hemodialysis training course bahrain specialsit hospital june 2013
DESCRIPTION
Review in Hemodialysis basics kinetics for fluids and electrolytes.TRANSCRIPT
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Better Care for All Hemodialysis Patients
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Hemodialysis Training Course29th of June 2013
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Update information on hemodialysis for the renal division.
Review guidelines and patient care.
Hands on session with technical support.
Evaluation for all the renal division staffing.
Aim:
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Hemodialysis basics kinetics for fluid and
electrolytes
Jafar Al-Said, M.B.CHb. MD. FASN. FACPNephrology and Internal Medicine Consultant
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Body fluid compartment.
Fluid transportation.
Definitions and terms.
Hemodialysis.
Hemofiltration.
Hemodiafiltration.
Membrane characters.
Types of Dialysis.
Indications of Dialysis.
Dialysis complications.
Scheme
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Male 0.6 of the total body wt.
Female 0.55 of the total body wt.
2/3 in intracellular. 1/3 in the extracellular.
¼ is intravascular. ¾ is interstitial.
Body fluid Compartment
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HD
70 Kg male
28Lit.
10.5Lit
3.5Lit
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Diffusion.
Convection.
Adsorption.
Ultrafiltration.
Hemodialysis.
Hemofiltration.
Hemodialfiltration.
Hemoperfusion.
Slow Low efficiency Hemodialysis (SLED).
Continuous Renal replacement (CRRT).
Definitions
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Water&
Solutes
Basic Principle of DialysisSemi permeable
membrane
Dialysate
Blood
At zero time End of dialysis session
Equilibration
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Molecular wt. (Atomic Mass) Molecule g/mol Na 22.9 Mg 24.3 Cl 35.4 K 39 Ca 40 HCO3 61 Urea 0.06kDa 60 PO4 94.7 Cr 113.1 Vit. B12 1355 B2 Microglubulin. 11,8 kDa 11,800 Albumin 66 kDa 66,000
500D-60KD
SMALL<500D
Large>500KD
Middle
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The Kidney
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HD filter
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Membrane Pores
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Principle: Solute transfer across semipermeable membranes along
concentration gradients (diffusion) Counter current flow for optimized efficacy
Selectivity: Low (dialysate composition)
Efficacy: High for small molecular weight substances (urea, creatinine,
electrolytes, buffer...) Low for higher molecular weight substances (small proteins,
mediators, etc.)
Hemodialysis
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Hemodialysis Diffusion
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Principle: - Solute transfer across semipermeable membranes by
pressure induced water flow (convection, "solute drag")
- Volume substitution (pre or post filter) Selectivity: - Low Efficacy: - Improved for higher molecular weight
solutes (small proteins, mediators, etc.) - Reduced for small molecular weight
substances (urea, creatinine, electrolytes, buffer base)
Hemofiltration
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Water flux across the membrane.
Pore size and pore size distribution.
Molecular size (molecular mass).
Molecular shape and configuration.
Charges (solutes and membranes).
Convective Transport Across Membranes: Determinants
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Hemofiltration
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Hemodialfiltration
Post-dilution
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Hemodialysis Circuit
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Material. Pore size. Surface area. Thickness of the membrane. Sterilization methods. Urea Clearance. Creatinine Clearance. B2 Microglobulin clearance. Ultrafiltration Coefficient.
Filter characteristics
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Efficiency:Rate of removal (diffusion) of small molecules.
As Urea
Flux:Rate of removal (convection) middle molecule.
B2microglob.
Ultrafiltration Coefficient (removal of water).
Mass Area Transfer KoA.
Filter membrane specifications
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Flux
Dialyzers Urea KoA (ml/min)
Urea Clearance ml/min
UF Coeff.ml/min/mmHg
Beta2 Micro.ml/min
Low Conventional
<450 <150 <12 <10
Low High efficiency
>600 >200 variable Variable
High
High flux variable variable >12 >20
High
Hemofilters variable variable >12 >20
Performance of different Dialyzers and Hemofilters
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IONs Concentration meq/l
Na+ 132-145
K+ 0 – 4
Cl- 103 – 110
HCO3- 0 – 40
Acetate 2 -37
Ca+ 0 -3.5
Mg+ 0.5 – 1
Glucose 0 -200mg/dl
Dialysate fluid composition
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1. Provide high quality of life.
2. Reduce Complication. BP, Sugar, bleeding, ..etc.
3. Solute Clearance. KT/V.
4. Solvent Clearance. Dry wt.
Dialysis Outcome and Adequacy
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Clinical: Pulmonary edema/
Desaturation. Pericardial rub. GI symptoms. Altered Mental status. Anasarca. Bleeding tendency. Anuria/ Oliguria. Infection/sepsis.
Indication of Hemodialysis
Biochemical:
• Hyperkalemia.• Metabolic Acidosis.• Intoxication:
ASA, Alcohol, Lithium.• Inducing Hypothermia.
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Volume and Fluid equilibration. Electrolytes normalization. Correction of Acidosis. Removal of endogenous toxins. Better HTN control. Reduce uremic symptoms: GI, Neurologic. Ca X PO4. Improved Nutrition. Immunity. Reduced bleeding.
Dialysis Benefits
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Hypotension. Infection. Bleeding. Arrhythmia. Dialysis Disequilibrium syndrome. Anaphylaxis. Air Embolism. Contamination from water Aluminium,
Chlorien. Asthenia, weakness, Malnutrition.
Dialysis Complications
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Duration.QB.QD.Anticoagulation.Ultrafiltration volume.Dialysate Temp.Certain fluid replacements.Na modeling. Medications.Labs.
Basic Dialysis orders
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Better Care for All Hemodialysis Patients