Overview of Kidney Failure and Treatment Options 2

8/8/2019 Overview of Kidney Failure and Treatment Options 2

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An Understanding of the Normal

KidneysThere are 3 prime functions :1. Excretion of the waste products of nitrogen

metabolism

2. Regulation of water and electrolyte balance3. Endocrine and metabolic functions

a. Production of Renin, which affects sodium, fluidvolume, and blood pressureb. Production of Erythropoietin , whichcontrols red cell production in the bonemarrowc. Production of Prostaglandin


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The normal kidney is a receptor site for several hormones produced

by other organsAnti-diuretic hormone (ADH)

produced by the pituitary glands, reduces the excretion of water

AldosteroneProduced by adrenal cortex, promotes sodium retention and

enhances secretion of potassium and hydrogen ion.

Parathyroid HormoneWhich increases phosphorous and bicarbonate excretion andstimulates conversion of vitamin D to the active 1,25 vitamin D form


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The Nephron

The nephron is the functional unit of the kidney.There are over a million such units in each of thetwo kidneys.The Glomerulus filters water and solutes of molecular weight less than 68,000 daltons(albumin). Such solutes include electrolytes andurea, creatinine, uric acid, glucose,amino acids,and low molecular weight proteins. This fluid isthe glomerular filtrate, and its rate production isthe glomerular filtration rate (GFR)


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> A man of average size has about 180 Liters of filtrate per day, or 100-120 ml/min.

>99% of this filtrate is reabsorbed in tubules

> The function of the Tubules are reabsorption andsecretion

>O f the 180 Liters of glomerular filtrate each day, about 2 L

remain as the final urine. The tubules conserve water and electrolytes by returning them to the blood


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Kidney Failure can be divided into :

A.Acute Renal Failure (ARF)B.Chronic Renal Failure (CRF)


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A. Common causes of acute renal

Failure :Infection, septicemiaMajor Trauma/ Heavy loss of bloodUrinary Tract obstructionDrug induced eg. pain killers, antibioticsIntrinsic kidney disease

Note : Acute renal failure is a sudden loss of kidney function and is potentially reversible


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B. Common causes of chronic

renal failureLong standing diabetes mellitus (Diabeticnephropathy)Inflammation of the kidney (Glomerulonephritis)

Infections of the kidney (Polycystic kidney)Long standing uncontrolled high blood pressure(Hypertensive nephropathy)Chronic analgesic abuse

Obstructive uropathy e.g.. Renal calculi

Note : Chronic renal failure is progressive andirreversible


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END STAGE RENAL FAILURE

(ESRF)The level of function of kidneys is measured by itsglomerular filtration rate (GFR). When The level of

function of kidneys is measured by its glomerular filtration rate (GFR). When GFR drops below 5-10 % of normal, the patient is said to be ESRF. The has tochoose one of the following options of renal replacementtherapy (RRT) to maintain life. The incidence of ESRF isabout 100-140 new patients/million population/year.


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Signs and Sypmtoms of ESRF

include :Nausea and vomitingBreathlessness

Pallor anemiaEdema facial, ascites, and swelling of ankleTiredness and lethargyRaised blood pressureUremic skin sallow discoloration


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Treatment O ptions for ESRF

1. R enal Transplantation

a . Living related renal transplant where one member of the family donate one of their kidneys.

b. Emotional related renal transplant where the spouse donate one of their kidney.

c. Cadaveric transplant where the kidneys are removed from a patient who is pronouncedbrain death and prior consent from family is obtained.

Blood grouping, tissue matching, and many other routine blood and x-rayinvestigations are done prior to transplantation. Patients have to be on long temmedications after transplantation to suppress immune response to thetransplanted kidney.


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2 . HEMODIALYSIS

This is the process of removing waste productsand excess fluid from the blood using the artificialKidney also called a dialyzer and an artificialkidney machine also called a hemodialysismachine . This treatment is done 3x a week,usually 4 hrs . per session, for the ret of thepatients life or until a renal transplant is done .



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3. Continuous Ambulatory Peritoneal Dialysis

CAPD uses the same principle of diffusion and is continuous and takes place withinthe patients peritoneal cavity. Patient does four exchanges each day and is moremobile compared to hemodialysis treatment. Each exchange or cycle has threephases:

a. A Drain Phase where the used dialysate is drained from peritonealcavityb. A Fill Phase where fresh dialysate is introduced into the peritoneal

cavityc. A Dwell phase where the fluid remains in the peritoneal cavity, and duringwhich time the majority of the fluid and solute removal (dialysis) occurs.

* The drain and fill phases are undertaken in sequence with the dwell phase and theprocedure takes about 20-30 minutes. With successful upgrading of CAPD systems,many patients are able to be safely put onto this program and there is bound to beincrease in number of new patients being treated on CAPD.



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U LT RAFILT RATION

Fluid is removed from the blood ultrafiltrationTo attract water the dialysis fluid containsglucose. The more glucose in the dialysate(high osmolarity), the more fluid can beremovedDuring dialysis the dialysate is diluted, andglucose is consumed in the body

Therefore ultrafiltration ceases, and after sometime fluid moves back into the blood.


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DIFF U SION

Waste products are removed from the blood bydiffusion. Diffusion through a membrane iscalled dialysis Waste products in the blood move to thecleaner dialysis fluid because of the differencein concentration.

When the concentration of waste products is of the same in blood and dialysate, no more nettransport takes place. The dialysate must thenbe exchanged


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HEM O DIALYSIS

Hemo means blood, Dialysis indicates some form of filtration. Hemodialysis is an exchange that takes placebetween a patients blood and a solution termed dialysateacross a semi-permeable membrane. This exchange removestoxins and water from the patients blood and corrects

electrolyte imbalances to near normal.

The basic principles involved in hemodialysis include thefollowing:

1.Diffusion2.O smosis3.Ultrafiltration

4.Convection


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DIFF U SIONMolecules in solution are in constant motion and spread uniformly throughout the solution. Therate of spread depends upon the concentration ,size and ionic status of the molecules inmotion. Diffusion can be defined as a flow of solutes from an area of higher concentration tolower solute concentration across a semi-permeable membrane.

OSMOSISThis is defined as the movement of water through a membrane from a higher to a lower water concentration area. The substance dissolved in water is known as solute

U LT RAFILT RATIONThis is the movement of fluid through a membrane caused by a pressure gradient. Indialysis, both positive and negative pressures on the blood and dialysate sidescontribute to fluid removal .

CONVECTIONThe movement of solutes with a water flow, also known as solvent drag". In other words during fluid removal, there is bound to be a small amount of membranepermeable solute loss together with the ultrafiltrate. During hemodialysis, solutessuch as urea, creatinine, uric acid, phosphates, electrolytes etc are removed by bothdiffusion and convection while water is removed by both osmosis and ultrafiltration.


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THE HEMODIALYSIS MACHINE

The hemodialysis machine is one of themain components needed to carry outhemodialysis treatment. The mainfunctions of the hemodialysis machineinclude:

1.Blood Related Functions2.Dialysate Related Functions


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Main Components of theHemodialysis Machine

A. Blood Pump

B. Heparin Infusion Pump

C. Dialysate Delivery System

D. Monitoring Devices


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1. B lood Circuit

a . Pressure Monitor These are T tubes attached to both arterial and venous blood lines and theypermit monitoring of pressure at various points in the blood circuit.They include:

Arterial Pressure Monitoring:-to monitor if arterial blood supply is adequate or not.-to detect if dialyzer is getting clotted when pressure monitoring is after bloodPump segment.

Venous Pressure Monitoring:-to detect any kink or clot on venous line distal to the venous chamber.-to help in calculation of TMP (Transmembrane Pressure)-to detect accidental separation of bloodline from AVF needle.b. Air Bubble Detector (ADB)

This is located just distal to venous pressure monitor. The purpose of the ABDis to prevent air bubbles which may have inadvertently entered the blood circuitFrom being return to the patient. The air bubble detector is attached to a relayswitch which automatically clamps the venous bloodline and shuts of the bloodpump whenever air is detected.


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2 . Dialysis Solution Circuit

a . Conductivity Monitor

If the proportioning system that mixes the concentrate with water malfunctions,an excessively diluted or concentrated dialysis solution will be produced. Highor low conductivity will result in high or low blood pressure and this affect patientseverely. Any dialysate that is not within the normal acceptable range will have to

be diverted to the drain.

b . Temperature Monitor

Malfunction of the heater element in the dialysis machine can result in the productionof excessively cold or hot dialysate. Use of cold dialysate causes the patient toexperience chills and shivers. O n the other hand, use of the dialysate greater than 42

degree C can lead to hemolysis and sweating. Thus, temperature sensors are used for continuous monitoring and the dialysate bypassed whenever out of safety limits.

c . Bypass ValveThis valve is solely responsible to divert dialysate to the drain whenever either thetemperature or conductivity is out of set safety limits.


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d . Blood Leak Detector

This device is placed in the dialysate out flow line (effluent line) and detects anyblood leak from the blood compartment and activates an alarm condition. Abeam of light is directed through a column of dialysate onto a photoelectric cell.

A change in translucence and light scatter in dialysate reduces the light receivedby the photocell, stopping the blood pump and activating both visual and audiblealarms. The presence of particulates and micro bubbles can trigger a falsealarm.

e . Negative Pressure / TMP RegulatorsThis consist of negative (dialysate) pressure pumps and regulators andcontinuously monitor the total TMP and achieve the desired goal for fluidremoval.


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O ptions available for upgrading of Hemodialysis machines

1.B icarbonateThis option allows the use of the two concentrate approach to prepare abicarbonate containing dialysis solution. This was previously used for acutely illpatients who are severely acidotic and has now become the standard buffer for chronic hemodialysis. Bicarbonate powder packed in bag or cartridges has anadvantage over solution as less storage space is required and there is less risk of contamination in freshly produced bicarbonate dialysate.

2 .Controlled U ltrafiltrationTwo common methods by which ultrafiltration rate can be precisely controlledinclude the so-called volumetric method and the use of flow sensors. This is veryuseful to maintain patients blood pressure. It also enables safe removal of thedesired amount of body fluids. Ultrafiltration controllers (UFC) have made easy theuse of high-flux dialyzers with higher KUF.

3.Programmable U ltrafiltrationNormally ultrafiltration is perform as a constant rate throughout the dialysis therapyand this was further enhanced with the availability of ultrafiltration controllers. Inthis era of information technology, dialysis machine also come with varioussoftware allowing the user to choose the desired rate and pattern of ultrafiltration(fluid removal). The options are shown in the form of graphs or bar charts over thetreatment time.


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4.Variable SodiumThis options permit rapid alteration of the dialysis solution sodium

concentration by simply turning a dial on the machine. The sodiumconcentration is usually altered by changing the proportioning of concentrateto water. This is good tool to use in managing patients with acute renalfailure and in patients with cardiac instability and low blood pressure.

5.Single Needle DialysisThis is not commonly used but is useful in patients with poor vascular

access. Here only one vascular access line (needle) is created and arterialand venous lines are kept either close or open at any one time. This is

achieved by the use of time settings or pressure settings incorporated inthe machines.

6. O n-Line Clearance Monitor This feature allows the nurse to keep tract of the current rate of clearance

of urea and the estimated Kt/v to achieved the desired goal. Remedial

measures like increasing blood flow or increasing treatment time can bemade during dialysis to achieve the set targets.

7.Blood Temp. Monitor The vasodilatory effect of temperature has been known to cause varied

problems and with this gadget, the problem is better controlled. This is goodfor patients with cardiac instability to stabilize blood pressure. There hasbeen no theories that cooler dialysate might give better treatment outcomes.


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Decalcification/Sterilization of HDmachine

The dialysis machine should be cleaned with alight disinfectant after each session of treatment.To avoid calcification along the dialysate path,

the machine should be rinsed with one of thedecalcifying agents such as Hemoclean or Puresterile which contain hydrogen peroxide,peracetic acid and sodium hypochlorite. Heatsterilization is still widely used to minimizedbacterial growth and spread of hepatitis.However the use of formaldehyde, although avery powerful and effective sterilant is on thedecline due to its potential carcinogenic effect

and environmentally unfriendly.


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Planned Preventive Maintenance

All machines have a check list for routine plannedpreventive maintenance and this schedule must bestrictly adhered to promptly. The purpose is :

1.To make sure that machine is safe2.To detect early, malfunctioning parts and cut down mean

breakdown time.3.To check all calibrations which include blood pump flow

rate, temperature, conductivity, blood leak detector, air bubble detector, negative pressure, etc.

4.To cut down unnecessary increase in cost of repairs.


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Types of Dialyzers, ClearanceAnd Biocompatability

A dialyzer is compose of dialysis membrane and supporting structure

There are four components:1. Blood Compartment2 . Dialysate Compartment3. Semi permeable membrane separating(1) and ( 2 ).4. Membrane support structure

The various characteristics of the dialyzer are :

1. Membrane material-Indicates blood compatibility, ultrafiltration (UF), clearance, and sterilizationmethod.

2 . U F coefficient -Indicates water permeability and generally molecular permeability. Three types areavailable, low flux, intermediate flux and high flux.

3. Clearance -Refers to the amount of blood which is cleared of a certain substance (eg urea) everyminute. The smaller the substance, the higher the rate of clearance.

4. Blood volume -The amount of blood required to fill (prime) the dialyzer.5. Surface Area -Influences clearance, ultrafiltration, blood volume, but not sieving coefficient.6. Sterilization - Dialyzers must be sterile and pyrogen -free. This can be achieved by sterilization

with ethylene oxide gas, steam or gamma radiation.


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Dialyzer FluxLow (standard) flux dialyzer

=substances larger than 8000 Daltons do not cross the membrane.=small marker molecules such as urea and creatinine pass through freely.=Pores are small and this is reflected by the low of ultrafiltration coefficient(between 2- 9 ml/mmHg/hour).=mainly cellulose and some synthetic membrane.

Intermidiate Flux

=UF coefficient 10-1 9 ml/mmHg/hour.=Synthetic membranes and altered cellulose-Polyacrylonitile (PAN)-Polysulfone-Polymenthylmethacrylate (PMMA)

High Flux Dialyzer =Substances larger than 8000 Daltons cross the membrane.=A high performing high-flux dialyzer has a sieving coefficient for Beta 3 micro

globulin > 0.6.=Ultrafiltration coefficient is generally > 20 ml/mmHg/hour reflecting the larger

pore size (20-80 ml/mmHg/hour) e.g.. Fresenius HF 70=Mainly Hemofilters.


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Sieving CoefficientDefined as membrane permeability to solutes during ultrafiltration.

=Small solutes pass through without problems.

=Permeability decreases with increasing molecular weight size.=Always express as a percentage.

Types of dialyzers available currently include the following:=PARALLEL PLATE DIALYZER (PPD)=HO LLO W FIBRE DIALYZERThe hollow fiber dialyzer is the most popular of the above two types

and is composed of a group of between 8,000 to 12,000 fiber-likestructures (capillaries) with an internal diameter of 200 microns.

Advantage of using Hollow fiber dialyzer =small priming volume=handy-small and compact=increase clearance of middle molecules=good ultrafiltration rate (UFR)=ease of processing reuse=reduced risk of leakage


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Clearance (K ) of a SubstanceThe volume of blood (or plasma) from which a substance is

completely cleared by the dialyzer per unit time (ml/min).The clearance values provided by the manufacturer for urea (mol wt 60) or creatinine (mol wt.112) etc are invitro values and slightly overestimated.

The formula used to calculate clearance (CL ) is:CL=A-V

------------- x Qb ml/min .

A A=arterial sample (e.g.. urea)V=venous sample (e.g.. urea


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Most dialyzer specifications include clearance of vitaminB 12 (mol.wt.1355). This is an indication of how wellthe membrane allows the passage of larger molecular weight solutes. There is an increase in clearance of larger molecules when high-efficiency or high-fluxdialyzer are used.

All dialysis staff must understand that the blood flow rateplays a major role in the effectiveness of dialysis

treatment and are encouraged to put the optimumpossible flow rate. The average flow rate is between300-350 ml/min for patients who are stable and have awell functioning vascular access.


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Mascular Weight (DALT O NS)1. S O DIUM - 232. CALCIUM - 403. UREA - 604. CREATININE - 1135. P O SPHATE - 1206. URIC ACID - 1687. ALUMINIUM - 7008. PH O SPH O RUS - 8389 . VIT B12 - 135510. INULIN - 5000

11. HEPARIN - 800-1200012. B 2 MICR O GLO BULIN - 1100013. ALBUMIN - 6800014. GL O BULIN - 18000015. RBC/WBC - > above


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However there are many disadvantages of using acetate based dialysate for beingrevealed and slowly but steadily began to bereplaced with bicarbonate based dialysate inthe 70s and aggressively in the 80s. The

patients who where dialyzed with acetate buffer experienced problems of hypotension, nausea ,vomiting , post treatment fatigue not feelingwell. The advantages of using bicarbonate

dialysate include less episodes of hypotension,nausea , vomiting , stable blood gases , better phosphate removal , better biocompatibility ,dialysis treament is better tolerated etc.


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Types of Dialysate ConcentratesThere are usually 5 compounds used in the preparation of dialysateconcentrate . They include sodium chloride, sodium bicarbonate or sodium acetate, calcium

chloride, potassium chloride and magnesium chloride.Acetate ConcentrateMany patients have been treated with this type of dialysate for many years but because of some of

the side effects experienced by patients, this is gradually being replaced with bicarbonatedialysate. The advantage of acetate concentrate is the it is stable during storage and is notprone to bacterial contamination. Acetate dialysate is not suited for rapid, high-efficiencydialysis or high-flux dialysis.

Serum carbonate is depleted and the acetate level may exceed the rate at which the liver canmetabolize it. All hemodialysis machines are designed to be able to use acetate concentrate asthe proportioning of reverse osmosis water and dialysate concentrate is simple in the ratio of 1part concentrate to 34 parts of water to produce acetate dialysate.

Bicarbonate Concentrate

When using bicarbonate in dialysis, 2 practical issues need special attention. The precipitation of calcium carbonate must be avoided. This is achieved by separating the calcium ions from thebicarbonate ions during storage. Thus bicarbonate concentrate is prepared in the form of twocomponents , a bicarbonate" component and an acid" component. During mixing the pHshould be below 7.3 and this is achieved by the addition of acetic acid in the A concentrate. Thesecond problem with bicarbonate concentrate is that it is an excellent growth medium for certainbacteria and should always be handled aseptically. Both from a microbiological and a chemicalpoint of view, bicarbonate concentrates should not be stored once the canisters are opened asstability will be affected due to liberation of carbon dioxide which acts as a stabilizer.


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1.Solution A (indicating acidified)concentrate contains most of the sodium,calcium, magnesium, potassium, chloride,and a small amount of acetic acid.

Eg. Sodium-75.00,Potassium-1. 9 ,Calcium-

1.25,Magnessium-0.70,Chloride-80.80 and Acetate-4.00 (mmol/L)2.Solution B (indicating bicarbonate)

concentrate contains the sodiumbicarbonate and part of the sodiumchloride.

Eg. Sodium-65.00,Chloride-26.00,and

Bicarbonate-35.00 (mmol/L)


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Q uality control when handlingdialysate concentrate.

1. Q uality control and quality assurance procedure should be establish toensure conformance to policies and procedures regarding dialysate quality.2. Staff handling new canisters of dialysate concentrate should verify correctformula and check that the caps are still intact.3. Liquid bicarbonate concentrate should not be used after being opened for more than 24 hour while the acid solution should be used wihtin 72 hours.

4. Ensure that only reverse osmosis water that meets AAMI standards is usedfor the preparation of the dialysate by the hemodialysis machine.5. Dialysate should be verifies for each dialysis and the nurse should check theconductivity reading on the hemodialysis machine and used the manualconductivity meter (myro meter / phoenix meter) whenever in doubt.6. Monthly dialysate analysis for both electrolyte content microbiological /endotoxin content should be done.7. O bserve an investigate for any undue intradialytic patient reactions of aserious nature or uncommon event.8. Ensure proper storage condition and away from sun light and poison puckand similar canisters.9 . Take extra precautions to check for bacterial growth when central deliverysystem for bicarbonate is used.10. Ensure that the hemodialysis machine are in good safe working order withall audio and visual alarms functional to detect any abnormality in the content of the concentrate being used.


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WATER TREATMENT F O RHEM O DIALYSIS

1. INTRO DUCTI O N

Water has a unique property of being an excellent solvent high heatcapacity and surface tension and hence it is very susceptible to becontaminated to the point were it becomes a health hazard.

Water is used extensively for making the dialysate required for hemodialysis treatment. A normal person drinks between 1.5-2 liter of water per day and this amount to about not more than 15 liter per week. A patienton hemodialysis is exposed indirectly to about 120 liter of water per session(Dialysate flow rate 500 ml x 60 min x 4 hours) of dialysis therapy and thisamounts to about 400 liters per week.

The quality of water used is therefore critical to the preparation of a dialysisfluid. It should be free of contaminants which have harmful effects on thehealth of the patient.

The contaminant which may be present in water include suspended solids,dissolve organic and inorganic, heavy metals and trace minerals andmicroorganism.


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Contaminants and potential toxiceffects .

Substance Toxic effect

1 Aluminum - Dialysis encephalopatyrin- Bone disease- Microcytic anemia

2. Calcium /

Magnesium - Hypercalcaemia- Hypomagnesaemia

3. Chloramines - Hemolysis, anemia4.Flouride - O steoporosis, O steomalacia5. Sodium - Hypertension

- pulmonary edema- tachycardia- vomiting- headache

6. Zinc - Anemia, nausea- vomiting

7. Sulfate - Nausea, metabolic acidosis8. Ph - Heparin inactivation

- itching9 . Microorganism - Febrile reaction


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Importance of water treatment1. To prevent premature damage to the hydraulic parts in the

machine.2. To facilitate production of dialysate with accurate electrolyte

content.3. To prevent long term side effects of inadequatley treated water.

Acceptable Water Content .

1. Calcium and magnesium


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HYGENIC ASPECTS O N WATER AND DISTRIBUTI O N LOO P

.No rough joints or surfaces

.No oversized pipes or tube

.Low surface area in softeners and lifter columns.

.Carbon filter upstream R O unit

.No stagnant or slow moving water

.Prevent air contamination in indirect feed of RO water.

.Facilities for disinfection


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AAMI Hemodialysis Water Q ualityStandard.

Substance Maximum concentration (mg/l )

Aluminum 0Chloramines 0.10Copper 0.10Fluoride 0.20

Nitrate 2.00Sulfate 100.0Zinc, barium 0.10 eachCalcium 2.00Magnesium 4.00Sodium 70.00Potassium 8.00Chlorine 0.50

Arsenic, lead, silver 0.005 eachChromium 0.14Cadmium 0.001Selenium 0. 9 Mercury 0.002Bacteria


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Reveres O smosis Water TreatmentEquipment Requirments.

1. Materials compatibility Any material that contract purified water in a water treatment system should be un reactive in nature toprevent contamination of the product water. Theseinclude materials such as plastic or appropriatestainless steel.

2. Disinfection protectionThe manufacture of the equipment is responsible for

recommending disinfectants to be used in the system ,assuring there is a means for removal of thedisinfectant used, and assure that there is a warningsystem so the water system cannot be used during thedisinfection mode.


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3. Safety requirements .Each water treatment device shall exhibit the following safety requirements:

3.1 Monitors shall be design so they cannot be disable while a patient is at risk except for brief necessary period under manual control with the operator at constant attention.

3.2 The sound emitted by audible alarms shall be at list 65 decibels (A scale) at three

meter and it shall not be possible to silence these alarm for more than 180 seconds.3.3 Resistively, conductivity or TDC (total dissolve solid) monitor shall be temperature

compensated.

3.4 O peration control should be position to minimized inadvertent resetting.

3.5 Electrical circuits shall be separate from hydraulic circuit and adequately protectedfrom fluid leaks.


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4. Treatment Devices

4.1 The decision making process requires three key input parameters:

a. The purity of the water requiredb. The quality of the municipal water supply (chemical and microorganism)c. The amount water required

4.2 Water treatment systems can be divided into three section :

a. PRE-TREATMENT consisting of water storage tanks sediment filter, softener,activated carbon filter and micro filter.

b. PRIMARY TREATMENT involving one or more reverse osmosis devices .c. THE DISTRIBUTI O N LOO P for reverse osmosis devises

A. P RE-T REATMENT(1) Raw water storage tanksThe material used should be off stainless steel (grade 304) or high densityPolyethylene (HDPE) the tanks should be place in a clean and safe environmentwith direct feed from the nearest main supply. The minimum size be1500 liter to2000 liters and com complete with cover. The tanks should be regularly inspectedfor dirt particle etc and clean at least once a year.


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(2 .)Filters

Pre filter also sediment filters o sand filters,remove large particle ranging from 500 microdown to about 5 micro and are generallyemployed to removed particles and prevent

fouling of devices farther downstream layer of coarse-to-fine sand (multimedia filter) removeparticle from the feed water. The method iseconomical and effective. Back washing at nightallows this sediment filter to flush the trappedmatter to the drain. The sand well assume itoriginal layer position and will be ready for dutythe following day.


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(4) Activated Carbon Filters

Carbon adsorption tanks should be size for the maximum of two tanks in a seriesconfiguration (one tank feeding the next) A simple port for testing the water after thefirst tank and before the next tank should be in place. Upon exhaustion(chlorine/chloramines breakthrough) of the first tank, the carbon media should bediscarded and replace with new carbon. The second tank should be move to the firstposition, and the new tank place in the last position. A formula is used to determineempty bed contact time (EBCT) and the goals is 6-12 minutes(3-6 minutes per working and polishing tank (S).

(5) Micro filter

Micro filter remove intermediate sized particle of 5-1 micron in diameter and are situatedin the pre treatment and primary treatment section of the system in order of decreasing particle size cut off.


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B. Primary treatment(1) R everse osmosis

UnitRO units are the most effective of treating water. They also prevent bacteria

and endotoxin passage. Dissolve solid are un able to pass through themembranes enclosed and pure water the hydraulic pressure overtakes theosmotic pressure. From this we derive the term reverse osmosis. All R O membrane are design for cross flow filtration so the feed water is separatedinto two streams a permeate (product water) of purified water which has passthrough the membrane and a concentrate which has a high concentration of

contaminant (reject water). Conductivity is the vital measurement in anyreverse osmosis system. Taken from the feed and product flows thepercentage of rejected dissolve solids remove is calculated by the formula.This should constantly be monitored electronically or manual but manualverification should be periodic. Common membrane used is the thin filmcomposite.

The R O should provide AAMI quality water and minimum rejection levelshould be set. The product water conductivity monitor should activate audibleand visual alarm when the product water conductivity exceeds the presentalarm limit. The audible alarm should be audible in the patient care areawhen reveres osmosis is the last chemical purification process in the water treatment system. The R O members should be regularly flushed to preventlayering of contaminant effectiveness of the membrane.


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TREATMENT SYSTEM


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TREATMENT SYSTEMMAINTENANCE AND Q UALITY

CO NTR O L1. The complete treatment system must be regularly disinfected filters and resin must be

periodically clean regenerated and change and precaution should be taken again theformation of biofilms.

2. Biofilm represent one of the most persistent problems in dialysis unit biofilm is a term used todescribe the bacteria attached to a surface surrounded by a matrix of their own making.This matrix protects them from this infecting agents and from being swept away by flowingfluid. It also attracts nutrients for bacterial growth. They form easily in any crevices or corner of container, pipes, treatment devices storage tanks and dialysis machine and areextremely difficult to remove. Steps in prevention include the avoidance of a water stagnation, low share (turbulent) rates dead end pipes, uneven surfaces and sharp bend inthe water treatment system and storage tanks.

3. The manufactured of the equipment is responsible for recommending disinfectant to be usedin the system assuring there is a means for removal of the disinfectant to safe levelrecommending testing method for the disinfectant used and assure that there is a warningsystem so the water system cannot be used during the disinfection mode.

4. The simple and easy-to-follow water system log is crucial. It should be numberedsequentially with corresponding number on a system itself. Normal operating parameter should be include on the log adjacent to the information being recorded. Make it easy for staff to utilized and educate them on the need to recognized and report abnormal findings.

5. The 10 % rule can be used to determine when to clean the R O membrane.

#10 % loss in product water flow.#10 % increase in pressure

#10 % loss in product water quality.


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In the proportioning system, the B concentrate is usuallydiluted partially with water the A concentrate is thenproportioned into the mixture just before it goes to thedialyzer. In the closed system,C O 2 cannot bubble off, thereaction between sodium bicarbonate and acetic acidcannot proceed to completion, and the hydrogen ioncontent keeps the calcium in solution. To minimizebacterial growth and also save on storage space,manufacturers now produce the bicarbonate in bothsolution and powder form (bags or cartridges). Many of thehemodialysis machines come with retrofit kits to facilitatethe use of powder bicarbonate. Many of the manufacturersof dialysate concentrates have different formulations with

different levels of calcium ions to meet the needs of different patients. Please note that whenever bicarbonatecartridges are used, a different concentrate A solution isused unlike the one used with liquid carbonateconcentrate.


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Benefits from using bicarbonate indialysis

Acute benefits + no vasodilatation

+ better fluid management

+ normal blood gases andbreathing

+ no physiological

accumulation of metabolites

+ better phosphate control

+ less cytokine induction

+ better control of acidosis

Long termbenefits : + normalize acid base balance

+ normalize protein metabolism

+ optimized body weight

+ -


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PRI O RITY F O R BICARB O NATEDIALYSIS IN HEM O DIALYSIS UNIT

1. During high flux dialysis.2. Dialysis of acutely ill patients.3. Dialysis of pregnant patients.4. In cachexic patients who continue to loose weight of adequate

acetate hemodialysis.

5. Patients who have severe nausea, vomiting or hypotension requiringfrequent fluid replacement therapy while on acetate dialysis.6. Patients who have severe cramps or generalized lethargy with or

without cramps during dialysis and during the interdialytic period.7. Patients with respiratory problem, e.g, those with already deforemed

chest wall.

8. Patients have angina occurring during acetate dialysis with/withoutarrythmia.9 . Patients with hyperphospatemia.10. Dialysis of geriatic patients.


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ANTIC O AGULATI O N ANDHEPARIN ADMINISTRATI O N

Factors that aid clotting of theextracorporeal blood :

1. Poor blood flow

2.High hematocrit3.High ultrafiltration rate resulting in bloodconcentration4.Blood transfusion during dialysis

5.Intradialytic lipid infusion6.Inadequately reprocessed dialyzer 7.Biocompatible membrane


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Factors to be considered beforedeciding heparin dose :

1. Body weight of patient2. Total volume of extracorporeal blood3. Blood flow rate4. Reuse of dialyzer

5. Hematocrit6. Intradialytic blood transfusion7. Any underlying bleeding state or disorder 8. Any abnormality in bleeding time and clotting time

readings9 . Pre Surgery10. Post Surgery11. Pericarditis

C M h d f H i i i


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Common Methods of Heparinization1. Continuous heparinization

- most common method ,safe and reliable one- Initial heparin dose /Bolus dose is given at start of dialysis & followed by constant heparin infusion pump available in the

machine.

- Average bolus varies between 3000-5000 iu , followed by continuous infusion of about 1000 iu per hour.- Heparin infusion is terminated 30 min.prior to end of dialysis

2 . Intermittent heparinization- An intravenous priming dose is given at the beginning of dialysis and smaller doses are repeated intermittently throughout the

treatment.- The initial dose is usually between 2000-4000 iu and 500-1000 iu given every hour thereof.- Monitoring of actual clotting time should be closely monitored- The activated clotting timer machine (ACT) is commonly used

NO

TE: In general the ACT reading should be 80%

above baseline during first 3 hrs. of dialysis and reduced to 40%

during lasthour

3. Tight Heparinazation- Indicated in patients who are slight to moderate risk for bleeding- A bolus dose of between 750- 1000 iu of heparin is given and clotting times are done 15 min. before the next hour and so on.

- A dose of heparin adequate to keep ACT at 40% above baseline is the rule in this technique

4. Heparin free dialysis- This method is gradually phasing off the Tight Heparin method and is commonly used in cases of active bleeding, recent

surgery,percarditis, intracranial bleed, etc.- The heparinsed saline used for priming the extracorporeal blood circuit is flushed out completely to ensure no

heparin infusion into patient.- A minimum of blood flow rate of between 175 200 mls/min is maintained throughout the dialysis- Every 20 30 minutes, a saline rinse is done to the extracorporeal circuit and physical observation made to

see any early signs of clotting. The additional saline used for periodic flushing should be included in thegoal set for fluid removal

- It is also preferable to use less thrombogenic dialyzer (e.g. polysulphone dialyzer.)

VASC U LAR ACCESS FO R HEMODIALYSIS


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VASC U LAR ACCESS FO R HEMODIALYSIS

B.H. Scribner was the first to create an arteriovenousshunt in 1 9 60 . It was the first permanent means of easyaccess to the blood for the treatment of chronic renalfailure.

A breakthrough came in the year 1 9 66 when thearteriovenous fistula was introduced by Cimino andBrescia.

In order to avoid side effects which might be detrimentalto the heart, vascular access is usually created onmedium- size artery such as radial and brachial artery.

The Vascular access is the main lifeline for the patienton hemodialysis

The need for vascular access in patients with renalfailure can be either temporay of permanent

Temporary Access


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Temporary AccessIndications : Temporary access is used in the following

group of patients who require hemodialysis or extracorporeal blood therapy :1. Patients with acute renal failure2. ESRD patients without permanent vascular access

3. CAPD patients requiring temporary hemodialysis4. Transplant recipients requiring temporary

hemodialysis5. Patients requiring either plasmapheresis or

hemoperfusion6. Patients awaiting maturity of AVF7. Patients on Continuous Renal Replacement Therapy

(CRRT)


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Types of temporary access :1. Single Lumen Catheter 2. Double Lumen Catheter

Most common are made of either Teflon,polyurethane (PUR) or silicone material

Common sites used for access include :1. Subclavian vein2. Internal Jugular vein3. Femoral vein


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Care of temporary vascular access :

1. Aseptic technique2. Proper administration of anticoagulant

including heparin block3. Constant observation for any signs of

inflammation4. Proper anchoring of catheter to avoid

dislodgement5. Look out for any signs of skin erosion,

thrombosis and hemorrhage


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Permanent access

The available types of permanent accessinclude the following :

1. Arteriovenous shunts not commonlyused now

2. Arteriovenous fistula (AVF)3. Arteriovenous grafts4. Permanent catheters


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1. Arteriovenous ShuntsThe Q uinton Scribner shunt consists of

two Teflon cannula, placed in the radialartery at the wrist and in vein of the lower

arm. Each cannula is connected to a pieceof silastic tubing, and the two tubes areexternally connected by a removable

Teflon connector. However due to itsmany complications and the need to be onoral anticoagulants, this is rarely usednow.


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2 . Arteriovenous fistulaThe Cimino Brescia arteriovenous fistula is the type of vascular access that is most commonly

used . The fistula is usually created between the radial artery at the wrist and the superficialcephalic vein by side to side , or better, end to side anastomosis.

It is constructed in non dominant hand . The AVF is usually allowed to rest and mature over a periodof between 6-8 weeks and the patient is advised to do light passive exercises of that hand.

Advantages of AVF1. It is superficial access in the lower arm2. Easy to cannulate3. Has minimal effect on their physical appearance4. Has quicker homeostasis post hemodialysis5. Patient has better arm comfort during dialysis

An Immature fistula1. Difficult to cannulate2. Has fragile veins resulting in blood leakage3. Has inadequate blood flows for effective hemodialysis

Complications of AVF1.Poor flow2.Thrombosis3.Ischaemia of the hand4.Edema of the hand5.Aneurysm6.Infection


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Care of AVF :1. Protect future access arm from damage to the

vasculature2. Allow adequate time for maturation of AVF3. Do not take blood pressure on fistula arm

4. Do not use tight fitting clothing across fistula arm5. No blood sampling or any venipuncture other than hemodialysis6. Feel for bruit or thrill at least 2-3 times a day7.Avoid prolong period of hypotension8. Report to HDU if any sluggish flow detected

3. Arteriovenous Grafts


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> The graft is inserted between artery and nearby vein> Both straight and semi curved graft configurations are commonly used

Types of synthetic grafts :1.PTFE grafts (Polytetrafluoroethylene)2.The Vectra Vascular Access Graft (VAG)3.Dacron or Teflon grafts ( Not commonly used)

Complications of Grafts :1.Thrombosis2.Graft Infection3.Steal Syndrome4.Pseudoaneurysms5.Anastomatic disruption

6.Embolic events7.Bleeding8. O cclusion9 .Stenosis10.Kinking/compression11.Swelling12.Skin erosion

Cannulation


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CannulationThese type of grafts may be punctured for vascular

access within 24hrs. After implant, provided nocontraindications are present.

Insert the blood access (dialysis) needle at a 45 degreeangle with the bevel up until the graft is penetrated. Theneedle is then rotated until the face of the bevel isdirected downward and advanced parallel to the graft.

If the blood access needle is inserted such that the anglebetween the needle axis and the graft is too small, tearsin the wall of the graft can occur.

If the needle is inserted 9 0 degree angle, it increases thepossibilty of puncturing the far wall of the graft, whichmay lead to hematoma formation

For best results follow the established practices


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For best results follow the established practiceslisted below :

1. Rotate cannulation sites2. Do not cannulate within 2 cm. of proximal or distal

anastomosis

3. Strict adherence to aseptic technique4. As with all dialysis, do not cannulate if there aresigns of infection, bleeding, swelling, edema,hematoma,or in absence of strong thrill

5. These graft generally seal within 1-5 minutesdepending on the anticoagulation regime used.Prolong compression or use of clamps may lead toclot formation, restricting flow through the graft


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DR Y WEIGHTThis is the weight to be maintained by any patient on chronic

hemodialysis, at this weight the following signs and symptoms canbe noted :Effort tolerance is goodNo shortness of breath (S O B)No signs of edema (Ankle, facial, ascites)Blood pressure under control with minimum drugs or noneNo cardiomegaly (CXR)Active d well rehabilitated

3 Importance of D R Y WT . :1. To help in setting total fluid to be removed (G O AL)2. To assess if patient is compliant to diet and fluid control3. To confirm if patient has put on body mass and not fluid

accumulation

HOW TO ASSESS D RY WEIGHT


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HOW TO ASSESS D R Y WEIGHT

1. Do chest X ray prior to initiating hemodialysis2. Adequate counseling and monitoring on diet3. Carry out gentle hemodialysis for 2-3 weeks4. Review by doctor to reduce antihypertensive drugs as

necessary

5. O bserve for presence of edema6. Record all signs and symptoms of during hemodialysis

like hypotension,vomiting,cramps,etc.7. Repeat CXR when desired weight is achieved

8. Review by doctor to confirm dry weight

Note : Dry wt. has to be reviewed at least three monthly toaccommodate for any increase in body mass due togood rehabilitation and adequate dialysis.

U LT RAFILT RATION


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> The filtration of water by pressure gradient between two sides of a semi permeable membrane.

Transmembrane Pressure (TMP)> The difference between pressure of the blood side and the fluid side on the membrane.

TMP = Venous pressure (VP)- Dialysate pressure (DP)TMP is expressed as mmHg

U ltrafiltration Rate ( U FR) > The amount of water removed per hour per millimeter of mercury transmembrane pressure

(ml/hr/mmHg/)

Osmotic Pressure> The pressure which develops when two solutions of different concentrations are separated by a

semi permiable membrane

U ltrafiltration Controller ( U FC )> UFC is incorporated in most of the hemodialysis machines and this gadget automatically

manages total fluid removal during hemodialysis treatment as per set goal

Sequential U ltrafiltration> Aims to get rid of excess water from the patient by doing hemodialysis without using anydialysate. This is also called isolated ultrafiltration and can be performed by most of thehemodialysis machines

> Indications : 1. Fluid O verload ( 3-4kg. Above dry weight)2.Patient in pulmonary edema

> Procedure : At the 1 st hr. or last hr. of dialysis depending on the clinical practice guidelines of thedialysis unit. In most centre this is done 1 st hr. and then followed by 4 hrs. of conventional dialysis.The patient should be advised that this is not ideal way to relieve fluid overload and better fluidand dietary compliance is needed

INTRADIALYTIC COMPLICATIONS AND


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INTRADIALYTIC COMPLICATIONS ANDMANAGEMENT

The intradialytic complications that can occur, in descending order of

frequency include the following :1. Muscle Cramps2. Nausea and Vomiting3. Headache4. Hypotension5. Chest pain and back pain6. Itching7. Fever and Chills8. Air embolism9 . Bleeding / Clotting10. Convulsions

11. Hemolysis12. Hypertension13. Disequilibrium syndrome14. Hematoma15. First use syndrome16. Hypoxia

Dialysis adequacy


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Dialysis adequacyPts. Are dialyzed 3x /week , 4hrs./ session

w/ the objective of achieving near normalchemical content in bloodImportance of providing adequate dialysis to

hemodialysis patients :1.Improved survival rate w/ minimum

complications2.Better quality of life

3.Better rehabilitation4.Less hospitalization5.Better wellbeing


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Signs of inadequate dialysis :1. Persistent hyperkalemia and metabolic

acidosis2. Poor protein intake due to anorexia3. Resistance to moderate doses of

Erythropoietin in achieving acceptable levels of

hemoglobin or hematocrit4. Marked uremia and its symptoms (e.g.itchiness, hiccup, loss of appetite,etc.)

Factors interfering with adequate dialysis1. Ineffective urea clearance2. Reduction in treatment time3. Blood sampling and timing errors

Infection Control in Hemodialysis


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Infection Control in Hemodialysis INFECTI O N constitute the second commonest cause of

death in chronic dialysis patients after cardiovascular

events.

Common sources of infection :1. Vascular access (Temporary vascular access

catheters and grafts)2. Use of contaminated bicarbonate concentrate3. Used of contaminated water to prepare bicarbonate4. Poor quality control during reprocessing of dialyzers5. Nosocomial transmission of blood borne diseases

(HBV,HCV,HIV,MRSA)6. Multiple blood transfusions to correct anemia7. Poor adherence to standard precautions protocol

L g t li ti f


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Long term complications of hemodialysis

1. Anemia2. Renal O steodystrophy3. Hepatitis

4. Malnutrition5. Dialysis Encelopathy6. Neoplasm7. Dialysis related Amyloidosis8. Cardiovascular disease9 . Uremic Neuropathy


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Medications for hemodialysis


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ypatients

1. Antihypertensive drugs> Common types are:a. Alpha blockersb. Beta Blockers (e.g. .metoprolol,labetol,atenol)c. Calcium channel blockers

(e.g. nifedipine,amlodipine)d. ACE Inhibitors(e.g. captopril,enalapril)

2. Phosphate Binders> Common types are :a. Calcium carbonateb. Calcium acetate

3. Hematinics4. Vitamin D

5. Erythropoietin


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Common psychological problems

encountered by patients onhemodialysis

1. Depressions (Including suicide)2. Uncooperative behavior 3. Sexual dysfunction

4. Rehabilitation

Treatment for psychological


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Treatment for psychologicalproblems

1. Patient should be informed about deteriorating illness andimpending outcome (i.e. CRF to ESRD )

2. Pre hemodialysis orientation3. Psychotherapy4. Patients who are rehabilitated on the hemodialysis program can

be a role models5. Simple exercises6. Referral to psychologist for counseling7. Use of drugs for more difficult patients8. Introduction of mentor system9 . Staff must be vigilant when someone who has been active and

well, suddenly begin to behave differently10. Staff should take initiative to organize family day outing with

patients and encourage them to write articles in dialysis bulletins

Overview of Kidney Failure and Treatment Options 2

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