PRESENTATION ON DIALYSIS

1. PRESENTATION ON DIALYSIS .

2. Patient with end stage of renal failure depend upon maintenance dialysis in order to survive. • DIALYSIS is the artificial process of getting rid of waste (diffusion) & unwanted water (ultra filtration) from the blood. Dialysis is an artificial way of doing the work of the kidneys, but it cannot replace the natural efficiency of the kidneys. If you are on dialysis you need to carefully regulate your diet.

3. INDICATIONS TO USE DIALYSIS ACUTE INDICATIONS • Acidemia from metabolic acidosis • Electrolyte abnormality • Intoxication • Overload of fluid • Uremia complications CHRONIC INDICATIONS • Symptomatic renal failure • Low glomerular filtration rate • Difficulty in medically controlling fluid overload

4. DIALYSIS HELPS, BUT IS NOT EFFICIENT AS THE KIDNEYS • Patients on dialysis need to be careful, about what & how much they eat & drink. • A significant no. of people on dialysis can work & lead normal lives. • Women on dialysis will probably not be able to get pregnant . • If a woman has a successful kidney transplant, her fertility should return to normal. • Dialysis has some effect on male fertility, but much less than on female fertility.

5. WHY IS DIALYSIS NECESSARY? • Approximately 1.5 liters of blood are filtered by a healthy person's kidneys each day. • We could not live if waste products were not removed from our kidneys. • People whose kidneys either do not work properly or not at all experience a buildup of waste in their blood. • Without dialysis the amount of waste products in the blood would increase and eventually reach levels that would cause comaand death.

6. PRINCIPLE OF DIALYSIS Dialysis works on the principles of the diffusion of solutes and ultra filtration of fluid across a semi-permeable membrane. Diffusion describes a property of substances in water. Substances in water tend to move from an area of high concentration to an area of low concentration.

7. works on the principles of the diffusion of solutes and ultra filtration of fluid across a semi-permeable membrane. • Blood flows by one side of a semi-permeable membrane, and a dialysate, or special dialysis fluid, flows by the opposite side. • A semi permeable membrane is a thin layer of material that contains various sized holes, or pores.

8. Plastic tubing attached to the needles connects the patient to the artificial kidney. • Artificial kidney contains, two compartments, one for the patient’s blood and one for a cleaning solution called- dialysate. A thin porous membrane separates these compartments. • Blood cells, proteins and other important substances in the blood remain in the compartment. • Smaller waste products- urea, creatinine and excess water- are washed away.

9. TYPES OF DALYSIS

10. HEMODIALYSIS • Removes waste & water by circulating blood outside the body, through an external filter- dialyzer. • Blood and dialysate are brought into the dialyser, which has an artificial membrane made of cellulose and other meterial. • The blood flows in one direction and the dialysate flows in the opposite.

11. In the latter type blood flows through microscopic lumina in bundle of thousand of hollow fibred, while dialysate circulate around the fibre. • The flow of the blood needed for adequate dialysis is high- usually 200-300 ml/ min and dialysate flows at 500 ml/min.

13. WORKING-: • Hemodialysis requires permanent access to the bloodstream through a fistula created by surgery to connect an artery and a vein. • Fistulas are often made near the wrist. • If the patient's blood vessels are fragile, an artificial vessel called a graft may be surgically implanted. • The dialysis fluid electrolyte content is similar to that of normal plasma. • Waste products and electrolites move by diffusion, ultrafiltration , and osmosis from the blood into the dialysate and are removed

14. The dialyzer is composed of thousands of tiny synthetic hollow fibers. • The fiber wall acts as the semipermeable membrane. • Blood flows through the fibers, dialysis solution flows around the outside of the fibers, and water and wastes move between these two solutions. • The cleansed blood is then returned via the circuit back to the body. • HemodialysisTreatrnent is usually for 3 to 5 hours, three times per week.

15. Before the blood process into the dialyser, the anticoagulant heparin is added to prevent cloating. • Inter-dialyticparenteral nutrition is a means of providing calories and protein (Dietary protein needs are about 1.2 g/kg, to make up for some losses through the dialysate)

16. 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 partially permeable membrane.

17. WORKING-: • Makes use of the semipermeable membrane of the peritoneum. • A catheter is surgically implanted in the abdomen and into the peritoneal cavity. • Dialysate containing a high-dextrose concentration instilled into the peritoneum, where diffusion carries waste products from the blood through the peritoneal membrane and into the dialysate; water moves by osmosis. • This fluid is then withdrawn and discarded, and new solution is added. Several types of peritoneal dialysis exist. • Each time the dialysate fills and empties from the abdomen is called one exchange.

18. Is less efficient method of removing waste product from the blood. • Treatment usually last longer than hemodialysis, about 10-12 hrs/day, 3 times a week. • Patients have higher needs of protein (about 1.2- 1.5g/kg body weight).

19. CONTINUOUS AMBULATOR PERITONEAL DIALYSIS • Is similar to peritoneal dialysis, except that the dialysate is left in the peritoneum and exchanged manually so that no machine is required. • Exchange of dialysate fluid are done 4-5 times daily making it a 24 hour treatment. • Protein losses are more than regular peritoneal dialysis. • ADVANTAGES-: • Avoidance of large fluctuation in blood chemical. • Patient can achieve a normal life style. • COMPLICATIONS-:

20. Peritonitis • Hypertension require additional fluid and sodium replacement. • Weight gain.

21. CONTINUOUS CYCLIC PERITONEAL DIALYSIS • A machine does the dialysis fluid exchanges. • It is generally done during the night while the patient sleeps. This needs to be done every night. Each session lasts from ten to twelve hours. • After spending the night attached to the machine, the majority of people keep fluid inside their abdomen during the day. • A study found that a significant number of patients prefer "dialysis while you sleep" treatment. • Another study found that nocturnal dialysis improves heart disease in patients with end-stage kidney failure.

22. Patients who choose PD have higher protein needs (about 1.2 to 1.5 g of protein per kilogram) because of greater protein losses. • Most people on PD do not have to limit potassium in their diet. Many need to add high-potassium foods to keep blood levels from getting too low; a typical intake is 3 to 4 g/day. • Advantages of this form of treatment are avoidance of large fluctuations in blood chemistry, longer residual renal function, and the ability of the patient to achieve a more normal lifestyle.

23. HEMOFILTRATION • The blood is pumped through a dialyzer or "hemofilter" as in dialysis, but no dialysate is used. • A pressure gradient is applied; as a result, water moves across the very permeable membrane rapidly, "dragging" along with it many dissolved substances, importantly ones with large molecular weights, which are cleared less well by hemodialysis. • Salts and water lost from the blood during this process are replaced with a "substitution fluid" that is infused into the extracorporeal circuit during the treatment. • Hemodiafiltration is a term used to describe several methods of combining hemodialysis and hemofiltration in one process.

24. HEMODIFILTRATION • Hemodialfiltration is a combination of hemodialysis and hemofiltration. In theory, this technique offers the advantages of both hemodialysis and hemofiltration.

25. INTESTINAL DIALYSIS • In intestinal dialysis, the diet is supplemented with soluble fibres such as acacia fibre, which is digested by bacteria in the colon. • This bacterial growth increases the amount of nitrogen that is eliminated in fecal waste. • An alternative approach utilizes the ingestion of 1 to 1.5 liters of non-absorbable solutions of polyethylene glycol or mannitol every fourth hour.

26. NUTRITION MANAGEMENT

27. NUTRITIONAL REQUIREMENT FOR ADULTS WITH RENAL DISEASE BASED ON THERAPY

29. Medical Nutrition Therapy • To prevent deficiency and maintain good nutrition status through adequate protein, energy, vitamin, and mineral intake • To control edema and electrolyte imbalance by controlling sodium, potassium, and fluid intake • To prevent or retard the development of renal osteodystrophy by controlling calcium, phosphorus, and vitamin D intake • To enable the patient to eat a palatable, attractive diet that fits his or her lifestyle as much as possible

30. DIETARY MANAGEMENT • FLUID AND Na BALANCE-: • Fluid should be continued at a normal level. • Dialysis patient with hypertension and edema may need to restrict intakes of Na and fluid. • Some patients with fluid retention have to watch their fluid intake carefully however. And if you are not producing urine, you have to reduce your fluid intake. • Haemodialysis patients often have greater restrictions on fluid intake than peritoneal dialysis patients.

31. If on hemodialysis your weight increases by around 0.5 kg per day between treatments - if it increases by more than this then you are suffering from fluid retention. • POTASSIUM-: • High intakes are not tolerated with less frequent dialysis. • The daily intake of potassium is 75-100mEq (3-4g). • This is usually reduced in ESRD to 40-65mEq (1.5-2.5g)/day and is reduced for the anuric patient on dialysis to 51mEq (2g/day). • PROTEIN-: • Dialysis is a drain on body protein, and the daily intake should be increased to compensate for this.

32. Protein losses of 20-30 g can occur during a 24 hr peritoneal dialysis. • A daily intake of 1.2-1.5 g/kg body weight is recommended. • ENERGY-: • Energy intake must be adequate to spare protein for -: • tissue protein synthesis • To prevent its metabolism for energy. • Between 25-30 kcal/kg body weight should be provided. • FLOURIDE-: • High level of fluoride in the serum of uremic patient appear to aggravate the existing bone diseases. • It should be restricted.

33. PHOSPHATE AND CALCIUM • Phosphate and calcium affect the health of the bones. When a person has kidney failure, the calcium level in their body tends to be too low and the phosphate level too high. • Treatment for kidney patients aims to raise blood calcium levels and lower blood phosphate levels. These aims can be achieved by moderating the phosphate content of your diet, by adequate dialysis,

34. IRON-: • Several types of anemia occur with dialysis. • It is caused due to-: • Inability of kidney to produce erythropoietin • Increased destruction of RBC’s. • A synthetic form of EPO, recombinant human EPO (r Hu EPO) is used to treat anemia of ESRD. • VITAMINS-: • Increased need for water-soluble vitamins because of losses during dialysis. • Fat-soluble vitamins A. D. and K are not supplemented. • Vitamin E may be supplemented.

35. Vitamin C 6o mg(not too exceed200 mg daily) • Folic acid 1 mg • Thiamin 1.5 mg • Riboflavin 1.7 mg • Niacin 20 mg • Vitamin B6 10 mg • Vitamin B12 6 mcg • Pantothenic acid 10 mg • Biotin 0.3 mg • CARBOHYDRATES-: • Glucose intolerance with both hyperglycemia & hypoglycemia is frequently observed in patients with ESRD. • A delayed action of insulin occur. • Control the intake of carbohydrate in the diet.

36. If there are problems with hypoglycemia, the addition of dextrose to the dialysate usually aviates the problem.

37. No matter what your state of health, you can almost always improve your condition by simple measures such as not smoking, eating healthily, and exercising regularly. • Weight loss is a problem that causes particular concern in kidney failure. This is usually because patients are not eating enough protein and energy-providing food. Malnourished people lose weight and muscle mass. Malnutrition can develop with patients on either haemodialysis or peritoneal dialysis. Dietitians monitor renal patients for any signs of malnutrition. • Peritoneal dialysis is less likely to work for patients who have a fat or distended tummy.   • Overweight patients should refer to a dietitian for advice.

38. KINETIC MODELING A method for evaluating the efficacy of dialysis relies on measuring the removal of urea from the patient's blood over a given period of time. This method, often called KT/V (where K is the urea clearance of the dialyzer, T is the length of time of dialysis, and V is the patient's total body water volume),should ideally produce a result higher than 1.4 per dialysis, or 3.2 per week

39. Another method to determine effective dialysis treatment is the urea reduction ratio. which looks at the reduction in urea before and after dialysis.

40. RISKS & SIDE EFFECTS DURING DIALYSIS • Bleeding from the Access Point • As dialysis is an invasive technique, the area surrounding the access point can be damaged and bleeding can occur. • Hypotension • Dialysis patients are at risk of a sudden drop in blood pressure (hypotension).However this can be controlled by medication. • Infections • Dialysis patients are generally more susceptible to infection. The access point should be kept clean, and any sign of infection (redness, itching, or other problems) watched for. Peritonitis with its associated flu-like symptoms, is also a possibility. Hence the importance of cleanliness and good general hygiene.

41. Cramps, Nausea and Headaches • Diseases • There is a slight risk of contracting hepatitis B and hepatitis C due to the the exposure of blood during the treatment. Vacination against the B strain is generally recommended. • Electrolyte Imbalance • This will almost certainly be detected via the normal blood tests conducted on dialysis patients. There are a variety of vital electrolytes (ionic species) in the blood that control a number of bodily process and this is too general an area for discussion here.

42. Anemia • The red blood cell volume in dialysis patients (especially hemodialysis patients) is often lower then normal. This is due to reduced levels of the hormone erythropoietin, which is produced by the kidneys and regulates red blood cell production.

43. REFERENCES