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Kidney Failure & Dialysis

UCONN BME 5040 - 1/30/2012 Frank Painter

Kidney Function
Bean shaped organ cell phone size 1/3lb million nephrons (glomerulus & tubules) ~million Glomerulus - filter - filtrate drains to tubule Urine formed in tubule - drains to renal pelvis Ureter flows to bladder Urethra drains bladder 1.5 to 2.0 l/day urine Maintains bodys balance-water, salts & acids Kidneys release hormones into body
EPO-RBCs, Remin-reg BP, Vit D-bone growth
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Kidney Anatomy

Kidney Function
Kidneys release hormones into body
Erythropoietin (EPO) stimulates production of red blood cells (RBC). Remin regulates blood pressure Vitamin D helps maintain normal bone growth

In kidney failure
Inadequate EPO leads to anemia Increased BP Bone disease and fractures
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Bone Disease and Fractures

Parathyroid hormone (PTH)
produced by parathyroid glands (in your neck). PTH tells your bones to release calcium into your bloodstream bloodstream. Too much PTH can become a problem in people with kidney disease.

Healthy kidneys convert a hormone called calcitriol to its active form of vitamin D. Calcitriol lets your body absorb calcium from food you eat. When your kidneys are not working well, they start to make less calcitriol - so even if you eat calcium, your body can't absorb it. PTH kicks in to make sure you always have enough calcium in your blood. Over time, this can weaken your bones.
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The Nephron
A tube; closed at one end, open at the other. Consists of: Bowman's capsule p . Located at the closed end,. Glomerulus. A capillary network within the Bowman's capsule. Blood leaving the glomerulus passes into a second capillary network (not shown in the figure) surrounding the Proximal convoluted tubule. Coiled and lined with cells carpeted with microvilli and stuffed with mitochondria. Loop of Henle. It makes a hairpin turn and returns to the Distal convoluted tubule, which is also highly coiled and surrounded by capillaries. Collecting tubule. It leads to the pelvis of the kidney from where urine flows to the bladder and, periodically, on to the outside world.
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Kidney Function
The nephron makes urine by filtering g the blood of its small molecules and ions and then reclaiming the needed amounts of useful materials. Surplus or waste molecules and ions are left to flow out as urine. In 24 hours the kidneys reclaim ~1,300 g of NaCl ~400 400 g NaHCO3 ~180 g glucose almost all of the 180 liters of water that entered the tubules.
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Kidney Failure
Failure to excrete urea & creatinine
tiredness, , weakness, , loss of appetite pp

Creatinine break down product of muscle As volume of H2O increases, tissues swell As phosphate incr, calcium decr bone loss Glomerulonephritis (inflammation of kidneys) Kidney stones, uncontrolled hypertension, inappropriate medication Chronic Kidney Failure (CKF) sudden or slow onset
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Renal Failure
Acute Renal Failure (ARF) deterioration that threatens body y function
Hypervolemia volume overload Hyperkalemia excess potassium

Chronic Renal Failure (CRF) longstanding, non-reversible (ESRD) requires End Stage Renal Disease (ESRD)dialysis & is candidate for renal transplant
Creatinine clearance (<900 umol/L) or Glomerular Filtration Rate (GFR) measures status
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Renal Failure
Causes of kidney failure
1. Diabetes abetes (40%) ( 0%) 2. High blood pressure (25%) 3. Genetics, autoimmune diseases, birth defects

Dialysis required at GFR of 15 ml/min or 20 ml/min for diabetes patients Canada Dialysis required at GFR of 10/ml/min or 15 patients US ml/min for diabetes p Must start dialysis at GFR of 6 ml/min Early dialysis prevents disease associated with severe uremia & minimizes long-term complications associated w/ renal failure
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Renal Failure Symptoms

Pale & sallow complexion F ti Fatigue (build-up of wastes or shortage of RBC) Shortness of breath (fluid build-up in the lungs) Body itch (waste build-up) Poor appetite (nausea & vomiting) g face & legs g ( (kidneys y cant remove fluid) ) Swelling Frequent urination at night or Passes little urine Ammonia Breath or taste (Waste build-up)
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Peritoneal Dialysis
Tube to peritoneal cavity (adjacent to intestines) P it Peritoneum i is th the membrane b Fluid left for a while to absorb waste products After 4-6 hours fluid is drained and replaced with fresh fluid Continuous ambulatory (home) Continuous cyclical (home) Intermittent (hospital) Nocturnal intermittent (sleeping)
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Hemodialysis Machine
Pumps blood and monitors flow for safety Cleans waste from blood Monitors blood pressure Monitors rate of fluid removal from patient Controls rate of waste and fluid removal by adjusting the dialysate concentration and pressure

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Fresenius

Cobe C3

Fresenius 2008K Baxter Gambro 19

Dialysis Machines
Gambro (first dialysis co Sweden) Cobe (US branch of Gambro) Fresenius B Braun Prismaflex Althin Nxstage Aksys
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Hemodialysis Machine
Dialyzer Cartridge semipermeable membrane that filters out wastes
A semipermeable membrane (or more accurately a selectively permeable membrane) is a membrane which will allow certain molecules or ions to pass through it by diffusion. The rate of passage depends on the pressure, concentration and temperature of the molecules (or "solutes") on either side, as well as the permeability of the membrane to each solute. Allows fluids and waste (uremic toxins) to pass through, but prevents exchange of blood components and microorganisms. Thousands of small fibers made of this semi-permeable membrane through which the blood is passed Dialysate is pumped around these fibers in the opposite direction
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Diffusion, Ultrafiltration and Osmosis

Diffusion exchange of things dissolved b a gradient by di t i in th the concentration t ti
Dialysate is adjusted to control flow

Ultrafiltration fluid crosses the membrane by difference in pressure across the membrane (convection) Osmosis movement of water out of the cells and interstitial spaces into the blood
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Scheme of semipermeable membrane: red = blood; blue = dialysing fluid; yellow = membrane
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Hemodialysis Machine
Dialysate
Mixture of Electrolytes, minerals, bicarbonate, purified water Absorbs the excess water, excess electrolytes, impurities and waste products from the blood Adjusted based on tolerance of treatment to increase the rate of fluid and waste removal.

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Hemodialysis Machine
Blood pump 400-500 ml/min Dialysate pumps Pressure sensors (blood and dialysate) Ultrasound sensors (air detectors) Tubing clamps Air traps Heparin pump

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Reuse of Dialyzer Cartridges

Labeled for the patient on which it was used d Cleaned Disinfected Tested prior to next use Reuse on the same patient only

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Vascular Access
Temporary large-bore venous catheters can support t acceptable t bl blood bl d fl flows Surgically joining an artery to a vein using blood vessels creating an arterio-venous fistula (AVF) more common Surgically joining an artery to a vein using a synthetic bridge creating an arteriovenous graft (AVG) prone to infection
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Vascular access

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Home Dialysis
The more the patient knows about the procedure d and d can d do on th their i own the th better they respond to treatment Doing home dialysis with more treatments, removing less fluid each time, improves response to treatment
Reduces typical post-dialysis symptoms like headaches, nausea, cramping, and feeling wash-out after treatments.
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Home Dialysis
Human factors engineering challenge S hi ti t d t Sophisticated technology h l used d at th home Requires easy-to-use machines Easier to set-up Easier to clean Fewer supplies Clear alarms Communication with dialysis ctr
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Peritoneal Dialysis
Peritoneum is the membrane After 4-6 hours fluid is drained and replaced with fresh fluid
Automated paritoneal dialysis (APD) Continuous ambulatory peritoneal dialysis (CAPD)

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Water Treatment Systems

Granular Activated Carbon to remove chlorine and chloramines Prefiltration for sediment removal Reverse Osmosis for total dissolved solids (TDS) and bacterial reduction. Deionization for TDS reduction Submicron filtration for particulate and bacteria removal Ultrafiltration for bacteria and endoto endotoxin in remo removal al Ultraviolet light for bacterial destruction Water Softening for calcium & magnesium removal Temperature Control
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Water Treatment Systems

Reverse Osmosis (RO) used to make city water ready for use in dialysis. City water is treated with chlorine and chloramines and filtered for particles. Dialysis water is purified by a combination of methods that include particle filtration, chlorine removal and RO. RO is a very efficient process for removing chemicals and even bacteria or viruses. RO-purified water is used to mix sodium bicarbonate solution, and by dialysis machines to make dialysate solution. RO water is also used by reuse machines to clean and reprocess dialyzer cartridges.

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Water Treatment Systems

The size of an RO system depends on the y stations in the facility. y number of dialysis A 20-station facility uses an RO system that produces eight gallons per minute and up to 4,500 gallons a day. A typical RO system supplies purified water to a storage tank. Water from the storage tank is pumped throughout the facility and kept constantly t tl moving i t to prevent t bacterial b t i l growth. th The Biomedical Tech helps monitor this entire process, ensuring that the RO water meets strict standards.
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Dialysis Water Issues

From ECRI & CDC During disasters arrange for clean water to be trucked to the facility.
Use appropriate type of water truck - cleaned and sanitized Get water from public water supply, not other source

Be cautious when buying water treatment products and supplies from third-party vendors
Vendors supply commercial operations and will not know the issues in dialysis water.
Carbon tanks, cleaning and disinfecting chemicals and replacement parts

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Dialysis Center
Staff
Renal Nurses Patient Care Technicians Reuse Technicians Nephrologists Biomedical Equipment Technicians

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Nephrology Nurses
RNs Assess patient condition teaching patients about their disease and its treatment oversee the dialysis treatment Review and administer medications evaluating patients' reaction to the dialysis treatment and medications reviewing the patients patients' status & report this to doctors
lab work, medications and activities

helping patients follow-up with their transplant center

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Patient Care Technicians

Patient Care Technicians
ensure e su e the t e co comfort ota and d sa safety ety o of t the e pat patients. e ts monitor the patients before, during and after dialysis treatment. Supervised by nephrology nurses Clean area Disinfect equipment Take vital signs Program P dialysis di l i machine hi Put patient on and off machine Most one-on-one time of any staff HS diploma & CPR certification
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BMETs
Maintain
Dialysis Dial sis machines
40-50 dialysis machines per BMET Quarterly PM

Reuse equipment Water treatment equipment Scales, Scales IV pumps, pumps centrifuges Train staff Address reported problems
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References
Medical Instrumentation: Application and Design, Third Edition, John G Webster, Editor, 1998, Wiley & Sons

http://www.kdf.org.sg/ http://www.nlm.nih.gov/medlineplus/ http://www.fda.gov http://www davita com/ http://www.davita.com/ http://vam.anest.ufl.edu/dialysis/ http://en.wikipedia.org/

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