOLUTE DIFFUSIVITY IN MEMBRANE

36 | P a g e NOTE: KEY WORDS ULTRAFILTRATION MOVEMENT OF WATER SOLUTE CONVECTION DRAGS THE SOLUTE INCREASE ULTRAFILTRATION; INCREASE CONVECTION FLUX SIZE OF THE DIALYZER THE NUMBER OF MEMBRANES THE SIZE OF THE LUMEN OF THE FIBERS THE MORE FIBERS THE DIALYZER HAS THE MORE CLEARANCE IT CAN DO (KoA)

TRANSMEMBRANE PRESSURE NORMAL VALUE: 0 20 ONCOTIC PRESSURE PRESSURE THAT HOLDS THE WATER ISOBARIC PRESSURE NO EXCHANGE IS DONE IN THE DIALYZER THERE IS EQUILIBRIUM

REUSING OF DIALYZER WILL CAUSE INCREASE TRANSMEMBRANE PRESSURE (TMP) PROTEIN POLARIZATION MEMBRANE OR KNOWN AS FOULING

FICKS LAW OF DIFFUSION

J = D x A x Dc / Dx
J - SOLUTE FLUX (MASS PER UNIT TIME) D SOLUTE DIFFUSIVITY IN THE MEMBRANE (cm / sec) A AREA OF DIFFUSION FRONT (cm2) Dc CONCENTRATION DIFFERENCE (MASS / VOLUME) Dx DISTANCE OF SEPARATION (cm) Ro RESISTANCE OF TRANSPORT OF SOLUTE

37 | P a g e Ko DIFFUSIV ITY cm / min; DESCRIBES THE DIFFUSIVITY OF A PARTICULAR SOLUTE KoA MASS TRANSFER ARE COEFFICIENT; SOLUTE AND PARTICULAR DIALYZER; R / T K SOLUTE K MEANS CLEARANCE; MASS EXITING / CONCENTRATION ENTERING; mg / min / mg / ml = ml / min

SOLUTE CONCENTRATION ENTERING (mg / ml)

DEVICE OR SYSTEM

MASS EXITING (mg / min)

SOLUTE K IS A MEASURE OF THE EFFICIENCY OF THE SYSTEM OR DEVICE IN REMOVING SOLUTE THYE CAPACITY OF THE DIALYZER FOR SOLUTE DIFFUSION SUMMARIZED BY THE KoA MODERN DIALYZERS HAVE HIGH KoA SMALL SOLUTE K IN MODERN DIALYZER IS MAINLY FLOW LIMITED (Qb AND Qd DEPENDENT) LARGE SOLUTE CLEARANCE (LOW KoA SOLUTE) IS TIME DEPENDENT MANUFACTURERS DATA FOR SOLUTE CLEARANCE INTERPRETING DIALYSIS ADEQUACY AIMS FOR DIALYSIS: PROLONG PATIENTS SURVIVAL REDUCE MORBIDITY BY REDUCING HOSPITALIZATION ADEQUACY DETERMINANTS SINGLE POOLS (sp) DONE 3 TIMES / WEEK spKt/v DELIVERED 1.2 spKt/v PRESCRIBED 1.3 MEDICAL TECHNICIAN FOR BLOOD SAMPLING IS NEEDED OPINION TO INCREASE DOSE FOR DIABETIC PATIENTS

38 | P a g e

OPNION FOR CLEARANCE (K) (MIDDLE MW SOLUTES) HIGH FLUX DIALYZER HDF POLYSULFONE IS USED FOR THR SYNTHETIC MEMBRANES; BIOCOMPATIBLE

CLEARANCE COMPUTATION Kt / V ACCURACY OF BLOOD RESULTS IS NEEDED TO DETERMINE THE CORRECT CLEARANCE

Kt / V FOR NON DIABETIC CLIENTS RANGES FROM 1.

2 1.4

Qbw BLOOD WATER FLOW NUMERATOR: K KoA BASED ON Qbw t TIME IN MINUTES

V VOLUME; THE DENOMINATOR URR UREA REDUCTION RATIO ( 1 PRE / POST) URR TARGET = 1.3; INDIVIDUALIZED Kt / V= IN (PRE / POST) Kt / V -IN (R (0.008 X t) (UF/W) QbW = Qb (1 - Hct) X 0.96 HOW TO CONVERT Hb TO Hct JUST MULTIPLY Hb BY .03 SAMPLE PROBLEM IF Qb IS 250 Hb IS 10.8 gm / dl CONVERT Hb TO Hct (10.8 gm / dl x .03 = 0.324) Qbw = 250 x (1 0.324) x 0.96 Qbw = 250 X (1 0.676) x 0.96 Qbw = 162

GO TO K CHART FOR DIALYZER WATSONS FEMALE 55% IW MALE 58% IW

39 | P a g e

SAMPLE PROBLEM FEMALE WEIGHS 60 KILOGRAMS FOR 4 HOURS K = 155 (F60 DIALYZER) TIME (MINUTES) CONVERT KILOGRAMS (kg) TO MILLIGRAMS (ml) 1 kg = 1000 ml 60 kgs x 1000 ml = 60,ooo ml 60,000 ml x .55 = 33,000 Kt/V = 155 x 240 / 33,000 Kt/v = 1.13

THEREFORE TO ENSURE THAT WE HAVE ACHIEVED ADEQUATE DIALYSIS WE WOULD NEED TO INCREASE THE TIME OF DIALYSIS TIME BY 35 MINUTES CHECKING FOR CLEARANCE AT LEAST EVERY 3 MONTHS IDEALLY SHOULD BE EVRY MONTH URR Kt/V WHEN TO CHECK PRESCRIBED Kt/v?

WHEN CHANGES TO Qb (VASCULAR PROBLEMS) IF YOU SUSPECT THAT THERE IS DECREASE IN CLEARANCE

MONITORING UREMIC SYMPTOMS

OLC MONITOR

MEASURES AND CORRELATE SYMPTOMS MONTHLY REVIEW WITH OCM FOR COMPARISON COMPARE PREVIOUS RESULTS (TREND ANALYSIS) ASSESS PATIENTS WELL BEING AND UREMIC SYMPTOMS EVALUATION ACCESS RECIRCULATION PRESCRIBED TIME DELIVERED ADVERSE EVENTS

40 | P a g e TECHNICAL PROBLEMS (e.g. NEEDLE REPOSITIONING, PRESSURE ALARMS)

TECHNICAL FAILURE FOR BLOOD TAKING OLC MONITOR QIP (EVERY INITIATION OF PROCEDURE NURSING MANAGEMENT / RESPONSIBILITIES PHYSICAL ASSESSMENT FLUID ASSESSMENT VASCULAR ACCESS ASSESSMENT

DIABETIC ASSESSMENT MACHINE MANAGEMENT HEMODIALYSIS BIM, BUM, QM DRUG ADMINISTRATION ANTI COAGULANTS VITAMIN D ANALOGUES

EPO PATIENT EDUCATION DIET AND FLUID (PROTEIN INTAKE) MEDICATION (ALBUMIN AND UREA) EVALUATION CQI (CONTINIOUS QUALITY INITIATIVE) DIALYSIS INDICATORS COMMUNICATION DIALYSIS SCHEDULE MACHINE PREPARATION WELCOME THE PATIENT PATIENT ASSSESSMENT PLANNING FOR DIALYSIS TREATMENT CANNULATION SAFE CONNECTION TO DIALYSIS MACHINE SETTLE PATIENT AND DOCUMENT CARE MONITORING PATIENT DURING PROCEDURE MOTIVATION PATIENT ENCOURAGEMENT

41 | P a g e COMPLETION OF DIALYSIS PROCEDURE CLEANING THE MACHINE AND EQUIPMENT PATIENT ASSESSMENT POST DIALYSIS DISCHARGE PATIENT FROM TREATMENT DOCUMENTATION OF CARE PROVIDED AND PLAN FOR THE NEXT TREATMENT

NOTE: FOR PATIENT WITH NO HEPARIN DURING DIALYSIS FLUSHING OF SALINE EVERY 15 MINUTES IS DONE; ST LESDT 100CC LABEL THE DIALYZER WITH THE PATIENTS COMPLETE NAME PREDIALYSIS PREPARATION MAKE SURE THAT THE MACHINE IS WORKING PROPERLY CHECK IF THE DIALYZER IS CORRECT PATIENT PREPARATION PHYSICAL ASSESSMENT WELCOME / GREET THE PATIENT BLOOD PRESSURE TAKING (BOTH STANDING AND SITTING) TO CHECK FOR ORTHOSTATIC HYPOTENSION WEIGH THE PATIENT TO CHECK FOR FLUID GAIN SAFE FLUID REMOVAL TARGET PATIENTS WELL BEING NUTRITION RECENT ILLNESS HOSPITALIZATION PERIPHERAL EDEMA VASCULAR ACCESS ASSESSMENT INSPECTION PALPATION AUSCULTATION APEX BEAT (CARDIAC PATIENTS) BLOOD SUGAR LEVEL (BSL) AND FEET ASSESSMENT FOR DIABETIC PATIENTS

DOCUMENTATION CANNULATION / VASCULAR ACCESS PREPARATION VASCULAR ACCESS ARM WASH CANNULATION TRAY SET UP

42 | P a g e DETERMINE SIZE OF THE NEEDLE DURING CANNULATION, POSITION THE CANNULA AT >2

-3

cm
TAPE SECURELY ENSURE PATIENT COMFORT

PREPARE FOR CONNECTION TO THE DIALYSIS MACHINE CONNECTION PROCEDURE UNFRACTIONATED HEPARIN STAT DOSE DIVIDED IN FOUR (4) DOSES EVERY 30 MINUTES BOLUS; WILL DEPEND ON THE PATIENTS BODY SIZE

SETTING THE Qb AT 150 ml/MINUTE THEN SLOWLY INCREASE TO THE PRESCRIBED RATE AND THEN AFTER TURN THE UF ON DURING DIALYSIS MONITOR PATIENTS VITAL SIGNS AS PRESCRIBED BY THE PHYSICIAN OR CENTERS PROTOCOL CAN HAVE RECREATIONAL ACTIVITIES TO AVOID BOREDOM; ACTIVITIES LIKE CARD GAMES, EXERCISE, AND GROOMING CLASSES

HYPOTENSION MAY BE DUE TO UFR > CARDIAC OUTPUT INCREASE RISK WITH DIABETIC AND MALNOURISHED PATIENTS PREVENTION o INCREASE DIALYSIS TIME o CHECK THE PATIENTS UF PROFILE o ISO UF MANAGEMENT o DETERMINE THE SEVERITY OF HYPOTENSION NOTE: PITTING EDEMA GRADES GRADE 1 ANKLE GRADE 2 KNEE GRADE 3 WAIST GRADE 4 ANASARCA

NOTE: EDEMA (+) MEANS THE DEPTH OF THE EDEMA

43 | P a g e

NOTE: HIRUDAN WAS THE FIRST ANTICOAGULANT USED (1880S) EPO; SYNTHETIC ERYTHROPOIETIN WAS DISCOVERED IN THE 1990S

VASCULAR ACCESS AND HEMODIALYSIS THE DIALYSIS VASCULAR ACCESS IS THE LIFELINE OF A DIALYSIS PATIENT CAN BE INTERNAL OR EXTERNAL ARTERY IS ANASTOMOSED TO THE VEIN BEFORE SURGERY CHECK FOR CHECK FOR ALLENS TEST PRE OPERATIVE EVALUATION

PRE EMPTIVE VASCULAR MAPPING SHOULD BE DONE AVF IS USUALLY THE IDEAL CHOICE SINCE IT IS OF YOUR OWN LOCAL VEIN AND IS GOOD FOR LONG TERM USE

DIALYSIS ACCESS

ACUTE

CHRONIC

CVDC (CENTRAL VENOUS DIALYSIS CATHETER)

ARTERIOVASCUL AR GRAFT (AVG)

ARTERIOVASCUL AR FISTULA (AVF)

44 | P a g e

IDEAL VASCULAR ACCESS IT SHOULD BE FOR LONG TERM USE SHOULD BE SAFE, WELL TOLERATED BY THE PATIENT AND HAS FEW COMPLICATIONS RELIABLE LONG LASTING PROVIDE CONTINIOUS BLOOD FLOW 400 mls / min CAN BE USED REPEATEDLY FOR ACCESS TO CIRCULATION SIMPLE EASY TO USE EASY TO PLACE

ACCEPTABLE TO THE PATIENT PAINLESS COSMETICALLY ACCEPTABLE ACCESS TYPES INTENAL ARTERIO VENOUS FISTULA (AVF) PROSTHETIC BRIDGE GRAFT (AVG) PTFE BOVINE AUTOLOGOUS VEIN (SAPHENOUS VEIN) OTHERS CENTRAL VENOUS CATHETER TEMPORARY; GOOD FOR ONLY 2 MONTHS TUNNELED CUFF CATHETER PORTS SITES FOREARM UPPER ARM THIGH THORAX

TRANSPOSED VEIN RADIOCEPHALIC ULNOCEPHALIC SNUFF BOX BRACHIAL CEPHALIC

45 | P a g e

ARTERIOVENOUS FISTULA (AVF) AVF SHOULD BE PREDOMINANT IN ALL ACCESS TYPES IT SHOULD BE >50% OF ALL ESRD PATIENT ADVANTAGES LOWER COMPLICATION LIKE THROBOSIS AND INFECTION SAFE AND RELIABLE PROVIDES GOOD FLOW DISADVANTAGES SLOW MATURATION (6 8 WEEKS) COSMETICC PROBLEMS OR CONCERNS DIFFICULT TO PLACE AND CANNULATE MADATORY POST OPERATION PHYSICAL EXAM 4 WEEKS AFTER SURGERY AVF FAILURES CAN BE IDENTIFIED DIALYSIS NURSES HAVE AN 80% ACCURACY IN PREDICTING THE ULTIMATE AVF UTILITY FOR DIALYSIS PATIENT TERMINATION

FOR AVF APPLY PRESSURE FOR AT LEAST 5

10

MINUTES
ARTERIOVENOUS GRAFT (AVG) PROSTHETIC BRIDGE GRAFT (PTFE) EITHER AUTOLOGOUS OR PROSTHETIC MATERIAL IN WHICH CIRCULATION IS ESTABLISHED BY SURGICAL ANASTOMOSIS TO BLOOD VESSELS ADVANTAGES EASY TO PLACE TO ANY POSITION RAPID MATURATION EASY TO CANNULATE PROVIDES GOOD BLOOD FLOW DISADVANTAGES HIGH THROMBOSIS RATE DUE TO ITS FORGEEIGN MATERIAL HIGHER INFECTION RATE THAN AVF LOW SURVIVAL RATE COSMETIC PROBLEMS FOR SOME PATIENTS

46 | P a g e

COMPLICATIONS PSEUDOANEURYSMS DUE TO EXCESSIVE USE INFECTION HEMATOMA CAUSED BY INFILTRATION STENOSIS o MAY BE DUE TO THROMBOSIS o CAUSED BY FAILURE; PROGRESSIVE STENOSIS ISCHEMIC LESIONS o DUE TO LACK OF CIRCULATION IN THE EXTREMITIES INFILTRATION o CAUSES HEMATOMA o NURSING INTERVENTION: ELEVATE THE HAND APPLY COLD COMPRESS USE TWO (2) DIGIT FINGER TO APPLY PRESSURE TERMINATION FOR AVG APPLY PRESSURE FOR AT LEAST 15

MINUTES
CENTRAL VASCULAR DIALYSIS CATHETER (CVDC) HAS A DACRON CUFF WHICH HOLDS THE CATHETER, IT IS SUTURED AND ALSO HELPS IN PREVENTING THE ENTRY OF BACTERIA CAN ONLY BE USED FOR A MAXIMUM OF 2 MONTHS; CAN ONLY USED WHEN THERE IS NO OTHER OPTION BECAUSE OF INCREASE RISK OF INFECTION COMMON SITES JUGULAR VEIN SUBCLAVIAN VEIN FEMORAL VEIN ADVANTAGES EASY TO PLACE CAN BE USED IMMEDIATELY NO NEED FOR NEEDLES IMMEDIATE HOMEOSTASIS POST DIALYSIS PAINLESS

47 | P a g e DISADVANTAGES HIGH INFECTION RATE HIGH THROMBOSIS RATE HIGH MORTALITY RATE RISK FOR CENTRAL VEIN STENOSIS PATIENT DISCOMFORT AND BODY IMAGE CONCERNS COMPLICATIONS INFECTION o EXIT SITE IS AT RISK FORR INFECTION o CATHETER INFECTION AND BACTEREMIA o NURSING RESPONSIBILITIES PALPATE THE SITE ASSESS FOR SIGNS OF INFECTION LIKE PAIN, REDNESS, AND DISCHARGE FROM THE SITE FLOW PROBLEMS o OCCLUSION o THROMBOSIS o CARDIOVASCULAR STENOSIS HEPARIN DOSE ARTERY LINE - 1.5 CC / 2 CC VEIN LINE 1.6 CC / 2 CC SHOULD BE PUSHED FAST SO THAT HEPARIN WILL COAT THE CATHETER BEFORE THE START OF DIALYSIS ASPERATE 5 CC OF BLOOD (TO ASPERATE BLOOD CLOTS) USE SALINE FOR FLUSHING BLOOD FOR SAMPLE PRE UREA o ASPERATE 5 CC o ASPERATE 10 CC o THEN ASPERATE THE BLOOD SAMPLE o RETURN 10 CC POST UREA o STOP PUMP o ASPERATE 10 CC

48 | P a g e CANNULATION APPROACHES VASCULAR ASSESSMENT IS A MUST POINTERS WHEN CANNULATING WHEN CANNULATING RETRACT THE SKIN FIRST ARTERY CANNULA HAS A BUCK EYE FOR AVF PUNCTURE THE VESSEL AT A 250

350 ANGLE FOR AVG PUNCTURE THE VESSEL AT A 350 450 ANGLE
PALPATE FOR THRILLS

ARTERIOVENOUS FISTULA (AVF) AUSCULTATE FOR BRUITS ARTERIOVENOUS GRAFT (AVG) BLUE THUMB VENOUS RED THUMB ARTERY

IF THE PATIENT DOESNT KNOW IMPEDE OR OCCLUDE THE CIRCULATION TYPES OF PUNCTURES ROPE LADDER BUTTON HOLE SAME PUNCTURE AREA AREA PUNCTURE - SAME AREA PUNCTURE, USUALLY USED TO INCREASE THE VESSEL SIZE

PRINCIPLES OF CANNULATION CANNULATION IS A SCIENCE HOW TO IMPROVE CANNULATION PRACTICE FOCUS

ALWAYS ADHERE TO THE STANDARD OPERATING PROCEDURE ASSESSMENT PALPATION AUSCULTATION POSITION OF CANNULA SPLINTING LENGTH OF THE VESSEL POSITION FROM ANASTOMOSIS DIRECTION OF CANNULA

49 | P a g e

SKIN PREPARATION HANDWASHING ALCOHOL SKIN PREPARATION CANNULA SIZE VESSEL SIZE PRESSURES AND Qb (REFER FROM PREVIOUS RECORDS) ANGLE AND DEGREE DEPENDS ON THE DEPTH OF THE VESSEL TAUNT THE SKIN FROM THE CANNULA ENTRY STABILIZING THE NEEDLE PROPER TAPING TECHNIQUE IT SHOULD BE COMFORTABLE FOR THE PATIENT ASWELL ASSESSMENT OF CANNULA PATENCY USE 0.9% SALINE FLUSH POINTS TO REMEMBER NEEDLES SHOULD BE ONE INCH APART FROM EACH OTHER ARTERY CANNULA SHOULD BE INSERTED 2

-3 INCHES

ABOVE THE ANASTOMOSIS SITE ARTERY CANNULA CAN BE INSERTED WITH THE TIP POINTING UP OR DOWN, AND SHOULD BE NEAR THE ANASTOMOSIS SITE VENOUS CANNULA SHOULD ALWAYS BE INSERT WITH THE TIP FACING UPWARDS ONE SITE IT IS SHOULD BE PREVENETED, IT IS USUALLY CAUSED BY OVER USED AREA

50 | P a g e

ACCESS CYCLE

ACCESS LOSS

ACCESS PLACEMENT

ACCESS REPAIR

ACCESS MAINTENANCE

INFECTION CONTROL 1996 - THE STANDARD PRECAUTIONS WAS ESTABLISHED HANDWASHING SHOULD BE DONE FOR ONE (1) FULL MINUTE TYPES OF HANDWASHING ANTIBAC GENERAL HEXOL YOU SHOULD ALWAYS TREAT EVERY PATIENT AS INFECTIOUS PERSONAL PROTECTIVE EQUIPMENTS (PPE) GLOVES MASK GOWN / APRON FACE SHIELD GOOGLES

51 | P a g e REDUCING TRANSMISSION PATIENTS WHO ARE CONTAGIOUS SHOULD BE SCHEDULED AT: THE LAST SHIFT OF THE DAY THE LAST PATIENT OF THE SHFT THE LAST CANNULATION OF THE SHIFT STAFF MEMBER SHOULD BE ON DAY OFF AFTER DISINFECTION OF MACHINE START OF THE DAY DISINFECTION BETWEEN POSITIVE PATIENTS FASTIDIOUSLY CLEAN THE EXTERIOR OF THE MACHINE ATTEND TO VISIBLE BLOOD SPILLS / TRACES IMMEDIATELY

FOR BLOOD SPILL, USE SALT TO ABSORB BLOOD DIALYSIS CONSUMABLES BEDS, TABLES, AND CHAIRS DO NOT USE COMMON TROLLEY FOR MEDICATION, STOCK, AND FOOD USE EXTERNAL PRESSURE TRANSDUCERS FOR EACH PATIENT AND DO NOT REUSE

MULTIPLE VIALS SHOULD BE SHARED WASTES DISPOSAL SHOULD BE COLOR CODED INFECTION IS NOT JUST STANDARD CONTROL BUT ALSO AWARENESS HEPATITIS B SURVIVES UP TO 3 DAYS; 72 HOURS ROUTINE PATIENT SCREENING SHOULD BE DONE VACCINATION IS ENCOURAGED DIALYSE HBsAG (+) PATIENTS SHOULD BE IN A SEPARATE ROOM OR ISOLATION ROOM PLACE THE PATIENT IN AN AREA WHERE THERE IS LESS TRAFFIC MACHINE SHOULD ALSO BE ISOLATED USE A DIFFERENT REPROCESSING MACHINE FOR ACCIDENTAL EXPOSURE HAVE YOUR BLOOD TEST TAKEN AFTER EXPOSURE THEN AFTER 6 MONTHS

52 | P a g e HEPATITIS C PREVENTION: ADHERENCE TO STANDARD PRECAUTION DECREASE SHARING OF MACHINES WITH INADEQUATE SURFACE DISINFECTION BETWEEN PATIENTS; ISOLATE MACHINE ISOLATE HEPATITIS C POSITIVE PATIENT DIALYZERS FROM OTHER PATIENTS ALWAYS DO HOT DISINFECTION AFTER EVERY USE

HIV DUE TO CONFIDENTIALITY ISSUES AND PATIENTS RIGHTS STANDARD PRECAUTIONS IS STILL APPLIED PATIENTS CHOICE OF TREATMENT MODALITY NO NEED FOR DESIGNATION, ISOLATION OR BE DIALYSED SEPARATELY DIALYZER MAY BE REUSED VREC (VANCOMYCIN RESISTANT ENTERO COCCI) SHOULD HAVE A DEDICATED MACHINE, ROOM, HOSPITAL SHOULD HAVE A DEDICATED STAFF THEY SHOULD HAVE THEIR OWN INDIVIDUAL CLAMPS, TORNIQUETS, AND BP CUFFS INDIVIDUAL BATHROOM

TUBERCULOSIS WHO ARE AT RISK: THOSE WITH SUPPRESED IMMUNE SYSTEM FOREIGN BORN PEOPLE FROM COUNTRIES WITH HIGH TB RATES HEALTH CARE WORKERS OR PRISON GUARDS ALCOHOLICS AND IV DRUG USERS USUALLY TRANSMITTED THROUGH DROPLET SIGNS AND SYMPTOMS: COUGH WILL NOT GO AWAY FEELING TIRED WEIGHT LOSS, LOSS OF APPETITE FEVER NIGHT SWEATS

53 | P a g e PHARMACOLOGICAL ASPECTS OF RENAL FAILURE DRUGS USED EPO VITAMIN D AND ANALOGUES PHOSPHATE BINDERS ANTI HYPERTENSIVES

ANTI COAGULANTS DRUG HANDLING vGFR WILL DEPEND ON THE DIALYZER NUTRITIONAL STATUS - ESRD PATIENT ARE PRONE TO REDUCED NUTRITIONAL STATUS VOLUME DISTRIBUTION PATIENT ON DIALYSIS HAVE A 3- 5 % FLUID GAIN EVERY 2- 3 DAY DIALYSIS DIALYSABILITY OF DRUGS MOLECULAR WEIGHT OF THE DRUG % OF PROTEIN BINDING MOLECULES PORE SIZE OF THE DIALYZER IRON IS GIVEN ONE HOUR BEFORE THE END OF TREATMENT VITAMIN D IS GIVEN ONE MINUTE BEFORE THE END OF TREATMENT EPO IS GIVEN SUBCUTANEOUSLY POLYPHARMACY PATIENT HAS LOT OF MEDICATIONS

BODY

PHARMACODYNAMICS

DRUG

PHARMACODYNAMICS PRINCIPLE DRUG RECEPTORS AND DURATION RELATION BETWEEN DRUG DOSE AND CLINICAL RESPONSE

54 | P a g e VARIATION IN DRUG RESPONSIVENESS HYPOREATIVE HYPERREATIVE HYPERSENSITIVITY TOLERANCE CLINICAL / BENEFICIAL VERSUS TOXIC EFFECTS OF DRUGS

DRUG

PHARMACOKINETICS

BODY

PHARMACOKINETICS (ADME) ABSORPTION SITE ADMINISTRATION TO SYSTEMIC CIRCULATION DISTRIBUTION TRANSFER OF DRUGS FROM SYSTEM TO TISSUES METABOLISM BIOTRANSFORMATION OF DRUGS EXCRETION / ELIMINATION REMOVAL TO THE BODY; EXCRETED IN THE FORM OF URINE, SWEAT, SALIVA, BREAST MILK, EXPIRED AIR METABOLISM MAINLY DONE IN THE LIVER EXCRETION RENAL AND / OR HEPATOBILIARY SYSTEM

FRAMEWORK OF EFFECTIVENESS MONITOR ADHERANCE EFFECTIVENESS OF SPECIFIC DRUGS EPO MANAGE Hb (HEMOGLOBIN) ANTIHYPERTENSIVES CONTROLS BLOOD PRESSURE VITAMIN D- ADEQUATE Ca LEVELS PHOSPHATE BINDERS CONTROLS SERUM PHOSPHATE ANTICOAGULANTS TO PREVENT CLOTTING OF CIRCUITS BUT NO UNNECESSARY BLEEDING

55 | P a g e

MEDICATIONS FOR CHRONIC KIDNEY DISEASE (CKD) ANEMIA IRON, ERYTHROPOETIN STIMULATING AGENTS (ESA) BONE PHOSPHATE BINDERS, VITAMIN D ANALOGUES ANTICOAGULANTS LMWH, UFH, ANTIPLATELETS BLOOD PRESSURE ACE, ARI, BLOCKERS LIPID LOWERING MEDICATIONS ANTIBIOTICS AND ANTIMICROBIALS

ESRD (END STAGE RENAL DISEASE)

MANAGEMENT RENAL REPLACEMENT THERAPIES DIALYSIS TRANSPLANTATION MEDICATION DIALYSIS TREATMENT ANTICOAGULANTS VOLUME REPLACEMENT SYMPTOM MANAGEMENT ANTIHYPERTENSIVES CARDIAC DRUGS EPO ANALOGUES VITAMIN D ANALOGUES PHOSPHATE BINDERS

CALCIUM PHOSPHATE Ca 8.8 10.5 mg / dl PHOSPHATE 25.5 mg / dl 5.5 mg / dl (PRE - DIALYSIS) IPTH 150 300 pg / ml Ca PHOSPHATE PRODUCT - < 600 mg2 / dl2 <60 mg 2 / dl 2 (PRE - DIALYSIS)

56 | P a g e TREATMENT APPROACHES DIETARY RESTRICTIONS EFFECTIVE CLEARANCE BALANCING THERAPHY ORAL CALCIUM VITAMIN D ANALOGUES DIALYSATE CALCIUM CALCIUM BASED BINDERS NON CALCIUM BASED BINDERS o RENAGEL o FOSRENOL CLANTHANUM (ABONATE) o SHOULD BE TAKEN WITH FOOD

TYPES OF PHOSPHATE BINDERS CALCIUM CARBONATE OR Ca ACETATE TUMS PHOSLO CALCINEW TRITRALAC

ANTICOAGULANTS MAINTENANCE INFUSION: LOW MOLECULAR WEIGHT LOADING DOSE: ONE BIG DOSE STAT DOSE: NEEDED DOSE HEPARIN MODELING HEPARIN FREE FLUSHING Q15 OF PNSS TIGHT RESTRICTEDPAATIENT WITH ANTI PLATELET RESTRICTED DOSE

RESTRICTED HEPARIN HEPARIN FACTS HEPARIN BINDS TO THROMBIN III HEPARIN HALF LIFE IS HOUR (30 MINUTES) LMW HEPARIN SAME WITH HEPARIN ANTICOAGULANT (PORE SIZE); MONITORING EFFECTIVENESS

57 | P a g e INTRADIALYTIC COMPLICATIONS COMMON COMPLICATION IS HYPOTENSION; HAPPENDS ABOUT 25% UF > CO; DECREASE CAPILLARY REFILL RATE (CRR) TREATMENT FOR HYPOTENSION STOP / REDUCE UF MODIFIED TRENDELENBURG POSITION INFUSE SALINE

PREVENTION REDUCE INTRADIALYTIC WEIGHT GAIN (DIETARY AND FLUID COMPLIANCE) DECREASE SODIUM INTAKE UNCOMMON COMPLICATIONS INCLUDES: HEMOLYSIS FEBRILE REACTION (RE-USE PROGRAM CAUSES INCREASE RISK) BLEEDING SEIZURES AIR EMBOLISM

DIALYSIS DYSEQUILIBRIUM SYNDROME TARGET IS ZERO TOLERANCE FOR HYPOTENSIVE EPISODES BLOOD PRESSURE IS EQUAL TO CARDIAC OUTPUT (CO) PERIPHERAL VASCULAR RATE (PVR); BP = CO PVR OTHER HEMODYNAMIC CHANGES VOLUME CHANGES CRAMPS (20% EVERY DIALYSIS) CONVULSION CARDIOVASCULAR PROBLEMS

FACTORS AFFECTING FLUID REMOVAL FLUID GAIN DIALYSIS TIME (Dt) CURRENT HYPERTENSIVES DIABETICS AGE SERUM ALBUMIN (NUTRITIONAL STATUS; DECREASE ALBUMIN) CARDIOVASCULAR DISORDER

58 | P a g e DIALYSIS ADEQUACY AND FLUID MODELING LOW WEIGHT GAIN FLUID EASY TO REMOVE HIGH WEIGHT GAIN - FLUID IS DIFFICULT TO REMOVE OTHER CAUSES: ARRYTHMIAS MI UNCOMMON OTHER CAUSES PERICARDIAL TAMPONADE AORTIC DISSECTION INTERNAL / EXTERNAL HEMORRHAGE SEPTICEMIA AIR EMBOLISM HEMOLYSIS PNEUMOTHORAX

CLINICAL PRACTICE STRATIGIES PATIENTS ACCUSTOMED TO FIXED DIALYSIS TIME INTRODUCTION OF EXTRA TIME FOR PATIENTS WITH HIGH FLUID GAINS NURSE IS RESPONSIBLE FOR ASSESSMENT OF PATIENTS FLUID STATUS PATIENT COUNSELING IS REQUIRED ON A REGULAR BASIS (SHOULD BE DONE EVERY TREATMENT)

TARGET WEIGHT GAIN SSHOULD BE <3%; MAXIMUM SHOULD BE 5% INFORMATION BOOKLET IS NECESSARY SALT REDUCTION IS ADVISED LECTURES ABOUT FLUID STATUS SHOULD BE PRESENTED BY A PATIENT CRAMPS MORE PRONOUNCED IN PATIENTS WHO REQUIRES HIGH ULTRAFILTRATION RATES COULD BE DUE TO HYPOTENSION AND VOLUME DEFICITS POSSIBLY DIALYZED BELOW THEIR WEIGHT POOR PERIPHERAL CIRCULATION COMPENSATORY MECHANISM TREATMENT SAME WITH HYPOTENSION DORSIFLEX THE FOOT

59 | P a g e CONVULSION UNRESOLVED HYPOTENSION OR SEVERE HYPOTENSION PROTECT THE PATIENT MAINTAIN THE AIRWAY INVESTIGATE THE CAUSE REHYDRATION (IV 200 m/s) RELAX MUSCLES (IV DIAZEPAM BUT MAY LOWER BLOOD PRESSURE FURTHER DUE TO MUSCULAR PROBLEMS) WARM COMPRESS INCREASE INTRAVASCULAR VOLUME; ADMINISTER SALINE, MANNITOL OR GLUCOSE ADMINISTER VITAMIN C AND VITAMIN E L-CARNITINE VARIED 5 100 mg / kg QUININE IS GIVEN TO REDUCE MUSCLE CONTRACTILITY

CHEST PAIN ISOLATE PATIENT FROM RISK DISCONNECT PATIENT TO THE MACHINE RECIRCULATE THE BLOOD WHILE MANAGING THE PATIENT ASSESS CAUSE OF CHEST PAIN OXYGEN THERAPY AND CARDIAC ASSESSMENT HYDRATION RELATED ARRYTHMIAS

MANAGE ACCORDINGLY CARDIAC ARREST DO CPR PLACE THE PATIENT ON THE FLOOR PLACE LINE, PNSS AT KVO

MACHINE TECHNICAL PROBLEMS AFFECTING PATIENTS AIR EMBOLISM COULD BE ARTERIAL BETWEEN PATIENT AND BLOOD PUMP DUE TO INCREASE NEGATIVE PRESSURE AND LEAKS IN THE CIRCUIT IN THIS SEGMENT

60 | P a g e CONCLUDING USING CLOSED METHOD (NOT THROUGH AIR DETECTOR) AIR IN THR DIALYSATE FLUID RESET OF AIR DETECTOR ALARM TREATMENT PREVENT FURTHER ENTRY FLAT, SUPINE POSITION MAY BE BETTER OVER TRADITIONALLY ADVOCATED LEFT LATERAL POSITION (DURANS POSITION) OXYGEN THERAPY AT 100% HYPERBARIC OXYGEN

PREVENTION PREVENT THE USAGE OF DEFECTIVE MACHINE MANAGEMENT CLAMP THE VENOUS LINE PLACE THE CLIENT IN A SUPINE POSITION OXYGEN THERAPY RESTARTING THE TREATMENT DEPENDS ON THE PATIENTS STATUS

DIALYZER REACTION TYPE A REACTION ANAPHYLACTIOD REACTION HAS A MORE RAPID ONSET IS RARE CASE: 7.0 / 1000 PATIENTS PER YEAR SIGNS AND SYMPTOMS o MAJOR SIGNS AND SYMPTOMS ONSET IS WITHIN 20 MINUTES DYSPNEA BURNING / HEAT SENSATION ON THE ACCESS SITE AGIOEDEMA o MINOR SIGNS AND SYMPTOMS URTICARIA RHINORRHEA ABDOMINAL CRAMPING ITCHING REPRODUCIBLE DURING SUBSEQUENT DIALYZER

61 | P a g e o DIAGNOSIS ITS HAS TO HAVE THREE (3) MAJOR SIGNS AND SYMPTOMS OR TWO (2) MAJOR AND ONE (1) MINOR CAUSE USE OF ETO STERILIZATION PAN MEMBRANES ACE INHIBITORS HIGH IgE

TYPE B REACTION CHEST AND BACK PAIN ONSET: 20 40 MINUTES DISAPPEARS OR LESSENS DRAMATICALLY DURING SUBSEQUENT HOURS OF DIALYSIS TREATMENT o SYMPTOMATIC AND SUPPORTIVE o ANTI HISTAMINE IS ADMINISTERED o EPINEPHRINE IS GIVEN PREVENTION o AVOID COMBINATION OF PAN MEMBRANE AND ACE INHIBITORS o USE ARB TO DECREASE THE RISK o AVOID CHEMICALS TREATMENT o STOP BLOOD PUMP AND CLAMP o OXYGEN THERAPY, BLOOD TRANSFUSION IF NEEDED o RESUME HEMODIALYSIS ONCE THE PATIENT IS STABILIZED

NOTE: EFFLUENT DIALYSATE IS THE COLOR BLUE TUBE HEMOLYSIS (REFER TO PAGE 88 OF THE TRAINING MANUAL) o CAUSES HYPOTENSION o STOP BLOOD PUMP o REMOVE THE BLOOD; DO NOT RETURN o ADMINISTER OXYGEN o BLOOD TRANSFUSION (BT) IF NEEDED; X MATCHED o START TREATMENT ONCE THE PATIENT IS STABLE DUE TO INCREASE K+ IN THE BODY

62 | P a g e BLOOD LEAK BLOOK LEAK PLEASE REFER TO PAGE 88 OF THE TRAINING MANUAL MANAGEMENT MINOR BLOOD LEAK o MUTE THE ALARM o TEST THE DIALYSATE o STOP THE DIALYSATE FLOW o TURN THE UF OFF o BYPASS THE MODE o RETURN THE BLOOD o DOCUMENT AND INVESTIGATE o DISINFECT THE MACHINE AFTER (FULL DISINFECTION) o HEAT CHEMICAL MAJOR BLOOK LEAK

DO ALL OF THE PROCEDURE IN MINOR BLOOD LEAK BUT DO

NOT RETURN THE BLOOD

FEBRILE REACTION INCREASE OF TEMPERATURE DURING HEMODIALYSIS INCREASE OF O.5 C; AXILLARY TEMPERATURE IS AT 37.5C MAJOR CAUSE PREXISTING INFECTIONS VASCULAR ACCESS INFECTIONS URINARY PROBLEMS RESPIRATORY TRACT INFECTION IF IT HAPPENDS WITHIN 20 MINUTES o DIALYZER REACTION o WATER TREATMENT IF IT HAPPENDS OVER 40 MINUTES o COULD BE AN UNDERLYING INFECTION / COMPLICATIONS o SITE INFECTION HAPPENDS ABOUT 70% OF ALL DIALYSIS PATIENTS PREVENTION LOOK FOR THE CAUSES OBTAIN BLOOD CULTURE AADMINISTER ANTI PYREGENICS CLUSTER OF SIMILAR CAUSES TO INVESTIGATE WATER REPROCESSING

63 | P a g e REDUCE THE USE OF CATHETER HEMODIALYSIS REDUCE SUSCEPTABILITY THROUGH: ADEQUATE HEMODIALYSIS PREVENT MALNUTRITION OPTIMIZE HEMOGLOBIN CONCENTRATION USE BIOCOMPATIBLE MEMBRANES

HEMORRHAGE INCREASE THE RISK DUE TO: PLATELET DYSFUNCTION HEPARIN INDUCED THROMBOCYTOPENIA USE OF ANTI COAGULATION DURING HEMODIALYSIS CO MORBID CONDITIONS: UNCONTROLLED HYPERTENSION LIVER DISEASE SEPSIS CERTAIN MEDICATION TECHNICAL PROBLEMS (LEUR LOCK CONNECTIONS) INCREASE RISK IF: NEEDLE IS UNSECURED ACCESS SITE SHOULD BE EXPOSED

COMPLICATION OF CLEARANCE DIALYSIS DISEQUILIBRIUM SYNDROME IN RARE CASES PATIENT WITH PRE EXISTING CNS LESION OR CONDITIONS CHARACTERIZED BY CEREBRAL EDEMA WITH INCREASE PRE DIALYSIS BUN SEVERE METABOLIC ACIDOSIS TREATMENT MOSTLY LIMITED COULD CAUSE SEIZURES (GIVE GLUCOSE, DIAZEPAM, PHENYTOIN) PREVENTION IDENTIFY INCREASE RISK PATIENTS REDUCE RATE OF CLEARANCE o DECREASE Qb (BLODD FLOW) o CO CURRENT FLOW OF DIALYSTAE AND BLOOD DIALYZER

64 | P a g e o o o PRURITUS 25% OF CASES DUE TO DRY SKIN ASSOCIATED PATHOGENS TREATMENTS SKIN EMOLLIENTS, PHOTOTHERAPY (UVB) OTHERS o RENAL TRANSPLANT o SAUNA o PARATHYROIDECTOMY o ACCUPUNCTURE AVOID IODINE, ETHYLENE OXIDE USE BIOCOMPATIBLE MATERIAL (POLYSULFONE) DECREASE DIALYSIS EFFICACY AND LIMIT UREA REDUCTION GLUCOSE IN DIALYSATE PROPHYLACTIC ADMINISTRATION (GLUCOSE AND FRUCTOSE) DECREASE DIALYSIS EFFICACY AND LIMIT UREA REDUCTION GLUCOSE IN DIALYSATE PROPHYLACTIC ADMINISTRATION IV MANNITOL 20% AT 50 ml / hr

NUTRITIONAL NEEDS OF ESRD CKD STAGE 1 AND 2 DECREASE PROTEIN IN THE DIET CKD STAGE 3, 4 AND 5 INCREASE THE PROTEIN NEEDS OF THE PATIENT FOR ENERGY FOR OLDER PATIENTS (60 YEARS OLD AND ABOVE) THEY SHOULD CONSUME 30 35 kcal / kg THIS IS DUE TO THERE SEDENTARY LIFESTYLE PROTEIN TO BE CONSUME SHOULD BE 1.2 g / kg OF HIGH BIOLOGICAL VALUE LIKE LEAN MEAT CHICKEN EGG WHITE MEAT

65 | P a g e FISH HEDONISTIC SOCIAL EATING NEEDS TO BE ACCOMPANIED BY SOMEONE SO THAT THEY WILL ENJOY THEIR FOOD IN SUMMARY ENERGY REQUIREMENT OF A UREMIC DIALYSED PATIENT IS EQUIVALENT/SIMILAR TO THAT OF A HEALTHY INDIVIDUAL PROTEIN REQUIREMENT OF DIALYSIS PATIENT EXCEED THOSE OF HEALTHY SUBJECTS THE CONTROL OF HUNGER AND SATIETY IS A HIGHLY COMPLEX NEUROENDOCRINE SYSTEM EARLY RESEARCH INDICATES MULTIPLE DEFECTS IN THE HUNGER SATIETY CONTROL SYSTEM IN UREMIA ENERGY INTAKE PLEASE REFER TO PAGE 99 OF THE TRAINING MANUAL

NUTRITIONAL ASSESSMENT ENHANCES THE QUALITY OF DIALYSIS CARE SGA - SUBJECT GLOBAL ASSESSMENT (PHYSICAL ASSESSMENT; POST DIALYSIS) SHOULD BE DONE EVERY 6 MONTHS DETERMINES THE NUTRITIONAL STATUS PROGRESSIVE ASSESSMENT AND IS A VALID TOOL FOR NUTRITIONAL ASSESSMENT CORRELATES WITH A RELATIVE RISK OF DEATH ABOUT 25% BMI, WHR (WEIGHT HEIGHT RATIO) FAT STORES (EYE PADS, TRICEPS AND BICEPS) MUSCLE MASS (TEMPLE, CLAVICLE, SCAPULA, AC JOINT, QUADRICEPS, KNEE) RATINGS A WELL NOURISHED B MILD / MODERATE UNDERNUTRITION C SEVERE UNDERNUTRITION

66 | P a g e

PATIENTS RECORD OF FOOD INTAKE, BODY WEIGHT, CHANGE IN GI SYSTEM AND FUNCTIONAL LOSS HISTORY TAKING CHANGES IN APPETITE OVER TIME AND FOOD HISTORY GASTROINTESTINAL SYMPTOMS ADEQUACY OF DIALYSIS ACTIVITY LEVEL

CLINICIANS EXAMINATION FOR EVIDENCE OF MUSCLE LOSS, FAT PRESENCE AND TISSUE TRAUMA BODY COMPOSITION ANALYSIS THIS IS TO ASSESS THE TISSUE ANTHROPOMETRY WEIGHING SCALES FOR WEIGHT STANDIAMETER FOR THR HEIGHT SKIN CALIPERS MID ARM CIRCUMFERENCE

DEFINITION OF FAT TYPES CENTRAL OBESITY GENERAL OBESITY THIS INDIVIDUALS ARE PRONE TO DIABETES

BCM PLEASE REFER TO PAGE 67 OF THE TRAINING MANUAL NUTRITIONAL ASSESSMENT APPROACH PLEASE REFER TO PAGE 98 OF THE TRAINING MANUAL

67 | P a g e NEED FOR ACCURATE BODY COMPOSITION INFORMATION IN MANAGEMENT OF CKD / DIALYSIS PATIENTS

VOLUME STATUS
HYPERTENSION ARTERIOSCLEROSIS VENTRICULAR HYPERTROPHY CARDIAC FAILURE VOLUME DISTRIBUTION OF TOXINS DIALYSIS INTOLERANCE

NUTRITIONAL STATUS
ADEQUACY OF INTAKE (CALORIE / ENERGY AND PROTEIN) LEAN BODY MASS FAT MASS (RELATIVE INTAKE AND RELATIVE INFLAMMATION)

FAILURE OF EFFECTIVE MANAGEMENT

INCREASE RISK OF MORTALITY AND DEATH

68 | P a g e OUTCOMES AND DIALYSIS

PATIENT FEEDBACK QoL

CLINICAL ASSESSMENT
(FLUID AND IW, UREMIC SYMPTOMS, NUTRITION, SGA)

CLINICAL PARAMETERS
(Kt / V, UREA, Kt)

OBJECTIVE DATA ANTHROPOMETRIC DATA HEIGHT WEIGHT IDEAL BODY WEIGHT TRICEPS SKIN FOLDS ARM MUSCLE CIRCUMFERENCE

69 | P a g e BIOCHEMICAL PARAMETERS PRE UREA ALBUMIN POTASSIUM PHOSPHATE

MONITORING MONITOR FOR NUTRITIONAL STATUS IDENTIFY OBSTACLES TO DIETARY COMPLIANCE PROVIDE RECOMMENDATION AND SUPPORT MODIFY MEAL PATTERN

PROTEIN 1.2 GRAMS / kg / DAY ANIMAL HAS HIGH QUALITY PROTEIN CONTENT >60% HIGH BIOLOGICAL PROTEIN EGGS, FISH, POULTRY, BEEF, PORK PLANTS HAVE LOW QUALITY PROTEIN CONTENT

CALORIES NORMAL CALORIC INTAKE FOR CKD PATIENTS 30 35 kcal / kg / DAY (KDOQI) >60 YEARS OF AGE SHOULD HAVE AN INTAKE OF 30 kcal / kg / DAY FOODS SOURCES OF CALORIE CARBOHYDRATES FATS PROTEIN

PHOSPHORUS FOODS FOODS TO AVOID NUTS AND SEEDS MILK AND DAIRY PRODUCTS SARDINES AND DRIED FISH ORGAN MEATS DRY BEANS AND PEAS WHOLEMEAL BREAD AND ALL BRAN CEREALS COLAS

70 | P a g e ALTERNATIVE FOODS BISCUIT, CAKES, SWEETS WITHOUT NUTS NON DAIRY CREAMER FOR COFFEE AND TEA 7 UP OR SPRITE WHITE RICE TAKE PHOSPHATE BINDERS

SODIUM RICH FOOD AVOID FOODS LIKE SALT MSG SOY SAUCE, OSYTER SAUCE AND FISH SAUCE SALTED OR CURED MEATS AND FISH CONVENIENCE FOODS

TIPS FOR CONTROLLING FLUID INTAKE MEASURE LIQUIDS AT THE BEGINNING OF EACH DAY USE SMALLER DRINKING CUPS OR GLASSES RINSE MOUTH WITH WATER, BUT DO NOT SWALLOW THE WATER KEEP MOUTH MOIST WITH CANDY OR LEMON SLICE

PROTEIN CALORIES PHOSPHORUS CALCIUM POTASSIUM SODIUM FLUID

NORMAL INTAKE PER DAY 1.2 gm / kg / day 30 35 kcal / kg / day <17 mg / kg (800 1200 mg / day) 1000 1800 mg / day 40 mg (50 - 80) / day 2000 3000 mg / day 1 L / day

71 | P a g e NUTRITION INTERVENTION LOSS OF APPETITE >2 PROTEIN INTAKE <1.2 gm / kg / day DIABETIC; NO IMPROVEMENT SGA <6; DECREASE IN BODY WEIGHT RECENT OR FREQUENT HOSPITALIZATION LEVELS LEVEL 1 - EDUCATION AND REVISED TARGET LEVEL 2 - NUTRITIONAL SUPPLEMENTS; ORAL NO IMPROVEMENT AFTER 2 WEEKS GO TO LEVEL 2 TO LEVEL 4 LEVEL 4 TUBE FEEDING

LEVEL 5 TPN; INTRADIALYSIS PARENTHERAL NUTRITION NOTE : A HUNGRY PATIENT IS A WELL DIALYZED PATIENT

REUSING THE COST OF REUSE COMMON CALCULATION DIRECT LABOUR PAYROLL CAPITAL EQUIPMENT DEPRECIATION WATER TREATMENTS CONSUMABLE AND REAGENNTS OVERHEADS AND MAINTENANCE CORRECT CALCULATION SAME EDUCATION AND TRAINING / CERTIFICATION / REVIEW QUALITY ASSURANCE (QA) DIALYZER TESTING LIABILITY INSURANCE MORBIDITY COSTS DATA HANDLING, MANAGEMENT, AND REPORTAGE REQUISITES RO TREATED WATER AND ULTRAFILTERED WATER RINSE WITH FORWARD AND REVERSE UF INTEGRITY TEST STERILANT DELIVERY SYSTEM

72 | P a g e

PERSONNEL DEDICATED PERSONNEL PROTECTION AND SAFETY TRAINING AND ASSESSMENT

PROCESS WATER TESTING (CFU AND LAL TEST) EQUIPEMENT MAINTENANCE AND TESTING DIALYZER HANDLING AND STORAGE DIALYZER LABELING STERILANT TESTING (IF IT SHOWS NEGATIVE - CHANGE) STERILIZATION VALIDATION RECORDS AND DOCUMENTATION ADVERSE EVENTS REPORTS

STEPS IN THE REPROCESSING USE PLEASE REFER TO PAGE 102 OF THE TRAINING MANUAL DIALYZER REUSE FLOW CHART PLEASE REFER TO PAGE 103 OF THE TRAINING MANUAL KUF ULTRAFILTRATION COEFFICIENT

STERILANT CAP THE PORTS SO THAT THE STERILANTS WILL NOT LEAK IF 7DAYS HAS PASSED AND THE DIALYZER DWELLS OVER THIS PERIOD WE NEED TO REPLACE THE DIALYZER THE STERILANT SHOULD DWELL FOR AT LEAST 11 HOURS AFTER 7 DAYS REPROCESSED DIALYZER IS TO BE FLUSHED WITH 300 ml OF NSS DRY PACK (NOT YET PROCESSED) WASH WITH 600 1000 ml NSS TO REMOVE THE ETO; ASSESS THE QUALITY OF THE DIALYZER

73 | P a g e CLEAN TEST DISINFECT SYSTEM

REVERSE OSMOSIS WATER (RO WATER)

RINSE

FAIL

PERFORMANCE TEST

FAIL

LEAK TEST

FAIL

GERMICIDE FILL

INSPECTION

REUSE DISINFECTANT DISCARD THE DIALYZER

74 | P a g e POTENTIAL RISK STAFF EXPOSURE TO NOXIOUS CHEMICALS EXPOSURE TO BLOOD / BLOOD PRODUCTS

PATIENTS SAME EXPOSURE TO BACTERIA CROSS INFECTION REPROCESSED DIALYZER STERILITY SAL (STERILIZATION ASSURANCE LEVEL) SHOULD BE NO GREATER THAN 1, 000, 000 (10 -6)

APPROPRIATE DEVICES DISINFECTANTS HYPOCHLORITE FORMALDEHYDE GLUTARALDEHYDE HEAT CITRATE PERACETATE HYDROGEN PEROXIDE (PHHP)

PERACETIC ACID (COMMONLY USED) TESTING FOR STERILITY DEVICE TESTING MICROBIAL CONTAMINATION PYROGEN TESTING

PATIENT TESTING (INFLAMMATORY MEDIATORS) REPROCESSING AND DIALYZER EFFECTIVENESS PERACETATE AND POLYSULFONE LOSS OF PORES AND REDUCTION OF AVERAGE PORE SIZE DECREASE HYDRAULIC PERMIABILITY DECREASE IN SOLUTE CLEARANCE (K) BLEACH AND POLYSULFONE INCREASE IN PORE SIZE INCREASE IN HYDRAULIC PERMIABILITY REDUCE / LOST ENDOTOXIN BARRIER FUNCTION

75 | P a g e IN SUMMARY WHEN YOU REPROCESS YOU BECOME THE MANUFACTURER; SHOULD REQUIRE GOOD MANUFACTURING PRACTICE QUALITY ASSURANCE (QA) MONITORING SHOULD BE DONE MUST MAKE ECONIMIC AND CLINICAL SENSE PRACTITIONERS MUST BE EDUCATED, TRAINED, AND BE CERTIFIED COMPETENT RISK TO STAFF AND PATIENTS MUST BE MINIMIZED / ERADICATED

CANNULATION NORMAL VENOUS PRESSURE IS <300 mmHg INCREASE IN VENOUS PRESSURE COULD MEAN: RESISTANCE INFLOW THERE IS A KINK ON THE LINES BLOOD CLOT SMALL NEEDLE SIZE BUT THE Qb IS HIGH NORMAL ARTERIAL PRESSURE IS 0 - -200 mmHg DECREASE IN ATERIAL PRESSURE COULD MEAN: THERE IS A KINK ON THE LINES THROUGH AND THROUGH / WALLING OF THE NEEDLE SMALL NEEDLE SIZE BUT THE Qb IS HIGH ONE OF THE CLAMPS ARE CLAMPED ATERIAL CANNULA HAS A BUCK EYE AN INCREASE IN TMP (TRANS MEMBRANE PRESSURE) COULD MEAN THERE IS A PROBLEM WITH THE DIALYZER (PROTEIN FOULING) NORMAL TMP IS 0 -20 mmHg CHECK THE NUMBER OF USAGE FOR THE DIALYZER

76 | P a g e

STEPS IN CANNULATION GREET THE PATIENT WEIGH THE PATIENT WASH HANDS WITH THE PATIENT ASSESS FOR: FLUID STATUS ANEMIA STATUS NUTRITION BLEEDING DISORDER SITE FOR ANY INFECTION DON CLEAN GLOVES AND OTHER PPE LOOSEN THE DRESSING PREPARE THE MATERIALS REMOVE CLEAN GLOVES DO HANDWASHING DON SURGICAL GLOVES PLACE THE LINING SOAK GAUZE WITH BETADINE LET IT SIT FOR 3 -5 MINUTES ASPERATE 6 -8 CC OF SALINE AFTER 3 5 MINUTES REMOVE THE GAUZE AND SCRUB THE LIMBS OF THE CANNULA

NOTE: AN DECREASE IN CONDUCTIVITY ALARM MEANS: THERE IS DECREASE IN CONCENTRATES NO CONCENTRATES WRONG PRONGS IN THE CONCENTRATES

77 | P a g e