1. Principles of dialysis
Dechu Puliyanda, MD
Professor of Pediatrics
Director, Pediatric Nephrology and Transplant Immunology
Cedars Sinai Medical Center
UCLA David-Geffen School of Medicine

2. What we will talk about today
Causes of renal failure
Indications for dialysis
Modalities for dialysis
Principles of dialysis
Hemodialysis
Peritoneal dialysis

3. Causes of renal failure in the African subcontinent
Septicemia
Malaria
Glomerulonephritis
Hemolytic Uremic syndrome
Nephrotoxins
Obstructive uropathies

4. Indications for dialysis
Intractable acidosis
Intractable Hyperkalemia
Fluid overload
Uremia
Need for transfusion in a patient with oliguria
Need for parenteral nutrition in a patient with oliguria
Removal of dialyzable toxins

5. Principles of dialysis: passage of solutes across a semi permeable membrane

6. Modalities of dialysis
Hemodialysis
Peritoneal dialysis
Continuous renal replacement therapy (CVVH)

7. Hemodialysis

8. Hemodialysis

9. Hemodialysis Need an access – either a catheter or fistula
Need extracorporeal blood flow
Needs to be done in a hospital setting
Needs anticoagulation
Rapid fluid and electrolyte shifts

10. Peritoneal dialysis

13. Cook’s catheter: inserted at bedside

17. Continuous Ambulatory Peritoneal Dialysis
Patients will be required to be dialysed 3 – 5 times per day by themselves. Gravity will draw the dialysate in and out of the peritoneal cavity, through the connecting tubing and bags. CAPD requires the patient to connect tubing and a bag of sterile dialysate to the peritoneal catheter. The bag is elevated to shoulder level, allowing the solution to flow into the peritoneum. Waste products and excess fluid pass from the blood, through the patient’s peritoneal membrane (lining of the abdomen), which acts as a filter, and into the dialysate. Once this is completed, all fluid and waste from the patient’s peritoneal cavity are drained and exchanged with a fresh solution.

18. Automated Peritoneal dialysis
Automated peritoneal dialysis (APD) is performed by a machine, called a cycler, while the patient is asleep. Like CAPD, APD uses the patient’s peritoneal membrane as a filter to draw waste and excess fluid from the patient’s blood into a dialysate solution. The APD machine automatically controls the timing of exchanges, drains the used solution and fills the peritoneal cavity with new solution; based on the prescribed number of exchanges. For extra treatment, dialysis solution remains in the patient’s peritoneal cavity during the day. The peritoneal cavity of most adults can comfortably hold two-to-three liters of fluid.

19. Advantages of Peritoneal dialysis
Fit the dialysis treatment around the patient’s lifestyle;
Patient independence;
Fewer visits to the dialysis unit (usually once a month);
Dialysis done during sleep time for some patients;
therapy is gentler and more similar to natural kidney function;
PD is portable and flexible;
Less fluid and diet restrictions;
No needles needed; and
Better blood pressure control.

20. Disadvantages Patients need to be well trained;
Permanent catheter access required;
Some risk of infection;
Some patients may show a slightly larger waistline (due to carrying fluid); and
Storage space required in the patient’s home.

21. Dialysis solutions ( dialysate)

22. Complications of peritoneal dialysis
Ineffective Peritoneal dialysis (omentum still being present or clots in catheter)
Hernias
Infections (peritonitis)
Leaks

23. Factors that contribute to poor outcome
Insufficient dialysis
Undernutrition
Infection
Lack of appropriate interdialytic care: no erythropoeitin, no active Vitamin D etc

24. Prevention of ESRD is the best strategy
Health education: avoid nephrotoxins
Infection control: good teaching of PD and effective hand hygiene
Antischistomal therapy
Antimalarial therapy
Vaccination against Tuberculosis, Hepatitis and pneumococcus
Screening UA among school aged children??