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Managing HD unit

Professor Hesham Elsayed


How we can Qualify and Quantify HD
therapy ?

Basics of Therapy in HD units


Quality Metrics ?
Differences between

Practice Guidelines and


Performance measures

J Am Soc Nephrol 22: 225234, 2011


Practice Guidelines Performance measures

Recommendations for clinical


Tools to assess compliance with
Definition care based on best available
standards of clinical care
evidence and/or expert opinion
Objectively summarize complex
Measure, report, and compare
Purpose and expanding medical
the quality of care
literature for use by clinicians

Comprehensive coverage of quality evidence and a


Focus diverse aspects of care for a commitment to improved
condition performance

General, as physician is
Detailed, as predetermined
ultimately responsible for
technical specifications are
Specificity applying recommendations
needed for objective and fair
appropriately to specific patient
comparisons between groups
circumstance
Management OF Uremia is a complex therapy
HD : a Filtration Therapy do you agree ?
What Biomarkers are of value in
CKD5HD ?
Biomarkers in
HD patients Adequacy
Proteomics
Biomarkers

Nutrition and Identification


Inflammation of Retention
solutes ,
Biomarkers proteins

biomarkers have the


potential to refine risk CKD-BMD Anemia
stratification based on Biomarkers Markers
standard risk scores and to
guide therapy in patients on CVR
hemodialysis Biomarkers
Score in Uremia ??

Scores are tools to combine complex information into a


numerical value.
to assist in making diagnoses and prognoses,
and to evaluate therapeutic results and scores to help
physicians when informing and advising patients
The Water Treatment Station and
Dialysate safety
Patients are facing > 400 L / week
Components ?
Monitoring ?
Risk points ?
Requirements : ultrapure ?
Ultraviolet lamp

No brass, aluminum,
or galvanized metal
parts can be used
1.3. Products - Water pre treatment

Sand filter
Removes large particles ranging in size from 500um down to
5um
1.3. Products - Water pre treatment

Activated carbon filter


Removes chlorine or chloramines through adsorption by microporous structure of the
activated carbon and also removes dissolved organic substances
Dialysate Water
When chlorine is removed it is almost impossible to
completely prevent bacterial proliferation in the
treated water and the dialysate
Does Cytokine inducing substances ( Endotoxin
cross the LF hemodialysis membrane ?
Cytokine-inducing substances," cross both low-flux
and high-flux hemodialysis membranes
Schindler R, et al, JASN 2004;15(12):3207
1.3. Products - Water pre treatment

Softener / ion exchanger

Prevents calcium carbonate scale formation on other water treatment devices


downstream
Softeners are ion exchangers and
usually have sodium-containing cation
exchange resins which exchange Na+
ions for Ca++ and Mg++
1.4. Products - Complete water system
softener / ion Fine Filter activated raw water inlet unit
exchange 50 - 10 um carbon filter sand filter

RO-system AquaSafe 08 permeate storage tank

Fine Filter
5 - 1 um
Dialysate Water
Pretreatment (softener, activated carbon,
microfiltration)
Water polishing system (double reverse-
osmosis system in series)
Distribution loop (permanent circulation of
water with immediate delivery to dialysis
machines)
Disinfection processes (UV, Filter)

Canaud B et al, Nephro-Urol Mon.


2012;4(3)
1.3. Products - Water pre treatment
Fine filter Microfilters:
remove intermediate sized
particles of 5 - 1 um

Submicronic filters:
usually membranes with pore
sizes down to 0.1 um

Ultrafilters:
membranes with pore size less
than 0.1um
Maximum allowable levels for total viable microbial count (TVC)
and endotoxins in dialysis water, in standard and ultrapure
dialysis fluid (dialysate) and online-prepared substitution fluid
Sampling sites of dialysis solutions
How much and where ? Kidney International (2009) 76, 665672
Monitoring Sampling sites of dialysis solutions
Microorganisms (CFU/ml Endotoxins (EU/ml)

Online hemodiafiltration

Purified water Sampling site: 1, 2, 3 <100 <0.25

Ultrapure dialysis fluid Sampling site: 4 <0.1 <0.03

Substitution fluid Sampling site: 5 <10-6 <0.03


Guideline 4.3 - Monitoring of feed, product
and dialysis water for haemodialysis

Clinical Practice Guideline by the


UK Renal Association and Association of Renal
Technologists
Guideline 4.3 - Monitoring of feed, product
and dialysis water for haemodialysis
Back Filtration and Backdiffusion ?
Dialysis Membrane Is NOT a One Way
Street

Increasing Flux Risks :

ET transfer

Albumin Loss
Backfiltration depends on
Dialyzer Geometry
Hemoconc. UF
Pressure drop
Protein
Fouling UF done

BF

Net UF =
UFR in proximal part -
Backfiltration volume in distal
part
Independent t-
Control group Patients group test
No CVD + CVD
P-
T
(Group B) (Group A) value

Mean SD 0.29 0.12 0.36 0.07


0.001
Endotoxin predialysis (Eu/ml) 3.903
Range 0.09 0.5 0.1 0.45

Mean SD 0.31 0.11 0.27 0.12


Endotoxin postdialysis (Eu/ml) 1.903 0.059
Range 0.1 0.52 0.1 0.63

The same 21 (35.0%) 27 (45.0%)


Decrease 16 (26.7%) 18 (30.0%)
Endotoxin delta change 2.552 0.279*
Increase 23 (38.3%) 15 (25.0%)

Elsayed etal , ADC February 2016


Endotoxin predialysis (Eu/ml)

0.40 EF
0.35
62.87
0.30
70 52.30
0.25
60
0.20
0.15
50

0.10 40

0.05 30

0.00 20

Control Patients 10
group group
0
Control group Patients group

Elsayed etal , ADC February 2016


PO4(mg/dl)
6.2 6.06
6
5.8
5.6
5.4
5.19
5.2
5
4.8
4.6
Low flux filter High flux filter

Elsayed etal , ADC February 2016


positive correlation between
hs CRP and endotoxin
predialysis

Elsayed etal , ADC February 2016


Type of filter

0.29
0.285
0.28
0.275
0.27
0.265
0.26
0.255
0.25
0.245
LOW FLUX FILTER HIGH FLUX FILTER

endotoxin predialysis and high flux filter


Elsayed etal , ADC February 2016
Back Filtration and Backdiffusion

Back-filtration and back-diffusion occur with all membranes,


both low-flux and high-flux, with the dialyser membrane acting
as a final barrier between the patient and any microbiological
contaminants in the dialysis fluid

Clinical experience suggests that the combination of ultrapure


dialysis fluid and the barrier provided by the dialysis membrane
is safe for back-filtration volumes of up to 8 L per treatment. Not
all currently available dialysis membranes have the same ability
to limit transfer of microbiological contaminants from dialysis
fluid to blood
Nephrol. Dial. Transplant. (2013)
Dialysis membrane with highest Endotoxin
Adsorption capacity ?
Pyrogen Retention capacity of Dialysis membrane as a
Final Barrier (Ex vivo IL-1b production) Artificial Organs
5000
32(7):547554 , 2008
4500

4000

3500
IL-1B level

3000

2500

2000

1500

1000

500

Polysulfone Purema Polyflux APS


ET transferee
through
Dialysis
membrane

Artif Organs, Vol. 28, No. 2, 2004

Endotoxin concentrations measured in the blood compartments of low


flux filters after challenge with purified endotoxin.
Protection Performance
BALANCE

ET retention
capacity

Clearanc
e
Sources of Endoxemia in CKD
patients ?
Sources of Endotoxemia in CKD patients
Nephron Clin Pract 2011;118:c165c172

Endotoxemia

Contamination of Tissues, Gut leaking


Fluids or Foreign Bodies

CHF
Sepsis
Volume overload

dialysate Splanchnic hypoperfusion


Excessive UF (IDH)

Catheter
Bacterial overgrowth
AVF
Motility disorders
constipation
The GUT

Uremia causes disruption of intestinal barrier structure

A gut Feeling of
immersed Uremic
Toxins

Gut source of the


Endotoxins
Endotoxemia is a GUT feeling

ET translocation

Intracellular
Paracellular
passage
passage
Cellular signaling
Tightjunction
through TLR4
Biological systems responsible for triggering
inflammation

TLR 3
Viral RNA

TLR4
Bacterial LPS

TLR9
Bacterial
Oligodeoxynucleotides(ODN)

Nephron Clin Pract 2011;118:c165c172


Dialysate individualization ?
Optimizing Dialysate
Optimizing haemodialysate composition Na+

Adverse reactions due to Adverse reactions due to an


an excessively LOW excessively HIGH
concentration concentration

Intradialytic cardiovascular Na+ Refractory hypertension


instability Intradialytic hypertension
Disequilibrium symptoms Increased thirst sense
(fatigue, muscle cramps, Pulmonary edema
headache, etc.)
Optimizing haemodialysate composition K+

Adverse reactions due to Adverse reactions due to an


an excessively LOW excessively HIGH
concentration concentration

Arrhytmogenic effect K+ Risk of insufficient potassium


amplified by a rapid removal with secondary
correction of metabolic hyperkalemia in the
acidosis, low dialysate interdialytic period
calcium concentration, Increased mortality
high ultrafiltration rate,
abrupt kalemia decrease
Optimizing haemodialysate composition HCO3

Adverse reactions due to Adverse reactions due to an


an excessively LOW excessively HIGH
concentration concentration

Acidosis with secondary HCO3 Increased calcium binding


abnormal protein to proteins, reduction of
metabolism and ionized calcium, and impaired
malnutrition cardiac muscle contraction
Osteodystrophy and arterial pressure
preservation
Hypoxemia, with further
impaired cardiac function
Optimizing haemodialysate composition Ca++

Adverse reactions due to an Adverse reactions due to an


excessively LOW concentration excessively HIGH concentration
Hypotension and cardiac Ca++ Long-term risk of vascular and
arrhythmias during hemodialysis and valvular calcifications
long-term risk of secondary
hyperparathyroidism Risk of over suppression of
Increased risk of sudden cardiac parathyroid hormone and adynamic
arrest bone disease, with high plasma [Ca]
Increased circulating parathyroid and soft-tissue calcifications
hormone levels (PTH) in the presence
of adynamic bone disease and low
serum PTH levels
Risk of excessive bone mineral loss
in patients with long daily or nocturnal
hemodialysis sessions
Optimizing haemodialysate composition Mg++

Adverse reactions due to Adverse reactions due to an


an excessively LOW excessively HIGH
concentration concentration

Leg cramps Mg++ Signs and symptoms of


Significant drop in mean hypermagnesemia
arterial pressure in the (hyporeflexia, weakness up to
association of dialysate paralysis that can involve the
calcium concentration of diaphragm, bradycardia,
1.25 mmol/L and hypotension, cardiac arrest,
magnesium concentration inhibition of parathyroid
of 0.25 mmol/L hormone secretion with
secondary hypocalcemia)
Optimizing haemodialysate composition Glucose

Adverse reactions due to Adverse reactions due to an


an excessively LOW excessively HIGH
concentration concentration

Risk of hypoglycemia Glucose Impaired triglyceride


Greater loss of metabolism
aminoacids in the dialysate Risk of pro-inflammatory
stimulus secondary to
hyperglycemia
What is the optimum pre and post
Blood HCO3 conc . ?
Do you check in your units ?
Optimizing haemodialysate composition HCO3
the ideal pre- and postdialysis plasma [HCO3] should
range between 24 and 28 mmol/L, although, most
patients have a pre-HD plasma [HCO3] of 1922 mmol/L
after the long interval between HD sessions. The
dialysate [HCO3] should not exceed 35 mmol/L
Association of predialysis serum bicarbonate
levels with risk of mortality and hospitalization in
the Dialysis Outcomes and Practice Patterns
Study (DOPPS) American Journal of Kidney Diseases 05/2013

Patients with midweek predialysis serum bicarbonate


levels of 20.1 to 21.0 mEq/L (mmol/L) faced the lowest
risk for mortality, whereas those with bicarbonate levels
of 21.1 to 22.0 mEq/L faced the lowest risk for
hospitalization. Both high (>27 mEq/L) and low (< or =17
mEq/L) serum bicarbonate levels were associated with
increased risk for mortality and hospitalization.
Single center study on 40 patients
Elsayed H , Shaaban A , M Heba

changes in MAP with changes in serum HCO3 at end of the session.


IDWG
Single center study on 40 patients
Elsayed H , Shaaban A , M Heba Kidney International2011;79(2):250-257
Rapid Fluid Removal During Dialysis is
Associated With Cardiovascular
Morbidity and Mortality
Time MAP HR pH HCo3
At the end
of the
session r -0.446 -0.110 0.043 0.067

P 0.004 0.501 0.794 0.682


-
IDWG
% Change r -0.365 0.273 0.127 0.294

P 0.021 0.089 0.434 0.066

Mean r -0.246 -0.163 0.168 -0.038


P 0.126 0.314 0.301 0.814
Dialysate as a substitution Fluid

On line Hemodiafiltration
On Line Preparation of HDF solution

The differences between the 2 available


systems ?:
2 Barrier System
And (2
) (1

3 Barrier System )

(3
)
On Line Preparation of HDF solution

Ledebo I JASN 2002;13:S78-S83


On Line Preparation of HDF solution
2 Barrier System

100 sessions Performance


12,000 liters over time
3rd Barrier
Disposable Filter
100% performance
Potassium Kinetics

How much is removed during HD session ?


What is K rebound ?
K kinetics during Hemodialysis
Mostly removed
within first 2 hours
of HD

CONCENTRATION
GRADIENT

51 mmol with 63 mmol with the 78 mmol with the


the 2-K dialysate 1-K dialysate 0-K dialysate
K Rebound After HD

[K] post-HD and [K] end of HD denote [K] 1h


after HD
and at 240 min of HD, respectively.
The finding of two
frequency peaks of
sudden death,
immediately before and
after the first weekly
haemodialysis session,
suggests that daily
haemodialysis, or at
least the abolition of the
long interdialytic interval
during the weekend,
could be helpful in
reducing this kind of
mortality.
Kidney International (2011) 79, 147 149.
Association of Dialysis Treatment
Practices with Mortality
Patient level
HR 95% CI p
Treatment time <210 min (vs. 210 min):
All-cause mortality 1.06 (1.00, 1.13) 0.04
Sudden death 1.13 (1.00, 1.27) 0.04
Other cardiovascular death 1.00 (0.89, 1.12) 0.96
Non-cardiovascular death 1.06 (0.97, 1.17) 0.20
Kt/V <1.2 (vs. 1.2):
All-cause mortality 1.06 (1.00, 1.12) 0.07
Sudden death 1.10 (0.97, 1.24) 0.15
Other cardiovascular death 0.96 (0.85, 1.08) 0.48
Non-cardiovascular death 1.10 (1.00, 1.21) 0.04
UF volume >5.7% of post-weight (vs. 5.7%):
All-cause mortality 1.09 (1.01, 1.19) 0.03
Sudden death 1.15 (1.00, 1.32) 0.04
Other cardiovascular death 1.17 (1.01, 1.36) 0.04
Non-cardiovascular death 1.00 (0.88, 1.14) 0.98
Association of Dialysate K*
with Mortality
Patient-level
Dialysate K 1.5 (vs. 3) Dialysate K 2-2.5 (vs. 3)
HR 95% CI p HR 95% CI p
All patients (N=37,741)
All-cause mortality 1.13 (1.03, 1.25) 0.01 1.08 (1.01, 1.16) 0.03
Sudden death 1.39 (1.12, 1.74) 0.004 1.17 (1.01, 1.37) 0.04
Other cardiovascular death 1.14 (0.95, 1.36) 0.16 1.04 (0.91, 1.19) 0.54
Non-cardiovascular death 0.99 (0.84, 1.17) 0.93 1.05 (0.94, 1.16) 0.38
Among patients with serum K 5 (N=17,327)
All-cause mortality 1.09 (0.95, 1.26) 0.23 1.08 (0.97, 1.20) 0.17
Sudden death 1.21 (0.91, 1.61) 0.18 1.11 (0.90, 1.38) 0.33
Other cardiovascular death 1.16 (0.88, 1.52) 0.29 1.00 (0.82, 1.21) 0.97
Non-cardiovascular death 0.97 (0.77, 1.22) 0.81 1.10 (0.93, 1.31) 0.27
Among patients with serum K <5 (N=20,414)
All-cause mortality 1.15 (1.00, 1.33) 0.04 1.06 (0.98, 1.15) 0.15
Sudden death 1.53 (1.10, 2.13) 0.01 1.18 (0.98, 1.42) 0.08
Other cardiovascular death 1.05 (0.85, 1.31) 0.64 1.05 (0.88, 1.24) 0.58
Non-cardiovascular death 1.03 (0.77, 1.38) 0.83 1.00 (0.88, 1.15) 0.95

*N
KD 1.5=5,493; NKD = 2-2.5=25,552; NKD 3=6,696
Association of Treatment Practices with
Sudden Death
Patient model All-cause mortality
Sudden death
Treatment time
(per 30 min lower)

Sp Kt/V
(per 0.1 unit lower)

UF volume
(per 1% higher)

Dialysate K
(per 1 mEq/l lower)

0.85 1.00 1.15 1.30

Hazard Ratio (95% CI)


*used predicted treatment from 1st stage
Timed treatment of HyperK
HD induced Blood Hemolysis
K Load during HD
Hemolysis
Blood line induced clotting

platelet contact activation


Formation of platelet fibrin - red cells
thrombus

Clin J Am Soc Nephrol 3: 382-386, 2008


Rough surface
Recommended
Blood Flow and Dialysis session length ?
DOPPS 4 (2011)
Prescribed blood
flow rate
(categories), by
country
DOPPS 4 (2011) Achieved
dialysis session length
(categories), by country
DOPPS Germany: Achieved
dialysis session length
(categories), by cross-section
DOPPS Japan:
Achieved dialysis
session length
(categories), by cross-
section
Dialyzer Flux used in Japanese patients
Therapeutic Apheresis and Dialysis Volume 14, Issue 6, pages 505540, December 2010

Flux used in Japanese HD patients According to functional


classification

98% are
90.00%
80.30%
80.00%

70.00%
HPM
60.00% 2011
50.00%

40.00%

30.00%
19.70%
20.00%

10.00%

0.00%

Others Type IV
Dialyzer surface area used in Japanese patients 2008
Therapeutic Apheresis and Dialysis Volume 14, Issue 6, pages 505540, December 2010

surface area m2
35.00%

30.00% 29.00%

25.00%

20.00% 18.70%
16.50%
15.00%
11.90% 11.60%
10.00%
7.10%
5.00%
2.10% 2.00%
1.00%
0.00%
<1.0 m2 1.0 m2 1.2 m2 1.4 - 1.6m2 1.8 m2 2.0 m2 2.2 m2 2.4 m2
1.5m2
Dialyzer Flux used in 14580Egyptian HD patients

Flux used in Egyptian HD patients


100.00%

90.00%

80.00%

70.00%
93.20%
60.00%

50.00%

40.00%

30.00%

20.00%

10.00% 6.80%
0.00%

Low Flux High Flux


Dialyzer surface area used in 14886 Egyptian
HD patients
surface area m2
70.00%
62.60%
60.00%

50.00%

40.00%

30.00%

20.00% 18.30%

9.80%
10.00%
3.30% 3.90%
0.40% 0.30% 0.20% 1.10% 0.10%
0.00%
< 1.0 m2 1.0 m2 1.1 m2 1.2 m2 1.3 m2 1.4 m2 1.6 m2 1.7 m2 1.8 m2 2.1 m2
Vascular Access
HD Vascular Access
How to choose the access
that is best for patients
About the pros and cons
of the different types of access
Why the access is important
to getting the most from
hemodialysis treatment
A continuous quality improvement
(CQI) program should be instituted to
investigate failed AV fistulas and
patients with non-AVF access.
There should be timely referral to nephrologists
who can initiate plans for AVF in appropriate
patients.
There should be early referral to surgeons for
evaluation and timely placement of AVFs.
Surgeons should conduct appropriate presurgical
evaluation and use current techniques in placing
fistulas.
Patients with AV grafts should be evaluated for
possible secondary AVF placement.
Patients with catheters should be evaluated for AVF
placement.
Dialysis staff should be well trained in cannulation
techniques and protocols.
AVFs should be regularly monitored with timely referral to
the appropriate specialist for failing AVFs.
Continuing education should be provided to all persons
involved in the care of patients with AVFs including the
patients themselves.
Data obtained through CQI should be regularly reviewed
and evaluated
HD Vascular Access

An AV (artery-vein) fistula AVF


is the best choice for hemodialysis.
HD Vascular Access

AVF
preferred because
it usually lasts longer and has
fewer problems like clotting and infections.
Vascular access use in Europe and the United States: CKD HD preparation
Results from the DOPPS Kidney International, Vol. 61 (2002),
program
Fistula First Initiative FFI

In 2003, the CMS and the ESRD networks jointly formed and
implemented a National Vascular Access Improvement Initiative
called the Fistula First Initiative (FFI)

The primary goal of this continuous quality improvement (CQI)


project was to increase the appropriate use of AVF for HD access
and to reach or exceed the K/DOQI guidelines of 50% in incident
and 40% in prevalent patients .
The recently revised goal is to have 65% of prevalent patients using
an AVF by 2009
DOPPS 4 (2011) Vascular access in use at cross-section, by
country
USA DOPPS
CANADA DOPPS
Vascular Access IN Egyptian HD patients : 22,070 patients
Elsayed H. Sarhan .I , Sharkawey M , etal
current Patients Vascular access
80.00%
72.50%
Functional AVF
70.00%
at the time of
60.00% data

50.00%

40.00%

30.00% 25.70%
20.00%

10.00%
1.70%
0.00%
AVF Catheter AVG
AVF Catheter AVG
Vascular catheter IN Egyptian HD patients : 5674 patients

current Patients Vascular Catheter


100.00% 94.20%
90.00%

80.00%

70.00%

60.00%

50.00%

40.00%

30.00%

20.00%

10.00% 5.87%
0.00%
Temporarily Permenant
Temporarily Permenant
Vascular Access IN Egyptian HD patients
: 22,070 patients
Prevalent Patients
70.00%

60.60% Vascular Catheter is


60.00%
required all the times in-
50.00% between Access Failure
40.00%

30.00%

20.00% 17.40%

10.00%

0.00%
First Access Failure Second Access Failure
First Access Failure Second Access Failure
What is the Egyptian rationale

Permanent
Temporarily catheter
AVF Catheter AVG
Insertion
EARLY USE The Easiest Infection facility
WEAK way for the rupture weak flow (
FISTULAS Nephrologist Fibrin sheath
Reversed
connection
infection

AVF Temp. AVF / AVG Temp. Permeant


Catheter Catheter catheter
HD Vascular Access

AVF
HD Vascular Access

An AV (artery vein) graft is the second choice for an access.


HD Vascular Access

AVG
HD Vascular Access

Catheter
HD Vascular Access Clinical Practice Guidelines
and Clinical Practice Recommendations
2006 Updates
CLINICAL PRACTICE GUIDELINES FOR VASCULAR ACCESS

GUIDELINE 1. PATIENT PREPARATION FOR PERMANENT


HEMODIALYSIS ACCESS
Appropriate planning allows for the initiation of dialysis therapy
at the appropriate time with a permanent access in place at
the start of dialysis therapy
HD Vascular Access

1.1 Patients with a glomerular filtration rate (GFR) less than 30 mL/min/1.73 m2 (CKD
stage 4) should be educated on all modalities of kidney replacement therapy (KRT)
options, including transplantation, so that timely referral can be made for the
appropriate modality and placement of a permanent dialysis access, if necessary. (A)

1.2 In patients with CKD stage 4 or 5, forearm and upper-arm veins suitable for
placement of vascular access should not be used for venipuncture or for the
placement of intravenous (IV) catheters, subclavian catheters, or peripherally inserted
central catheter lines (PICCs). (B)

1.3 Patients should have a functional permanent access at the initiation of


dialysis therapy
Time necessary for AVF and AVG prior to HD
HD Vascular Access

1.3.1 A fistula should be placed at least 6 months before the


anticipated start of HD treatments. This timing allows for access
evaluation and additional time for revision to ensure a working
fistula is available at initiation of dialysis therapy. (B)
1.3.2 A graft should, in most cases, be placed at least 3 to 6
weeks before the anticipated start of HD therapy. Some newer
graft materials may be cannulated immediately after
placement. (B)
HD Vascular Access

Evaluations that should be performed before placement of a permanent HD


access include :
1.4.1 History and physical examination, (B)
1.4.2 Duplex ultrasound of the upper-extremity arteries and veins, (B)
1.4.3 Central vein evaluation in the appropriate patient known to have a
previous catheter or pacemaker. (A)
Best Tool/Technique?

Physical Exam!
Look, Listen, and Feel
Use Your:

Eyes

Ears

Fingertips 114
HD Vascular Access
Look for Complications
Changes in Access
Redness
Drainage Infection
Abscess
Cannulation sites Distal Areas of Access Extremity
Aneurysms
Hands/Feet:
Changes in Access Cold
Extremity
Skin color Central Painful Steal Numb
Edema
Small blue or syndrome
or purple outflow
veins Fingers/Toes:
Hematoma vein
Bruising
stenosis Discolored
116
Stenosis

Frequent cause of
early fistula failure

Stenosis

117

Photo courtesy of L. Spergel, MD


HD Vascular Access
Infection

Lower rate with AVF compared with other access types1,2


Staphylococcus aureus the most common pathogen2
Patients and dialysis team personnel have high rates of
Staphylococcus on skin3
Handwashing before, after, and between patients is critical4

1. National Kidney Foundation. Am J Kidney Dis. 2006;48(suppl 1):S1-S322.


2. Dialysis Outcomes and Practice Patterns Study (DOPPS) Guidelines. Available at: www.dopps.org.
3. Kirmani N, et al. Arch Intern Med. 1978;138:1657-1659.
4. Boyce JM, Pittet D. MMWR 2002;51(RR16):1-44.
120
Role of 6s in AVF ?
In general, such an access has a flow of
approximately 600 mL/min, is less than 0.6
cm below the surface of the skin, and has
a minimal diameter of 0.6 cm (Rule of 6s)
In general, a working fistula must have all the following
characteristics:
1-blood flow adequate to support dialysis, which usually equates
to a blood flow greater than 600 mL/min;
2-a diameter greater than 0.6 cm, with location accessible for
cannulation and discernible margins to allow for repetitive
cannulation;
3- a depth of approximately 0.6 cm (ideally, between 0.5 to 1.0
cm from the skin surface).
This combination of characteristics can be remembered easily as
the Rule of 6s.
HD Vascular Access

2.1 The order of preference for placement of fistulae in


patients with kidney failure who choose HD as their initial
mode of KRT should be (in descending order of
preference):
2.1.1 Preferred: Fistulae. (B)
2.1.1.1 A wrist (radiocephalic) primary fistula. (A)
2.1.1.2 An elbow (brachiocephalic) primary fistula. (A)
2.1.1.3 A transposed brachial basilic vein fistula: (B)
HD Vascular Access

2.1.2 Acceptable: AVG of synthetic or biological


material, such as: (B)
2.1.2.1 A forearm loop graft, preferable to a straight
configuration.
2.1.2.2 Upper-arm graft.
2.1.2.3 Chest wall or necklace prosthetic graft or lower-
extremity fistula or graft; all upper-arm sites should be exhausted
HD Vascular Access

2.1.3 Avoid if possible: Long-term catheters. (B)


2.1.3.1 Short-term catheters should be used for acute
dialysis and for a limited duration in hospitalized
patients. Noncuffed femoral catheters should be used
in bed-bound patients only. (B)
2.1.3.2 Long-term catheters or dialysis port catheter
systems should be used in conjunction with a plan for
permanent access. Catheters capable of rapid flow
rates are preferred. Catheter choice should be based
on local experience, goals for use, and cost. (B)
HD Vascular Access

2.1.3.3 Long-term catheters should not be placed on


the same side as a maturing AV access, if possible. (B)
HD Vascular Access
2.4 Catheters and port catheter systems:
2.4.1 The preferred insertion site for tunneled cuffed
venous dialysis catheters or port catheter systems is the right
internal jugular vein. Other options include the right external
jugular vein, left internal and external jugular veins, subclavian
veins, femoral veins, and translumbar and transhepatic access
to the IVC. Subclavian access should be used only when no
other upper-extremity or chest-wall options are available. (A)
2.4.2 Ultrasound should be used in the placement of catheters.
(B)
2.4.3 The position of the tip of any central catheter should be
verified radiologically. (B)
HD Vascular Access
GUIDELINE 7. PREVENTION AND TREATMENT OF CATHETER AND
PORT COMPLICATIONS

7.1 Catheters and ports should be evaluated when they


become dysfunctional.
Dysfunction is defined as failure to attain and maintain an
extracorporeal blood flow of 300 mL/min or greater at a
prepump arterial pressure more negative than 250 mm Hg. (B)
Catheter
Catheter
HD Vascular Access

7.3 Methods that should be used to treat a dysfunctional or


nonfunctional catheter or port include:
7.3.1 Repositioning of a malpositioned catheter. (B)
7.3.2 Thrombolytics, using either an intraluminal lytic,
intradialytic lock protocol, or an intracatheter thrombolytic
infusion or interdialytic lock. (B)
HD Vascular Access

7.3.3 Catheter exchange with sheath disruption, when


appropriate. (B)

7.4 Treatment of an infected HD catheter or port should


be based on the type and extent of infection.
HD Vascular Access

7.4.1 All catheter-related infections, except for catheter


exit-site infections, should be addressed by initiating
parenteral treatment with an antibiotic(s) appropriate
for the organism(s) suspected. (A)

7.4.2 Definitive antibiotic therapy should be based on


the organism(s) isolated. (A)
HD Vascular Access

7.4.3 Catheters should be exchanged as soon as possible and


within 72 hours of initiating antibiotic therapy in most instances,
and such exchange does not require a negative blood culture
result beforethe exchange. (B)
Follow-up cultures are needed 1 week after cessation of
antibiotic therapy (standard practice).
7.4.4 Port pocket infections should be treated with systemic
antibiotics and irrigation, in conjunction with the manufacturers
recommendations.(B)
HD Vascular Access
HD Vascular Access
Short Notes :
In catheters recently placed, inadequate blood flow usually is the
result of mechanical obstruction, improper tip location affected
by patient position, or a problem of catheter integrity.

The need to use a Trendelenberg position to achieve adequate


blood flow from a catheter placed in great veins leading to the
right atrium always implies that the catheteris improperly placed.
HD Vascular Access

The location of obstruction may reside in the following areas:

1. Intraluminal thrombuswithin lumen of catheter, partial or


complete occlusion.
2. Catheter tipin catheters with side holes at tip of arterial
limb, thrombus may occlude or act like ball valve.
3. Fibrin sheath (fibrin sleeve)fibrin adheres to external surface
of catheter, thrombus trapped between sheath and catheter
tip.
4. Fibrin tail (fibrin flap)fibrin adheres to CVC end, ball valve
effect.
HD Vascular Access
HD Vascular Access

GUIDELINE 8. CLINICAL OUTCOME GOALS


8.1 Goals of access placement:

8.1.1 Each center should establish a database and CQI process


to track the types of accesses created and complication rates for
these accesses.
HD Vascular Access

8.1.2 The goals for permanent HD access placement


should include:
8.1.2.1 Prevalent functional AVF placement rate of
greater than 65% of patients. (B)

8.1.2.2 Cuffed catheter for permanent dialysis access


(eg, not as a bridge) in less than 10% of patients. Long-
term catheter access is defined as the use of a dialysis
catheter for more than 3 months in the absence of a
maturing permanent accessgraft or fistula. (B)
HD Vascular Access

8.2 The primary access failure rates of HD accesses in the


following locations and configurations should not be more
than the following:
8.2.1 Forearm straight grafts: 15%. (B)
8.2.2 Forearm loop grafts: 10%. (B)
8.2.3 Upper-arm grafts: 5%. (B)
8.2.4 Tunneled catheters with blood flow less than 300 mL/min:
5%. (B)
INFECTION TYPES RELATED TO
VASCULAR CATHETER ?
HD Vascular Access
Treatment of an Infected HD Catheter or Port (CPG 7.4)
Definitions
Exit-site infection. Inflammation confined to the area surrounding
the catheter exit site, not extending superiorly beyond the cuff if
the catheter is tunneled, with exudate culture confirmed to be
positive.
Tunnel infection. The catheter tunnel superior to the cuff is
inflamed, painful, and may have drainage through the exit site
that is culture positive.
Catheter-related bacteremia. Blood cultures are positive for the
presence of bacteria with or without the accompanying
symptom of fever
Infections of Catheters

200 Hours Course for Person In Charge


HD Vascular Access

Catheter exit-site infections alone usually can be salvaged with


topical and oral antibiotics without the need for catheter
replacement
CRB is the major reason for catheter loss

It is a life-threatening condition requiring initial hospitalization


and parenteral antibiotic therapy if the patient is clinically septic
HD Vascular Access

An alternative to this management of dialysis CRB


(systemic antibiotics with catheter exchange, as well
as removal of the infected catheter) is catheter
salvage by combining systemic antibiotics in
conjunction with antibiotic locks
HD Vascular Access

Bacteremia with tunnel-tract involvement should


prompt catheter removal. Unstable patients require
removal of the catheter for rapid response to therapy.
The Work Group believes that a minimum of 3 weeks of
systemic antibiotic therapy is needed to treat CRB and
that new permanent access should not be placed until
culture results have been negative for at least 48 hours
after cessation of antibiotic therapy
Clinical Guideline

KDOQI Clinical Practice


Guideline for Hemodialysis:
2015 Update
Clinical Guideline
Grade for Quality of Evidence
A: High quality of evidence. We are confident that the true effect
lies close to that of the estimate of the effect.
B: Moderate quality of evidence. The true effect is likely to be
close to the estimate of the effect, but there is a possibility that it is
substantially different.
C: Low quality of evidence. The true effect may be substantially
different from the estimate of the effect.
D: Very low quality of evidence. The estimate of effect is very
uncertain and often will be far from the truth
Clinical Guideline
Summary of Recommendation Statements

Guideline 1: Timing of Hemodialysis Initiation


Guideline 2: Frequent and Long Duration Hemodialysis
Guideline 3: Measurement of Dialysis: Urea Kinetics
Guideline 4: Volume and Blood Pressure Control:
Treatment Time and Ultrafiltration Rate
Guideline 5: New Hemodialysis Membranes
In patients with CKD, does starting dialysis
earlier improve outcomes ?
Clinical Guideline
Guideline 1: Timing of Hemodialysis Initiation
1.1Patients who reach CKD stage 4 (GFR < 30 mL/min/1.73
m2), including those who have imminent need for
maintenance dialysis at the time of initial assessment,
should receive education about kidney failure and options
for its treatment, including kidney transplantation, PD, HD in
the home or in-center, and conservative treatment.
Clinical Guideline

Guideline 1: Timing of Hemodialysis Initiation


1.2The decision to initiate maintenance dialysis in patients who choose
to do so should be based primarily upon an assessment of signs
and/or symptoms associated with uremia, evidence of protein-energy
wasting, and the ability to safely manage metabolic abnormalities
and/or volume overload with medical therapy rather than on a
specific level of kidney function in the absence of such signs and
symptoms. (Not Graded)
Early versus late Dialysis

Study Treatment
Patients were randomly assigned either to commence
dialysis when the estimated GFR was 10.0 to 14.0 ml per
minute (early-start group) or
to continue to receive routine medical care and
commence dialysis when the estimated GFR was 5.0 to
7.0 ml per minute (late-start group).
Enrollment, Randomization, and Follow-up.
Cooper BA et al. N Engl J Med 2010;363:609-619.
Primary and Secondary Outcomes, Including Adverse Events.
Cooper BA et al. N Engl J Med 2010;363:609-619.
KaplanMeier Curves for Time to the Initiation
of Dialysis and for Time to Death.

among patients with progressive chronic kidney


disease, clinical outcomes, including survival, are
similar between patients in whom dialysis is initiated
early and those for whom dialysis is electively
delayed. The results show that with careful clinical
management, dialysis may be delayed until either
the GFR drops below 7.0 ml per minute or more
traditional clinical indicators for the initiation of
dialysis are present.

Cooper BA et al. N Engl J Med 2010;363:609-619.


Clinical Guideline

Rationale for Guideline 1.1


Recent KDIGO (Kidney Disease: Improving Global
Outcomes) and prior KDOQI guidelines recommend
referral of all individuals with GFR < 30 mL/min/1.73 m2 to
a nephrologist, stressing that timely nephrology referral
maximizes the likelihood of adequate planning for KRT (
Kidney Replacement Therapy )to optimize decision
making and outcomes.
Clinical Guideline

Rationale for Guideline 1.2


The balance among the benefits, risks, and
disadvantages of initiating or not initiating dialysis should
be evaluated, taking into account education received
and preferences expressed by the patients and/or their
caregivers.
Symptoms of uremia are nonspecific, and attempts
should be made to evaluate for other, sometimes
reversible, causes of symptoms
Clinical Guideline

Rationale for Guideline 1.2


The decision to initiate KRT should not be based on
estimated GFR (eGFR) level alone, in large part
reflecting the imprecision of measurement
the Work Group thought that sufficient data exist to
discourage reliance on a specific eGFR level. In
patients with advanced CKD, serum creatininebased
estimating equations are substantially influenced by
muscle mass, making eGFR both a marker of
sarcopenia and kidney function
Clinical Guideline Factors Creatinine
level
Demographic characteristics
Older age Decreased
Clinical Settings Affecting Creatinine Generation
Female sex Decreased
African Americanaa Increased
Hispanic Decreased
Asian Decreased
Clinical characteristics
Muscular habitus Increased
Rhabdomyolysis Increased
Loss of muscle (amputation, neuromuscular diseases,
Decreased
cachexia)
Cirrhosis/advanced liver disease Decreasedbb
Protein-energy wasting/inflammation Decreased
Dietary characteristics
Vegetarian/vegan diet Decreased
High meat diet Increased
Descriptive Nomenclature for Various HD
Prescriptions
Duration Frequency
Proposed Name Time of Day
(h/session) (sessions/wk)
Conventional HD Daytime 3-5 3-4
Frequent HD
Short Daytime <3 5-7
Standard Daytime 3-5 5-7
Long Nighttime >5 5-7
Long HD
Long thrice weekly Nighttime or daytime >5 3
Long every other
Nighttime >5 3.5
night
Long frequent Nighttime >5 5-7
Clinical Guideline

Guideline 2: Frequent and Long Duration Hemodialysis


2.2We recommend that patients considering in-center
short frequent hemodialysis be informed about the risks
of this therapy, including a possible increase in vascular
access procedures (1B) and the potential for
hypotension during dialysis. (1C)
Clinical Guideline

Guideline 2: Frequent and Long Duration Hemodialysis


2.3Consider home long hemodialysis (6-8 hours, 3 to 6
nights per week) for patients with end-stage kidney
disease who prefer this therapy for lifestyle
considerations
HD during Pregnancy ?
Clinical Guideline

Guideline 2: Frequent and Long Duration


Hemodialysis
2.5During pregnancy, women with end-stage
kidney disease should receive long frequent
hemodialysis either in-center or at home,
depending on convenience
Blood Flow Rates
Dialysate Flow Rate
Definitions
Clinical Guideline
Descriptive Nomenclature for Various HD Prescriptions

Blood flow rate


Standard 300 mL/min
Low flow <300 mL/min

Dialysate flow rate


Standard 500 mL/min
Low flow <500 mL/min
Clinical Guideline
Guideline 3: Measurement of Dialysis---Urea Kinetics
Target Dose (Guideline 3.1)
This guideline is unchanged from the previous guideline.
Small-solute clearance is currently considered the best
measure of HD and its adequacy. Kt/V, the fractional urea
clearance, is the most precise and tested measure of the
dialyzer effect on patient survival and is the most frequently
applied measure of the delivered dialysis dose.
Clinical Guideline
Methods for Measuring Urea Clearance
Urea Kt/V is most conveniently measured using mathematical
modeling of the predialysis and postdialysis serum urea
concentration.

This method provides an integrated or average clearance


during the entire HD and is patient specific, often called the
delivered HD dose
Clinical Guideline
Methods for Measuring Urea Clearance

The predialysis blood sample must be drawn before


injecting saline, heparin, or other potential diluents.
The postdialysis blood sample should be drawn from
the dialyzer inflow port using a slow-flow method
(100 mL/min for 15 seconds) or a stop-dialysate-flow
method (for 3 minutes). These measurements should
be done at least monthly as recommended in the
previous guidelines
Clinical Guideline
Methods for Measuring Urea Clearance

Kt/V calculated using the equilibrated postdialysis blood urea


nitrogen (BUN) level (eKt/V) is recommended by some as a
more accurate determinant of the dialysis
Methods used to measure eKt/V require waiting 30 minutes
after stopping HD to obtain the postdialysis blood sample, or
an alternative mathematical manipulation of the BUN in the
immediate postdialysis blood sample
Target HD dose ?
Clinical Guideline

Guideline 3: Measurement of Dialysis---Urea Kinetics


3.1We recommend a target single pool Kt/V (spKt/V) of 1.4
per hemodialysis session for patients treated thrice weekly,
with a minimum delivered spKt/V of 1.2. (1B)
Why Urea is used for assessing the HD
dose ?
The ideal representative solute for assessment of clearance
should be:
easily measured and freely move by diffusion through the dialysis
membrane and among body compartments
without sequestration in remote compartments or
binding to macromolecules in the serum.
Clinical Guideline

Guideline 4: Volume and Blood Pressure Control---Treatment


Time And Ultrafiltration Rate
4.1.1Consider additional hemodialysis sessions or longer
hemodialysis treatment times for patients with large weight gains,
high ultrafiltration rates, poorly controlled blood pressure, difficulty
achieving dry weight, or poor metabolic control (such as
hyperphosphatemia, metabolic acidosis, and/or hyperkalemia).
Clinical Guideline
Guideline 4: Volume and Blood Pressure Control---Treatment
Time And Ultrafiltration Rate
4.2We recommend both reducing dietary sodium intake as well as
adequate sodium/water removal with hemodialysis to manage
hypertension, hypervolemia, and left ventricular hypertrophy. (1B)

4.2.1Prescribe an ultrafiltration rate for each hemodialysis


session that allows for an optimal balance among
achieving euvolemia, adequate blood pressure control
and solute clearance, while minimizing hemodynamic
instability and intradialytic symptoms
Myocardial Stunning ?
Clinical Guideline
Higher ultrafiltration volumes have been shown to be
associated with higher odds of myocardial stunning.
In addition, HD itself is associated with decreases in
myocardial blood flow that are accentuated by
ultrafiltration.
These data suggest that microcirculatory changes are not
solely due to reductions in plasma volume and may be
caused by other factors as well.
Taken together, the above considerations informed the
opinion of the Work Group to recommend minimizing
ultrafiltration rates as best possible in order to maximize
hemodynamic stability and tolerability of the HD procedure
Clinical Guideline

Guideline 5: Hemodialysis Membranes

All are still debatable on


Low Flux
High Flux
HDF
184

We recommend the use of biocompatible, either high


or low flux hemodialysis membranes for intermittent
hemodialysis. (1B)

KDOQI Clinical Practice Guideline for


Hemodialysis Adequacy: 2015 Update
Nephrologist Opinion ?
The best dialysis therapy? Results from an international survey among
nephrology professionals High Flux HDF > 7 years
ago !!

Only 7%
recommend LF
dialysis

Ledebo I , and Ronco C NDT Plus 2008;1:403-408



Can Not use a RCTs with and without using a
Parachute while jumping from airplane
Fibers Development is increasing Both in Fluxes and in
Volume
HPM
HF
LF
Fiber development and Volume is increasing (Flux and Amount)

- Larger Pores
- biocompatibility
- adsorptive features

149,600,000 km
2.250,000
Patients on HD

DIALYZER FLUX USE


LOW FLUX HIGH FLUX
120%

100%

80%
46%
60% 67%
40%

54%
20%
33%
0%

YEAR 2000 YEAR 2013


High Flux suitable for large volume UF

Filtration
Profiles Low-
flux vs high-
flux Dialysers
1980
1990
LF membranes
2000
No Albumin leak HF Membrane
Minimal Albumin HPM
Leak Allow < 3gm
Albumin Leak
Dialyzer
membrane
Pore
diameter
HF Dialysis Membranes
Blood Purif 2014;38:167173

Area of Researches


Uremic toxins and Pore diameter Is Not a Simple Button and a Hole

Mass Transport Area


Coefficient
size
Dragging
force =
convect
shape

Electric
charge
Different Molecule Diameters
Open Journal of Nephrology, 2013
solute MW Diameter
Dalton D nm
Urea 60 0.48
Glucose 180 1.0
Endothelin 4282 2.6
B2m 11800 3.88
Albumin 66000 7.8
urea Compartment
al solute as Ph protein-bound solutes
15%
Rebound
Robust rebound


Question to be Addressed

Should we wake up on an Installment of HDF


program in Egypt ? YES / NO ?.

FOULING is
IF YES NECESSARY
EQUIPMENT
not
allowed

MORE
IF NO BASIS OF
CHOICES
DATA ARE
REQUIRED
HDF mission ?
Targeting better Toxin removal (Amount and Types)
Looking for better outcome

Deferred Organs damage Higher Convection TTT


Not only CV
MORTALITY
Dialysis Dose Based on Urea Kt/V Is Focusing on Small Uremic
Toxins not Reflecting CKD Patient Needs

Kt/V
Diffusive
Dose

Middle Molecules ? Dialysis Adequacy

Anemia Quality of
Correction Life
Blood

Patient
Adequate
Pressure
Fluid Mgt.
Control
Adequate
Removal

Removal of Metabolic Adequate


Middle
Molecules
Mineral

Middle
Removal Bone

Needs
Small Disease
Molecules
Electro- Control

Molecules lytes &


Acidosis
Correction
Symptom
Free

Nutrition
Correction

Reduced
Morbidity &
Mortality

No Inflam-
mation
Convective Dose
A Component That Needs to Added to Diffusive Dose

Kt/V
Convective Diffusive
Dose Dose

Middle Molecules Dialysis Adequacy


Patient
Adequate Metabolic
Removal
Middle Needs
Molecules

Normalizing factor : Body Weight, Body Surface Area, Lean Body Mass
Therapy types

Hemodialysis Hemofiltration Hemodiafiltration


B B mmHg B mmHg

D D

high-flux
low-flux

mmHg mmHg

D F D
B B B
H2O water soluble molecules
HDF - Hemodiafiltration

B mmHg
Combination of two
dialysis technics,
hemodialysis and D
hemofiltration:
high clearance of
conventionel small
molecules by diffusion mmHg
linked with
D
high clearance of middle
molecules by convection. B

20/12/2017
Decision related Factors
Patient selections

clinical Residual Uremic syndrome

High Convection therapy


Logistics
Special clinical situation as
Myeloma
Economics
OL-HDF
Equipment

Dialyzers - Infusion line

Water Treatment

Infusion volumes

Economic sponsoring
HDF Decisions and Researches
Towards Better Dialysis

Higher Prolonged
Membranes Adsorption
Convection TTT Sessions
Improve
Remove Bigger
Higher SC Amplified Clearance compartmental
molecules
Removal

Removing MM HE-HDF Improve Rebound Protein Bound Toxins


Main Limiting Factors in Achieving High Convective Volume or
Blood Purif 2015;40(suppl 1):
Qi

Dialyzer

Pressure control Hematocrit


Dialysis Machine Hemoconcentration
Volume control Protocrit

Blood Flow
Vascular Access
Nephrol Dial Transplant
(2013) 0: 18

Critical FF %
Severe
Hemoconc.
Filtration
Fraction
UFR/QB
Plasma water , Hematocrit and protein changes during
100% HDF
90% 22%
80% 36%
70%

60% 37%
50%
33%
40%

30%

20% 41%
31%
10%

0%
Start End
Hct protein / protein bound water plasma water
HDF PRESSURE CONTROL

Feedback control
30 min Fouling
Decrease membrane

60 min TMP
function

TMP

180 min clotting

TIME
HDF VOLUME CONTROL

60 min HEMOCONCENTRATION

120
TMP TMP
min

180 min clotting


Common Fouling in Technique
High UFR against QB

Hemoconc.
Membrane Fouling
UFR/QB
>20%
No Feedback
control
DECREASED
DELIVERED
DOSE
CONCLUSION

HD therapy is a Puzzle that should be


optimized based on a multi-marker
approach
HD adequacy is only one part of the
therapy optimization and QC system
Thank You