Dialysis 1

Dialysis
Dialysis
Intervention

Patient receiving dialysis

ICD-9-CM [1]
39.95

MeSH [2]
D006435

In medicine, dialysis (from Greek "dialusis", meaning dissolution, "dia", meaning through, and "lysis", meaning
loosening) is a process for removing waste and excess water from the blood, and is primarily used to provide an
artificial replacement for lost kidney function in people with renal failure. Dialysis may be used for those with an
acute disturbance in kidney function (acute kidney injury, previously acute renal failure) or for those with
progressive but chronically worsening kidney function–a state known as chronic kidney disease stage 5 (previously
chronic renal failure or end-stage kidney disease). The latter form may develop over months or years, but in contrast
to acute kidney injury is not usually reversible, and dialysis is regarded as a "holding measure" until a renal
transplant can be performed, or sometimes as the only supportive measure in those for whom a transplant would be
inappropriate.[3]
The kidneys have important roles in maintaining health. When healthy, the kidneys maintain the body's internal
equilibrium of water and minerals (sodium, potassium, chloride, calcium, phosphorus, magnesium, sulfate). Those
acidic metabolism end products that the body cannot get rid of via respiration are also excreted through the kidneys.
The kidneys also function as a part of the endocrine system producing erythropoietin and calcitriol. Erythropoietin is
involved in the production of red blood cells and calcitriol plays a role in bone formation.[4] Dialysis is an imperfect
treatment to replace kidney function because it does not correct the endocrine functions of the kidney. Dialysis
treatments replace some of these functions through diffusion (waste removal) and ultrafiltration (fluid removal).[5]

History
Dr. Willem Kolff, a Dutch physician, constructed the first working dialyzer in 1943 during the Nazi occupation of
the Netherlands.[6] Due to the scarcity of available resources, Kolff had to improvise and build the initial machine
using sausage casings, beverage cans, a washing machine and various other items which were available at the time.
Over the following two years, Kolff used his machine to treat 16 patients who suffered from acute kidney failure, but
the results were unsuccessful. Then, in 1945, a 67-year-old woman in uremic coma regained consciousness
following 11 hours of hemodialysis with the dialyzer, and lived for another seven years before dying of an unrelated
condition. She was the first-ever patient successfully treated with dialysis.[6]
Dialysis 2

Principle
Dialysis works on the principles of the diffusion of solutes and
ultrafiltration of fluid across a semi-permeable membrane. Diffusion
describes a property of substances in water. Substances in water tend to
move from an area of high concentration to an area of low
concentration.[7] Blood flows by one side of a semi-permeable
membrane, and a dialysate, or special dialysis fluid, flows by the
opposite side. A semipermeable membrane is a thin layer of material
that contains various sized holes, or pores. Smaller solutes and fluid
pass through the membrane, but the membrane blocks the passage of
larger substances (for example, red blood cells, large proteins). This
replicates the filtering process which takes place in the kidneys, when
the blood enters the kidneys and the larger substances are separated
from the smaller ones in the glomerulus.[7]

The two main types of dialysis, hemodialysis and Peritoneal dialysis,

remove wastes and excess water from the blood in different ways.[3]
Hemodialysis removes wastes and water by circulating blood outside
A hemodialysis machine
the body through an external filter, called a dialyzer, that contains a
semipermeable membrane. The blood flows in one direction and the
dialysate flows in the opposite. The counter-current flow of the blood and dialysate maximizes the concentration
gradient of solutes between the blood and dialysate, which helps to remove more urea and creatinine from the blood.
The concentrations of solutes (for example potassium, phosphorus, and urea) are undesirably high in the blood, but
low or absent in the dialysis solution and constant replacement of the dialysate ensures that the concentration of
undesired solutes is kept low on this side of the membrane. The dialysis solution has levels of minerals like
potassium and calcium that are similar to their natural concentration in healthy blood. For another solute,
bicarbonate, dialysis solution level is set at a slightly higher level than in normal blood, to encourage diffusion of
bicarbonate into the blood, to act as a pH buffer to neutralize the metabolic acidosis that is often present in these
patients. The levels of the components of dialysate are typically prescribed by a nephrologist according to the needs
of the individual patient.

In peritoneal dialysis, wastes and water are removed from the blood inside the body using the peritoneal membrane
of the peritoneum as a natural semipermeable membrane. Wastes and excess water move from the blood, across the
peritoneal membrane, and into a special dialysis solution, called dialysate, in the abdominal cavity which has a
composition similar to the fluid portion of blood.
Dialysis 3

Types
There are three primary and two secondary types of dialysis: hemodialysis (primary), peritoneal dialysis (primary),
hemofiltration (primary), hemodiafiltration (secondary), and intestinal dialysis (secondary).

Hemodialysis
In hemodialysis, the patient's blood is
pumped through the blood
compartment of a dialyzer, exposing it
to a partially permeable membrane.
The dialyzer is composed of thousands
of tiny synthetic hollow fibers. The
fiber wall acts as the semipermeable
membrane. Blood flows through the
fibers, dialysis solution flows around
the outside of the fibers, and water and
wastes move between these two
solutions.[8] The cleansed blood is then
returned via the circuit back to the
body. Ultrafiltration occurs by
increasing the hydrostatic pressure
across the dialyzer membrane. This
usually is done by applying a negative
pressure to the dialysate compartment Hemodialysis schematic
of the dialyzer. This pressure gradient
causes water and dissolved solutes to move from blood to dialysate, and allows the removal of several litres of
excess fluid during a typical 3 to 5 hour treatment. In the US, hemodialysis treatments are typically given in a
dialysis center three times per week (due in the US to Medicare reimbursement rules); however, as of 2007 over
2,500 people in the US are dialyzing at home more frequently for various treatment lengths.[9] Studies have
demonstrated the clinical benefits of dialyzing 5 to 7 times a week, for 6 to 8 hours. This type of hemodialysis is
usually called "nocturnal daily hemodialysis", which a study has shown a significant improvement in both small and
large molecular weight clearance and decrease the requirement of taking phosphate binders.[10] These frequent long
treatments are often done at home while sleeping, but home dialysis is a flexible modality and schedules can be
changed day to day, week to week. In general, studies have shown that both increased treatment length and
frequency are clinically beneficial.[11]
Dialysis 4

Peritoneal dialysis
In peritoneal dialysis, a sterile solution containing glucose is
run through a tube into the peritoneal cavity, the abdominal
body cavity around the intestine, where the peritoneal
membrane acts as a semipermeable [Link] peritoneal
membrane or peritoneum is a layer of tissue containing blood
vessels that lines and surrounds the peritoneal, or abdominal,
cavity and the internal abdominal organs (stomach, spleen,
liver, and intestines).[12] The dialysate is left there for a period
of time to absorb waste products, and then it is drained out
through the tube and discarded. This cycle or "exchange" is
normally repeated 4-5 times during the day, (sometimes more
often overnight with an automated system). Each time the
dialysate fills and empties from the abdomen is called one
exchange. A dwell time means that the time of dialysate stay
in patient's abdominal cavity—wastes, chemicals and extra
fluid move from patient's blood to the dialysate across the Schematic diagram of peritoneal dialysis

peritoneum. A drain process is the process after the dwell

time, the dialysate full with waste products and extra fluid is drained out of patient's blood.[13] Ultrafiltration occurs
via osmosis; the dialysis solution used contains a high concentration of glucose, and the resulting osmotic pressure
causes fluid to move from the blood into the dialysate. As a result, more fluid is drained than was instilled. Peritoneal
dialysis is less efficient than hemodialysis, but because it is carried out for a longer period of time the net effect in
terms of removal of waste products and of salt and water are similar to hemodialysis. Peritoneal dialysis is carried
out at home by the patient. Although support is helpful, it is not essential. It does free patients from the routine of
having to go to a dialysis clinic on a fixed schedule multiple times per week, and it can be done while travelling with
a minimum of specialized equipment.

Hemofiltration
Hemofiltration is a similar treatment to hemodialysis, but it makes use of a different principle. The blood is pumped
through a dialyzer or "hemofilter" as in dialysis, but no dialysate is used. A pressure gradient is applied; as a result,
water moves across the very permeable membrane rapidly, "dragging" along with it many dissolved substances,
importantly ones with large molecular weights, which are cleared less well by hemodialysis. Salts and water lost
from the blood during this process are replaced with a "substitution fluid" that is infused into the extracorporeal
circuit during the treatment. Hemodiafiltration is a term used to describe several methods of combining hemodialysis
and hemofiltration in one process.

Hemodiafiltration
Hemodialfiltration is a combination of hemodialysis and hemofiltration. In theory, this technique offers the
advantages of both hemodialysis and hemofiltration.

Intestinal dialysis
In intestinal dialysis, the diet is supplemented with soluble fibres such as acacia fibre, which is digested by bacteria
in the colon. This bacterial growth increases the amount of nitrogen that is eliminated in fecal waste.[14] [15] [16] An
alternative approach utilizes the ingestion of 1 to 1.5 liters of non-absorbable solutions of polyethylene glycol or
mannitol every fourth hour.[17]
Dialysis 5

Starting indications
The decision to initiate dialysis or hemofiltration in patients with renal failure depends on several factors. These can
be divided into acute or chronic indications.
• Indications for dialysis in the patient with acute kidney injury are:[18]
1. Metabolic acidosis in situations where correction with sodium bicarbonate is impractical or may result in fluid
overload.
2. Electrolyte abnormality, such as severe hyperkalemia, especially when combined with AKI.
3. Fluid overload not expected to respond to treatment with diuretics.
4. Complications of uremia, such as pericarditis, encephalopathy, or gastrointestinal bleeding.
5. Intoxication, that is, acute poisoning with a dialyzable substance. These substances can be represented by the
mnemonic SLIME: salicylic acid, lithium, isopropanol, Magnesium-containing laxatives, and ethylene glycol.
• Chronic indications for dialysis:
1. Symptomatic renal failure
2. 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.
3. Difficulty in medically controlling fluid overload, serum potassium, and/or serum phosphorus when the GFR
is very low

References
[1] http:/ / icd9cm. chrisendres. com/ index. php?srchtype=procs& srchtext=39. 95& Submit=Search& action=search
[2] http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2011/ MB_cgi?field=uid& term=D006435
[3] Pendse S, Singh A, Zawada E. Initiation of Dialysis. In: Handbook of Dialysis. 4th ed. New York, NY; 2008:14–21
[4] Brundage D. Renal Disorders. St. Louis, MO: Mosby; 1992
[5] http:/ / www. kidneyatlas. org/ book5/ adk5-01. ccc. QXD. pdf Atlas of Diseases of the Kidney, Volume 5, Principles of Dialysis: Diffusion,
Convection, and Dialysis Machines
[6] An online source for kidney disease and dialysis information. http:/ / www. davita. com/ dialysis/ c/ 197; Davita: 2010
[7] Mosby’s Dictionary of Medicine, Nursing, & Health Professions. 7th ed. St. Louis, MO; Mosby: 2006
[8] Ahmad S, Misra M, Hoenich N, Daugirdas J. Hemodialysis Apparatus. In: Handbook of Dialysis. 4th ed. New York, NY; 2008:59-78.
[9] http:/ / www. usrds. org/ 2007/ pdf/ 04_modalities_07. pdf USRDS TREATMENT MODALITIES
[10] Rocco [Link] frequent hemodialysis: back to the future? In: Advances in Chronic Kidney Disease. Volume 14, issue 3; 2007:e1-9.
[11] http:/ / www. homedialysis. org/ learn/ types/ Daily therapy study results compared
[12] Blake P, Daugirdas J. Physiology of Peritoneal Dialysis. In: Handbook of Dialysis. 4th ed. New York, NY; 2008:323-338
[13] Kallenbach J.Z. In: Review of hemodialysis for nurses and dialysis personnel. 7th ed. St. Louis, Missouri:Elsevier Mosby; 2005.
[14] http:/ / www. medscape. com/ medline/ abstract/ 15293039
[15] http:/ / www. medscape. com/ medline/ abstract/ 17517814
[16] http:/ / www. medscape. com/ medline/ abstract/ 17999333
[17] http:/ / www. medscape. com/ medline/ abstract/ 1904625
[18] Irwin, Richard S.; James M. Rippe (2008). Irwin and Rippe's intensive care medicine. Lippincott Williams & Wilkins. pp. 988–999.
ISBN 0781791537, 9780781791533.
Dialysis 6

External links
• Machine Cleans Blood While You Wait ([Link]
pg=PA103#v=onepage&f=true)—1950 article on early use of Dialysis machine at Bellevue Hospital New York
City—i.e. example of how complex and large early dialysis machines were
• Dialysis search engine ([Link] Clinic locations around the World
• Global Dialysis ([Link] and community for dialysis patients and
professionals
• Virtual Dialysis Museum ([Link] and pictures of dialysis
machines through time
• Virtual CKD patient/care giver community ([Link] far the largest
CKD discussion forum on the web.
• HDCN Online journal ([Link] medical lectures pertaining to various aspects of
dialysis and nephrology; intended for physicians and nurses, not for patients.
• Information on Nephrology & Kidney Disease for Professionals and Patients ([Link]
• Nephrology Now Meta-Journal and Online Journal Club ([Link]
literature update service, as well as a place to discuss important articles with colleagues around the world.
• The Noor Foundation UK ([Link] UK based charity that sets up and runs free
kidney dialysis centres in 3rd world countries
• American Kidney Fund ([Link] United States nonprofit organization that provides
treatment-related financial assistance to dialysis patients
• National Kidney Foundation ([Link] major voluntary nonprofit health organization, is
dedicated to preventing kidney and urinary tract diseases, improving the health and well-being of individuals and
families affected by kidney disease and increasing the availability of all organs for transplantation
• American Association of Kidney Patients ([Link] national non-profit organization founded
by kidney patients for kidney patients
• HDCN Online journal ([Link] medical lectures pertaining to various aspects of
dialysis and nephrology; intended for physicians and nurses, not for patients
• The Kidney Foundation of Canada ([Link]
• Dialysis Clinics ([Link] of dialysis centers in United States.
Article Sources and Contributors 7

Article Sources and Contributors

Dialysis Source: [Link] Contributors: AHRtbA==, Abanima, Academic Challenger, Accuruss, Acroterion, Actualpirate, Adirays99, Adrian,
Afr77, Ahernconsulting, Ahmednh, Alan2005, Alansohn, Ali, Allgoodnamesalreadytaken, Allstarecho, Andyabides, Angela, Animum, Ann Stouter, Anna Frodesiak, Antandrus, Arcadian, Art
Carlson, Avono, AxelBoldt, Ayman Qasrawi, BRUTE, BeerGeek, Beetstra, Begoon, Bellemonde, Bemoeial, Bensaccount, BillpSea, Biologos, Bloodshedder, Bobet, Brandon, CSharpMinor,
Can't sleep, clown will eat me, Capricorn42, Chaldor, Challiovsky, Chinneeb, Christian75, Chrysaor, Contempo1254, Corticopia, CptUnconscious, Cptmurdok, Crywalt, D Dinneen, DARTH
SIDIOUS 2, DMahalko, Dark Samus, Davidruben, Dcpeters, DeadEyeArrow, Delirium, Delldot, Dialysiscenters, Diberri, Dicklyon, Discospinster, DocWatson42, Dontworry, DoriSchatell,
DzWiki, ESkog, Ed Poor, Edgar181, El C, ElTyrant, Entheta, Epbr123, Evercat, Everyking, Falcon Kirtaran, Fckskwl, Felix-felix, Flyingidiot, Forschung, Fosterche, FunPika, Gaff, Gene
Nygaard, Geoffrey Wickham, George415, GermanX, Germnrottie, Gioto, Gogo Dodo, GoingBatty, Gracenotes, Graham87, GreatWhiteNortherner, Gwernol, HPJoker, Hancong, Hauskalainen,
Hswapnil, Hu12, [Link], Icseaturtles, Ike9898, ImperfectlyInformed, Indiajal, Istomas, Iwu001, [Link], JDspeeder1, JNW, Jackehammond, Jarseen, Jayjg, Jazzbeer27, Jclemens, Jepitts,
Jfdwolff, Jncraton, Job314, John254, Joyous!, Jtdaugir, JuneGloom07, Jusdafax, KBrown, Karpov33, Kaszeta, Katherine, Katoa, Kbir1, Kjramesh, Ksyrie, Kummi, Kungfuadam, KyleB, Kyoko,
Lamro, Lawinslow, Lazarus1907, LedgendGamer, Limjason, Lindmere, Lisatwo, Lupo, M1ss1ontomars2k4, M7, MER-C, Mani1, Master&Expert, McSly, MementoVivere, Metju, Michael
Schubart, Minkchawla, Mlpearc, Mmxx, Moonside, MrStalker, Munkee, Myanw, Najafhaider, Natalya, Ndkartik, Nephron, Nickky60, Nicoledeath, Noq, Nsaa, Onco p53, Oniscoid, Pakaran,
Panscient, Papte, Pathoschild, Pauli100, Peter in s, Pikiwyn, Pinethicket, Pinkadelica, Pizza1512, PizzaMargherita, Poeloq, Prad7187, Qasinka, QuizzicalBee, R'n'B, R3m0t, RG2, RJaguar3,
RattleMan, Rbanzai, Realm of Shadows, Reconsider the static, Renaldialysis, ReyBrujo, Richardarcher, Rjwilmsi, Roberthilley@[Link], Rodney Boyd, Ronark, Rror, RudolfCardinal,
Runkidney, S spiegel, SHAHINOVE, SJP, Salamurai, Scarwing, SchnitzelMannGreek, SconeHead, Sdornan, Sherryshang, Shinkolobwe, Silvermask, SimonP, Sjakkalle, Skraz, Snaxe920,
SpaceFlight89, SpuriousQ, StaceyGrove, Stephan Leeds, Stevietheman, Stillnotelf, Superm401, Teapotgeorge, Templarion, Tempodivalse, The Thing That Should Not Be, Thingg, Tide rolls,
TigEer, Timc, Tipiac, Tom davies, TubularWorld, Typhoonchaser, Ubergeek1027, Ucucha, Unckc, Veinor, Versus22, Vinsfan368, Vsmith, WazzaMan, Wik, Xaosflux, Xeno, Yanamad,
Yaris678, YassineMrabet, Zackkelly, Zidane tribal, आशीष भटनागर, とある白い猫, 553 anonymous edits

Image Sources, Licenses and Contributors

File:Patient receiving dialysis [Link] Source: [Link] License: Public Domain Contributors: Anna Frodesiak
File:[Link] Source: [Link] License: GNU Free Documentation License Contributors: Greg g, Landstuhli,
Moscvitch, Smooth O, 2 anonymous edits
Image:[Link] Source: [Link] License: Creative Commons Attribution 3.0 Contributors: Ingolfson, Nanoxyde,
Smooth O, YassineMrabet, 1 anonymous edits
Image:Peritoneal [Link] Source: [Link] License: Public Domain Contributors: National Kidney and Urologic Diseases
Information Clearinghouse, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, USA

License
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