ABC of Haemodialysis

Dr Gensy M W Tong
Director of Renal Center
Hong Kong Baptist Hospital
09 Sept, 2021

Basic Introduction to Dialysis (c) Copyright 01/09/2021

Outline of “ABC of Haemodialysis”

1. Medical condition requiring haemodialysis

2. Pre-requisites for haemodialysis (Patient’s or
machine’s side)
3. Practical issue in haemodialysis
4. Complications of chronic haemodialysis
1. Cardiovascular disease
2. Vascular access
5. Goals of haemodialysis

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 Once kidneys fail, acutely or chronically,
dialysis is required temporarily or
permanently

Haemodialysis goal:
electrolyte balance
Peritoneal
(HD) water balance
remove toxicity dialysis (PD)
Medical condition requiring haemodialysis
can be achieved within 2-4hrs for water, electrolytes balance and removal of toxicity so patient condition can
be stabilized in short period of time. HD very good for acute renal failure patient

Chronic kidney disease (CKD) stage V Acute kidney injury

decreased urine output
1. Oliguric to anuric acute kidney injury
2. Fluid overloading condition unresponsive to
diuretics therapy
3. Hyperkalemia unresponsive to pharmacological
therapy
4. Severe metabolic acidosis unresponsive to
pharmacological therapy

130 90 60 30 15 0
*Glomerular Filtration Rate, mL/min/1.73m2

for CKD patient whether to choose PD and HD depends on

renal status
social factor
family factor
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Haemodialysis

Haemodialysis is performed by a
specialised machine which
removes some of metabolic
waste products and excessive
water from the blood, part of
the job performed by normal
kidneys.
Haemodialysis machine could
not replace kidneys.
eg function of kidney:
for RBC reproduction
BP control
ca and other hormones control and release

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Pre-requisite for HD
(on patient’s side)
Vascular access and pumping heart
Pre-requisites for haemodialysis

Simplified diagram of haemodialysis Pre-requisites

1.Vascular access (central
catheter / fistula or graft)
2.Pumping heart
3.Haemodialysis machine +
dialyzer + dialysate
(water treatment by
reverse osmosis)
if patient has poor heart, the BP cannot be controlled and circulation cannot reach the hand
hard to start HD and the blood pump can only drive 300ml blood around the hand and the
machine

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Types of Vascular Access for Haemodialysis
time needed after surgery for wound healing first before usage

Tunneled or non-tunneled
Arteriovenous fistula (AVF) Arteriovenous Graft (AVG) central venous catheter
6mm or above for the ideal AVF diameter
2 weeks to several 2-3 months
depends on the condition of the artery and
venous

wound heal and decrease swelling 0.5-1 hr after catheter insertion for
then can use very urgent case
likely within 2 weeks

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Haemodynamic condition determinates the types of
haemodialysis suitable for the patient

Pumping
heart
BP is the largest concern for decide which option for HD

Unstable BP
requiring
Normal BP
inotropic
support

Continuous
Slow flow
renal Nocturnal in-
intermittent In-center HD Home HD
replacement center HD
HD
therapy (CRRT)
in slow blood flow for material exchange
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Pre-requisite for HD
(on machine side)
Dialyzer and preparation of dialysate
Haemodialysis (HD) Machine

Hemodialysis machine could be regarded as an extension of the human body

Human Body HD Machine

Neurohormonal system controlling Haemodialysis regimen ordered

blood flow to Glomeruli by nephrologist

Veins & Arteries Bloodlines

Heart Blood Pump

Kidney Dialyser

Dialysate drained out from

Urine
dialyser

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Haemodialysis circuit
3-5hrs

haemodialysis machine is a safe machine traditional way of HD seperated by membeane

Clean the blood by removing waste product

Circulate dialysate through the

Circulate patient’s blood through the dialyzer
dialyzer
prevention of air embolism
Generate dialysate from water and
concentrates of electrolyte salts

Anticoagulant blood
opposite direction with blood
for ultimate dialysis effeciency
Provide a means for removing water from blood (ultrafiltration)

Patient Side HD Machine Side

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Composition of Dialysate

Ultra-pure water (endotoxin-free) is produced by the water treatment

system.

The acid concentrate has precise amounts of sodium chloride, potassium chloride, magnesium
chloride, calcium chloride, glucose, and acetic acid. The acetic acid is added to lower the
dialysate’s pH.

The bicarbonate concentrate has sodium bicarbonate (buffer)

► Cartridges dry sodium bicarbonate (bibag) is used in place of a liquid bicarbonate concentrate -
obviates the problem of bacterial growth in bicarbonate concentrate

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Final Dialysate Concentration
When the concentrates are diluted to achieve the pre-set concentration of electrolytes
high blood electrolytes then low preset concentration of electrolytes

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Water Treatment System (Reverse Osmosis)
Water treatment system for satellite centre or hospital
single RO for home HD or ICU setting

Dialysate Fluid

Bicarbonate
Acid and
Sodium bicarbonate
Potassium concentrate
Magnesium
Calcium
Glucose

Chloride
+
Treated
Water

Removes contaminants through various treatment Reverse Osmosis removes endotoxins, viruses, bacteria The average HD patient is exposed to about 360 liters of fluid
stages such as sediment, Chlorine and chloramines, and thus provides ultrapure water for haemodialysis. per week.
calcium, and magnesium.

single RO

Portable single water treatment system for home HD and ICU

Pre-treatment Reverse Osmosis

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Dialyzer: contains Bundle of Fibers
A dialyzer is made from a bundle of thin hollow fibres (synthetic) containing very small
pores that work like a sieve.

High Biocompatible
Membrane such as
Polysulfone
membrane

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Dialyzer: Fibers Dimensions and Pore Structure
Asymmetric : Pore Size facing blood compartment < Pore Size facing Dialysate Side ®

Porosity (outer)

Pore-size (inner)
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Dialyzer: Semipermeable Membrane
A semipermeable membrane is a type of thin flexible filter that allows only particles smaller
than certain size to pass through. The larger molecules, such as albumin and blood cells,
can’t pass it through.

Bacterium
Red blood cell
Albumin or Middle molecules, i.e.
protein-bound molecule

membrane
Semi-permeable
ß 2-Microglobulin (The
type of dialyze
determines the ease of
these particles passing
through
Electrolytes
water can pass
Urea, creatinine through the
membrane without
Blood Dialysate difficulty

Compartment Compartment
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Mechanism of On-line HDF in removing uremic toxins

Ultra-pure dialysate moves

quickly from blood Uremic toxins of
compartment to dialysate Convective force larger in size is
compartment and create a
greater convective force removed
Red blood cell
Albumin or
protein-bound molecule

membrane
Semi-permeable
Electrolytes
water can pass
Urea, creatinine through the
membrane without
Blood Dialysate difficulty

Compartment Compartment
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Schematic representation of different classes of uremic toxins with their molecular
size and relevant clinical effects
the larger the molecular size the more toxic the molecules are

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Schematic representation on the spectrum of molecules removed by
haemodialysis method.

On-line HDF (on-line help remove larger molecule

special membrane material tgt
with high speed try to filter large haemodiafiltration) anaemia and uremic neuropathy better
molecule to the dialysis HDx (extended haemodialysis)
compartment

Middle-flux
lowest removal rate
Low-flux
membrane in the machine can only allow small molecules passing through

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Permeability of Dialyzer Membranes (the types of uremic toxins
being removed)
The Permeability of dialyzer (old term is pore size of dialyzer) determines the size of molecules
passing across the membrane!!
On-line
Low-flux HD HDF/HDx
LF MF HF HDF

L
L L L L L L L
L L
L L L L
L L L
Urea H2O Urea H2O Urea H2O Urea H2O

Phosphate Phosphate Phosphate

albumin
ß 2-m ß 2-m

Uraemic toxins should

be larger in size
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The permeability of dialyser membrane determines the amount
of uremic toxin being removed

LF HF theranova HDF

Molecules Low-flux HD High-flux HD HDx On-line HDF

removed (expanded HD)

H20
++++ ++++ ++++ ++++
Urea/Creatinine
+++ ++++ ++++ ++++

Uremic toxins
+ ++ ++++ ++++ or
+++
albumin
- - + -
The membrane characteristics usually determines the types of uremic toxins passing through
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Practical issues of
haemodialysis
Indication for initiation of haemodialysis in renal failure
Chronic kidney disease stage V
1. Fluid overloading
2. Hyperkalemia
3. Uremia
4. Protein-wasting
5. Pericardial effusion
Acute kidney injury/failure
1. Oliguric to anuric condition
2. Fluid overloading condition
unresponsive to diuretics therapy
3. Hyperkalemia unresponsive to
pharmacological therapy
4. Severe metabolic acidosis
unresponsive to pharmacological
therapy
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Time of starting haemodialysis is NOT guided by serum creatinine !!

Creatinine is NOT a Drop in oral intake

reliable marker for kidney
function!! Loss of muscle
bulk
Drop in the serum
creatinine (falsely low
serum creatinine)

Serum creatinine drops because of

muscle wasting!!!
Kidney function is statically poor
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Application of different mode of haemodialysis

Application of HD in
renal failure

Chronic renal failure Acute renal

(CKD stage V) failure

Intermittent haemodialysis or
In-center HD or continuous renal replacement
Daily home HD
HDF therapy (CRRT)

Duration and frequency of

3-5 hours/shift 6-8 hours/shift haemodialysis varies according to
2-3 times/week the metabolic needs
3-6 times/week

6hrs already very ok

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Haemodialysis prescription
if the concentration too high should not given high flux causing to drastic change causing uremic encephalopathy

1. Type of Dialyzer (high flux or low flux or special dialyzer)

2. Anti-coagulation (Caution in bleeding tendency)
3. Duration of each session of haemodialysis
4. Blood flow rate (Qb) high BF rate would cause high workload to heart
5. Dialysate flow rate (more important in conventional HD)
6. Ultrafiltration rate (free water removal rate)
7. Dialysate composition ( [K], [Ca], [HCO3])
8. Dialysate Temperature
9. Mode of dialysis: HD or HDx or HDF (better clearance of PO4
and uremic toxins in the latter two)

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Complications of chronic
haemodialysis
Complication of chronic HD
• Cardiovascular disease (leads to mortality)
• Vascular access complication (often leads to
dialysis inadequacy)
• Dialysis inadequacy (leads to mortality) fatigue, nausea, loss in appetite
• Metabolic bone disease (secondary or tertiary
hyperparathyroidism) (increase co-morbidity) Ca, bone pain, #
phosphate level

• Drop in quality of life (strong psychosocial interference)

• Recurrence of renal anaemia if above complications persists

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Low life-span in dialysis patients compared to general
population

Age [years old] Expected remaining life- Expected remaining life-

span in dialysis patients span in General population
[yrs] [yrs]

40-44 8 30-40

60-64 4.5 17-22

US Renal Data system 2009 Annual Data Report.

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Dialysis patients has high risk of death

Annual mortality rate: 181 deaths/

1000 patient-years
US Renal Data system 2015 Annual Data Report

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Cardiovascular disease is the main cause of mortality in
dialysis patients

Causes of death among US dialysis patients 2011-2013

Sudden
cardiac death

Other cardiovascular
causes include
AMI/atherosclerotic
heart
disease/CHF/CVA/other
cardiac disease

US Renal Data system 2014 Annual Data Report

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Multiple risk factors for SCD in dialysis patients
Acute risk factor
Chronic risk 1.Cardiac stress due
factor to fluid changes
2.Cardiac stress due Chronic cardiac
1.Age/DM/uremia/
to electrolytes changes
inflammation changes
1.LVH
2. CKD-MBD
vascular and
vascular changes eg
stenosis/ calcification
2.CAD
cardiac disease of vessel
3.Low ejection
3. Cardiac fraction
sympathetic over-
activity

Cardiac
arrhythmia/
SCD

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Cardiovascular disease is the leading
cause of death in dialysis patients
over the past 30 years worldwide,
even with lots of new advances in
haemodialysis
Vascular access complication in haemodialysis
Tunneled catheter
1. Mal-positioning
2. Infection:
• Exit site infection
• Catheter-associated
bacteremia
3. Extra-luminal narrowing: fibrin
sheath
4. Intra-luminal narrowing:
thrombosis
5. Mechanical problem: break
in the catheter
6. Central venous stenosis (up
to 40% of haemodialysis
patient with a temporary
catheter)
AVF AVG
1. Primary failure in maturation 1. Acute thrombosis post-
2. Acute thrombosis post-creation creation
3. Infection: at puncture site
2. Infection: at puncture site
4. Stenosis: infection
• At the anastomotic site
3. High output congestive
• At the venous limb of the AVF
heart failure
5. Aneurysmal formation
4. Arterial steal syndrome
6. Arterial steal syndrome (most
common in the brachiocephalic
fistula)
7. High output cardiac failure
(most common in the
brachiocephalic fistula)
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Optimal position of Tunneled catheter for HD

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Problems in tunneled central catheter for HD

Kink in catheter Malpositioned catheter tip

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Problems in tunneled central catheter for HD
catheter related bloodstream infection cuff for securing the catheter inside under the skin

Exit site infection Exposed cuff

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Problems in tunneled catheter for HD
can try IV thrombolysis for intraluminal patency

Fibrin sheath extending outside the catheter Organised thrombus blocking the tip and
blocking all the side-holes of the catheter. side-holes of catheter

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Normal-looking AVF and AVG

Normal AVF Normal AVG

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Complication of vascular access – central venous
stenosis

Completely occluded subclavian vein leading to massive Right upper limb

swelling, the transposed basilic vein AVF is still patent

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Complication of vascular access – central venous stenosis

dilated superficial vein

Man with right subclavian vein stenosis. Collateral veins developed over his chest
wall and shoulder
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Steal syndrome

vascular assess complication

Patient with brachiocephalic AVF with Comparing the poorly-perfused

bluish discoloration of the distal hand to normally perfused hand
fingers. Combination of pre-existing with pink color
disease of DM and peripheral
vascular disease with vascular
calcification from chronic dialysis

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Goals in chronic haemodialysis

Immediate goals Intermediate goals long-term goals

• Removal of fluid • Hb 10-12.5 g/dl • Improvement in Quality of
overloading condition Life
• Near to normal • Adequacy of dialysis
• Correction of electrolytes
disturbance (K/HCO3/Ca) albumin (it could • Correction of renal anaemia
• Correction of anemia by reduce the mortality • Maintenance of nutrition
intra-dialytic blood in the first year) • Reduction of metabolic
transfusion bone disease
• Improvement in the • Reduction of cardiovascular
• Maintenance of Quality of Life disease
haemodynamic stability
• Preservation of functioning
vascular access
• Regain of self-care ability

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