HEMODIALYSIS

1.) Definition
• From Greek "dialusis", meaning dissolution, "dia", meaning through, and "lysis",
meaning loosening) is primarily used to provide an artificial replacement for lost
kidney function in people with renal failure.
• It is a process of cleansing the blood of accumulated waste products. It is used
for patients with end-stage renal failure or for acutely ill patients who require
short-term dialysis.
• Requires transporting blood from the client through a dialyzer, a semipermeable
membrane filter in a machine. The dialyser contains many tiny hollow fibers.
Blood moves through the hollow fibers. Water and wastes from the blood move
into the dialysate fluid that flows around the fibers, but the protein and RBC’s do
not. The filtered blood is returned to the client. The entire cycle takes 4-6 hours
and is performed three times a week.

2.) Frequency
Frequency depends upon the three types of hemodialysis:
Conventional hemodialysis
The procedure of conventional hemodialysis are: patients attached to a dialysis
machine; the function of a dialysis machine is to push blood to circulate through the
patient’s body and machine, at the same time, monitor temperature, blood pressure and
time of the procedure; if patient is using fistula or graft, two huge-gate needles on
patients’ side: one brings wastes- full blood from patients’ body to the dialyzer, while
another needle carries clean blood back to the body; it is offered three times a week
and 4 to 6 hours per session. Patients are required to follow their rigid schedule.
Daily hemodialysis
The procedure of daily hemodialysis is similar to the conventional hemodialysis except it
is performed six days a week and about 3 hours per session.
Nocturnal hemodialysis
The procedure of nocturnal hemodialysis is similar to conventional hemodialysis except
it is performed six nights a week and six-eight hours per session while patient sleep.
Three basic kinds of vascular access for hemodialysis:
Arteriovenous fistula- is useful because it causes the vein to grow larger and stronger
for easy access to the blood system. The best long-term vascular access for
hemodialysis because it provides adequate blood flow, lasts a long time, and has
a lower complication rate than other types of access. A surgeon creates an AV
fistula by connecting an artery directly to a vein, frequently in the forearm.
Connecting the artery to the vein causes more blood to flow into the vein. As a
result, the vein grows larger and stronger, making repeated needle insertions for
hemodialysis treatments easier.

• Arteriovenous graft- the graft becomes an artificial vein that can be used
repeatedly for needle placement and blood access during hemodialysis. A graft
doesn’t need to develop as a fistula does, so it can be used sooner after
placement, often within 2 or 3 weeks. Compared with properly formed fistulas,
grafts tend to have more problems with clotting and infection and need
replacement sooner. However, a well-cared-for graft can last several years.
 • Venous catheter for temporary access- If your kidney disease has progressed
quickly, you may not have time to get a permanent vascular access before you
start hemodialysis treatments. You may need to use a venous catheter as a
temporary access.
A catheter is a tube inserted into a vein in your neck, chest, or leg near the groin. It
has two chambers to allow a two-way flow of blood. Once a catheter is placed, needle
insertion is not necessary.
Catheters are not ideal for permanent access. They can clog, become infected, and
cause narrowing of the veins in which they are placed. But if you need to start
hemodialysis immediately, a catheter will work for several weeks or months while your
permanent access develops.

3.) Indications
Indications of dialysis in acute renal failure (ARF)
• Severe fluid overload not expected to respond to treatment with diuretics
• Refractory hypertension
• Uncontrollable hyperkalemia
• Nausea, vomiting, poor appetite, gastritis with hemorrhage
• Lethargy, malaise, stupor, coma, delirium, asterixis, tremor, seizures
• Pericarditis (risk of hemorrhage or tamponade)
• bleeding diathesis (epistaxis, gastrointestinal (GI) bleeding and etc.)
• Severe metabolic acidosis where correction with sodium bicarbonate is
impractical or may result in fluid overload
• Blood urea nitrogen (BUN) > 70 – 100 mg/dl
Indications of dialysis in chronic renal failure (CRF)
• Pericarditis
• Accelerated hypertension poorly responsive to antihypertensives
• Progressive uremic encephalopathy or neuropathy such as confusion, asterixis,
myoclonus, wrist or foot drop, seizures
• Bleeding diathesis attributable to uremia
• Symptomatic renal failure
• Low glomerular filtration rate (GFR) (RRT often recommended to commence at a
GFR of less than 10-15 mls/min/1.73m2). In diabetics dialysis is started earlier.
• Difficulty in medically controlling fluid overload, serum potassium, and/or serum
phosphorus when the GFR is very low

4.) Importance of hemodialysis

• To cleanse the blood from harmful wastes, excess fluids, electrolytes and toxic
substances
• Controls uremia
• To normalize electrolyte balance, fluid balance, and acid-base balance
• To stabilize weight
• Relieves manifestation of renal failure (RF) temporarily until client regains kidney
function
• Sustains life with irreversible kidney disease
• Keeps client alive until kidney donor is available
• Physically prepares the client to receive transplanted kidney
• Functions when your kidneys can no longer do so on their own
• helps you live, work and enjoy life despite failing kidneys as it serves
5.) Complications

Dialysis >Aused by removing urea nitrogen from the blood too rapidly in
Disequilibrium relation to its rate of removal from the brain
Syndrome (DDS) >s/sx: nausea, vomiting, mental confusion, hallucination,
convulsion & headache
Acute Hypertension >Due to sodium and water excess, also occurs with anxiety and
DDS
Hypotension >Excessive ultrafiltration that occurs several hours after dialysis
has started
>when moves rapidly from patient into the dialyzer
>excessive antihypertensive agents
Nausea & Vomiting >Frequent causes include DDS, hypertension, anxiety, peptic
ulcer, and reaction to medication
Headache >Occurs with hypertension, anxiety, DDS
>treatment: eliminating/controlling cause, analgesics and
tranquilizers may be used
Acute Bleeding >Occasionally in total heparinization, a pt may bleed due to peptic
ulcer or recent surgical wound
Muscle Cramps >caused by rapid sodium and water removal, calcium shifts %
neuromuscular sensitivity
>treatment: reducing ultrafiltration pressure or administering IV
saline or both, muscle relaxant, heat & massage
Cardiac >due to hypertension, electrolyte disturbances, fluid overload or
arrhythmias anemia
Chest pain >hypotension and cardiac arrhythmias frequently resulting in
angina
Shortness of breath >caused by overload, CHF & pulmonary embolism

6.) Preparations before, during, and after the procedure

Before:
 • weigh the patient
• take vital signs
• assess any acute illnesses
• obtain laboratory tests
• Inspect skin over the fistula or graft for signs of infection
• Palpates for a thrill over vascular access or listen for bruit
• Note color of skin and nail beds and mobility of fingers
• Wash skin over fistula or graft with soap and water

During:
• Avoid puncturing same site that was used previously
• Heparin (a medication that prevents blood clotting) is given
• Monitor vital signs
• Assess for any complications

After:
• Have patient lie on bed after to prevent hypotensions, light headedness, and
dizziness
• Assess vital signs
• Do not administer injections for 2-4 hours to allow metabolism and excretion of
heparin to a safe level
• Remove needle and apply pressure dressing
• Before discharging observes for DDS

7.) Nursing Interventions

• Protect and observe aseptic technique in caring for the vascular access
• Monitor body weight, vital signs, and complications
 • Dietary with fluid restriction, low in Na, k, phosphorus, fat, protein, and high in
calcium
• Administer IVT slowly
• Care of catheter site with soap and water prevent infection and maintain hygiene

Comparison of Hemodialysis and Peritoneal Dialysis:

Type of Advantages Disadvantages

Dialysis
 • Rapid removal of solutes • Bulge from fistula or graft is
and water obvious

• Takes less time • Risk for vascular

complications, infection,
distal ischemia, carpal tunnel
Hemodialysis • No risk for peritonitis syndrome, hypotension,
disequilibrium

• Personnel perform • Strict fluid and dietary

procedure in a dialysis restrictions
center
• Lifestyle cycles around
dialysis appointments

• Home hemodialysis requires

space for the machine and
training to use it

• Simple to perform • More time consuming

• Facilitates independence
• Weight gain from glucose in
• Easier access the dialysate

Peritoneal • No anticoagulation
• Peritonitis is a potential
• Fewer problems with complication
hypotension or
disequilibrium
• Requires training and
• Less rigid dietary and motivation
fluid restrictions

• More flexibility in lifestyle

and activities