Kidney Replacement Therapy: Hemodialysis Notes

ESKD Treatment Options

  • Hemodialysis

  • Kidney Transplant

  • Peritoneal Dialysis

CKD Management

  • Early referral: stage 3b/4; eGFR < 30mL/min.

  • Education on renal replacement therapy types:

    • Hemodialysis (vascular access).

    • Peritoneal Dialysis (peritoneal access).

    • Kidney Transplantation.

  • Living-related kidney transplant.

  • Cadaver transplant.

  • Transplant before dialysis initiation.

Hemodialysis

  • Removes waste and excessive fluid from blood via a semipermeable membrane.

Hemodialysis Treatment

  • Typically 3 times a week, 4 hours each.

  • Involves dialysis machine, hemodialyzer, dialysate, water treatment, and vascular access.

Hemodialysis - Key Components

  • Blood pump: Draws blood from the patient.

  • Dialyzer: Filters blood against dialysate fluid to remove unwanted components.

  • Dialysate: Contains acid and bicarbonate mixed with treated water.

Connection Types

  • Catheter: Tube inserted into a vein in the neck, chest, or leg.

  • Fistula: Surgically created connection of an artery to a vein.

Dialyzer Function

  • Waste products move from blood into the dialysate.

  • Filtered blood remains in hollow fibers and returns to the body.

Key Processes

  • Ultrafiltration: Achieved by lowering hydrostatic pressure in the dialysate compartment compared to the blood compartment, described by transmembrane pressure (TMP).

  • Diffusion: Movement of solute across the semi-permeable membrane down on the concentration gradient (urea, creatinine, potassium).

Dialysate

  • Solution with plasma-like values to create concentration gradients for diffusion.

  • Consists of Acid (A) and Bicarbonate (B) solution mixed with purified water.

Water Treatment

  • Reduces risk of infection.

  • Removes ions (calcium), chlorine, chloramines, bacteria, and endotoxins.

  • Involves sediment, charcoal/carbon, water softener, and reverse osmosis filters.

Vascular Access Options

  • AV Fistula: adjoining of an artery & vein

  • AV Graft

  • Catheter

Temporary Vascular Access

  • Internal Jugular Vein (IJC)

  • Subclavian Vein (SVC)

  • Femoral Vein (FVC) - for 2/52 only

Vascular Access Complications

  • During insertion: Pneumo/hemothorax, subclavian artery injury, brachial plexus injury.

  • During dialysis: Thrombus formation, sepsis, disconnection/leakage.

Permanent Vascular Access - Arteriovenous Fistula (AV fistula)

  • Adjoining of an artery & vein

  • Arterial blood causes veins to enlarge

  • Needs at least 6/52 for maturation

Arteriovenous Graft

  • Synthetic tube loop attached to an artery & vein.

  • Can be used sooner than a fistula (2/52 after insertion).

Immediate Fistula Care

  • Elevate arm.

  • Avoid pressure.

  • Keep warm.

Fistula Monitoring

  • Check for bleeding/swelling.

  • Inspect for infection.

  • Check for thrill/bruit.

Subsequent Care – Health Education

  • Prevent thrombosis.

  • Prevent infection.

  • Preserving Fistula Integrity

Nurse Responsibilities

  • Fistula assessment.

  • Care of patients on HD - pre, during, post.

Pre-Dialysis Care – Patient Assessment

  • Fluid status.

  • Monitor vital signs.

  • Medication.

Pre-Dialysis Care – Vascular Access inspection

  • Check for thrill/bruit.

  • bulging or aneurysm

  • Signs of infection

  • Swelling of hand

Pre-Dialysis Care

  • Confirm identity, explain procedure.

  • Instruct to empty bladder.

  • Review blood results.

  • Machine & Equipment Preparation

Pre-Dialysis Care – Infection Control

  • Perform hand hygiene.

  • Use PPE.

  • Clean vascular access sites.

Pre-Dialysis Care – Documentation

  • Record pre-HD weight, vital signs, patient complaint, condition of vascular access.

During Dialysis Care

  • Machine monitoring setting

  • Monitor patient status (BP, chest pain, cramps, giddiness).

Post-Dialysis Care

  • Monitor vital signs.

  • Check vascular access site.

  • Fluid and Weight Monitoring

  • Documentation

Complications of HD

  • Hypotension.

  • Cramps.

  • Clotting of blood lines.

  • Air embolism.

  • Blood leak.

  • Disequilibrium syndrome.

Hemodialysis Treatment Options

  • Hemodialysis – 4 hours

  • Slow continues ultrafiltration (SCUF)

  • Sustained low-efficiency dialysis (SLED)

  • Continues renal replacement therapy (CRRT)