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Hemodialysis: History and Current Perspective

Hemodialysis: History and Current Perspective. Nadeem A Siddiqui MD Dallas Nephrology Associates. Hemodialysis:History and Current Perspective. History of Dialysis Principles of Hemodialysis Practice of Hemodialysis Complications of Hemodialysis. Dialysis.

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Hemodialysis: History and Current Perspective

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  1. Hemodialysis: History and Current Perspective Nadeem A Siddiqui MD Dallas Nephrology Associates

  2. Hemodialysis:History and Current Perspective • History of Dialysis • Principles of Hemodialysis • Practice of Hemodialysis • Complications of Hemodialysis

  3. Dialysis Process by which the solute composition of a solution “A” is altered by exposing it to a second solution “B” through a semi-permeable membrane

  4. Necessary pre-requisites for Hemodialysis 1) Semi-permeable membrane 2) Anticoagulation 3) Knowing what to remove and how much of it

  5. 1773: Nurepuel isolates Urea by boiling urine in a pan

  6. 1828: Wohler synthesizes Urea and describes its molecular structure

  7. Thomas Graham (1805-1869)

  8. 1850 Glasgow, Scotland: Thomas Graham ‘s experiment to demonstrate diffusion across a semi-permeable membrane (Pergamon paper)

  9. Dialysis Membranes • 1750:Advances in the dovelopment of smokeless gunpowder led to the synthesis of a strong Nitrocellulose called “collodion”. It was a combination of Nitric acid and cotton • Addition of Camphor to this substance led to the synthesis of stable and strong “plastics” • 1957:Helmut Staldiger polymerized “Cellulose”

  10. 1913:The First Hemodialysis Experiment

  11. 1937: William Thalhimer successfully lowers BUN by performing Hemodialysis in anephric dogs

  12. 1926:The First Human Experiment • George Haas used a collodion tube arrangement to successfully dialyze human subjects • Allergic reactions to impurities in Hirudin led him to abandon his experiments

  13. 1937:Nils Alwall used the Alwall Kidney to perform the first ever hemodialysis treatment at the university of Lund, Sweden

  14. “ If I have seen farther it is because I have stood on the shoulders of Giants” Sir Isaac Newton

  15. Hemodialysis:History and Current Perspective • History of Dialysis • Principles of Hemodialysis

  16. Mechanisms of Solute transfer • Diffusion • Convection

  17. Diffusive Clearance • A result of random molecular motion • Influenced by concentration gradient of the solute and its Molecular weight as well as by the membrane permeability to the solute

  18. Convective Clearance • Water molecules passing through a SPM carry with them the solutes in their original concentration. This is called the “solvent drag phenomenon” • Water can be made to move across a SPM by the application of either a hydrostatic or an osmotic gradient

  19. Hemodialysis:History and Current Perspective • History of Dialysis • Principles of Hemodialysis • Practice of Hemodialysis

  20. The Hemodialysis circuit

  21. Dialysis Membranes

  22. Dialysis Solution

  23. Water Purification

  24. Water Treatment System for Hemodialysis

  25. Vascular Access

  26. Indications for initiating Hemodialysis • In patients with calculated creatinine clearance <20 ml/min/1.73 m2the onset of: *Uremic symptoms Nausea/emesis Altered sleep pattern *Altered mental status Coma Stupor Tremor Asterixis Clonus Seizures

  27. Indications for Hemodialysis *Pericarditis or Tamponade (urgent indication) *Uremic platelet dysfunction (urgent indication) *Refractory volume overload *Refractory hyperkalemia *Refractory Metabolic acidosis with anuria

  28. Indications for Hemodialysis • Steadily worsening renal function in a patient with measured 24 hour urinary creatinine clearance<15 ml/min when accompanied by worsening azotemia, poor nutritional status and refractory edema

  29. Equations for estimation of renal function • Cockcroft and Gault equation • MDRD Formula

  30. The Cockcroft-Gault equation • Cr Cl =(140-age) x wt/72(serum Cr) Decrease 15% for women Decrease 20% for paraplegia,40% for quadriplegia Increase 12% for AA males

  31. The MDRD formulaModification of diet in renal disease study JASN2000 • GFR (ml/min/1.73m2)= 186 x Pcr -1.154 x age -0.203 x1.212 if black X0.742 if female The MDRD equation calculates GFR, hence values are lower than those of creatinine clearance by Cockcroft Gault equation.

  32. Measurement of nutritional status • Physical Exam Skin fold thickness Mid arm muscle thickness • Protein catabolic rate <1* • Serum Albumin • Serum Cholesterol • Blood Lymphocyte count

  33. Monitoring Dialysis Adequacy

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