The Kidneys and How They Work

On this page:

• What do the kidneys do?

• What is renal function?
• Why do kidneys fail?
• How do kidneys fail?
• What are the signs of chronic kidney disease (CKD)?
• What medical tests detect kidney disease?
• What are the stages of CKD?
• What can be done about CKD?
• What happens if the kidneys fail completely?
• Points to Remember
• Hope through Research
• For More Information
• Acknowledgments

The kidneys are a pair of vital organs that perform many functions to keep the blood
clean and chemically balanced. Understanding how the kidneys work can help a person
keep them healthy.

What do the kidneys do?

The kidneys are bean-shaped organs, each about the size of a fist. They are located near
the middle of the back, just below the rib cage, one on each side of the spine. The
kidneys are sophisticated reprocessing machines. Every day, a person’s kidneys
process about 200 quarts of blood to sift out about 2 quarts of waste products and extra
water. The wastes and extra water become urine, which flows to the bladder through
tubes called ureters. The bladder stores urine until releasing it through urination.

The kidneys remove wastes and water from the blood to form urine. Urine flows from
the kidneys to the bladder through the ureters.

Wastes in the blood come from the normal breakdown of active tissues, such as
muscles, and from food. The body uses food for energy and self-repairs. After the body
has taken what it needs from food, wastes are sent to the blood. If the kidneys did not
remove them, these wastes would build up in the blood and damage the body.

The actual removal of wastes occurs in tiny units inside the kidneys called nephrons.
Each kidney has about a million nephrons. In the nephron, a glomerulus—which is a
tiny blood vessel, or capillary—intertwines with a tiny urine-collecting tube called a
tubule. The glomerulus acts as a filtering unit, or sieve, and keeps normal proteins and
cells in the bloodstream, allowing extra fluid and wastes to pass through. A
complicated chemical exchange takes place, as waste materials and water leave the
blood and enter the urinary system.

In the nephron (left), tiny blood vessels intertwine with urine-collecting tubes. Each
kidney contains about 1 million nephrons.

At first, the tubules receive a combination of waste materials and chemicals the body
can still use. The kidneys measure out chemicals like sodium, phosphorus, and
potassium and release them back to the blood to return to the body. In this way, the
kidneys regulate the body’s level of these substances. The right balance is necessary for
life.

In addition to removing wastes, the kidneys release three important hormones:

• erythropoietin, or EPO, which stimulates the bone marrow to make red blood
cells
• renin, which regulates blood pressure
• calcitriol, the active form of vitamin D, which helps maintain calcium for bones
and for normal chemical balance in the body

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What is renal function?

The word “renal” refers to the kidneys. The terms “renal function” and “kidney
function” mean the same thing. Health professionals use the term “renal function” to
talk about how efficiently the kidneys filter blood. People with two healthy kidneys
have 100 percent of their kidney function. Small or mild declines in kidney function—
as much as 30 to 40 percent—would rarely be noticeable. Kidney function is now
calculated using a blood sample and a formula to find the estimated glomerular
filtration rate (eGFR). The eGFR corresponds to the percent of kidney function
available. The section “What medical tests detect kidney disease?” contains more
details about the eGFR.

Some people are born with only one kidney but can still lead normal, healthy lives.
Every year, thousands of people donate one of their kidneys for transplantation to a
family member or friend.

For many people with reduced kidney function, a kidney disease is also present and
will get worse. Serious health problems occur when people have less than 25 percent of
their kidney function. When kidney function drops below 10 to 15 percent, a person
needs some form of renal replacement therapy—either blood-cleansing treatments
called dialysis or a kidney transplant—to sustain life.

Why do kidneys fail?

Most kidney diseases attack the nephrons, causing them to lose their filtering capacity.
Damage to the nephrons can happen quickly, often as the result of injury or poisoning.
But most kidney diseases destroy the nephrons slowly and silently. Only after years or
even decades will the damage become apparent. Most kidney diseases attack both
kidneys simultaneously.

The two most common causes of kidney disease are diabetes and high blood pressure.
People with a family history of any kind of kidney problem are also at risk for kidney
disease.

Diabetic Kidney Disease

Diabetes is a disease that keeps the body from using glucose, a form of sugar, as it
should. If glucose stays in the blood instead of breaking down, it can act like a poison.
Damage to the nephrons from unused glucose in the blood is called diabetic kidney
disease. Keeping blood glucose levels down can delay or prevent diabetic kidney
disease. Use of medications called angiotensin-converting enzyme (ACE) inhibitors or
angiotensin receptor blockers (ARBs) to treat high blood pressure can also slow or
delay the progression of diabetic kidney disease.

High Blood Pressure

High blood pressure can damage the small blood vessels in the kidneys. The damaged
vessels cannot filter wastes from the blood as they are supposed to.

A doctor may prescribe blood pressure medication. ACE inhibitors and ARBs have
been found to protect the kidneys even more than other medicines that lower blood
pressure to similar levels. The National Heart, Lung, and Blood Institute (NHLBI), one
of the National Institutes of Health, recommends that people with diabetes or reduced
kidney function keep their blood pressure below 130/80.

Glomerular Diseases

Several types of kidney disease are grouped together under this category, including
autoimmune diseases, infection-related diseases, and sclerotic diseases. As the name
indicates, glomerular diseases attack the tiny blood vessels, or glomeruli, within the
kidney. The most common primary glomerular diseases include membranous
nephropathy, IgA nephropathy, and focal segmental glomerulosclerosis. The first sign
of a glomerular disease is often proteinuria, which is too much protein in the urine.
Another common sign is hematuria, which is blood in the urine. Some people may
have both proteinuria and hematuria. Glomerular diseases can slowly destroy kidney
function. Blood pressure control is important with any kidney disease. Glomerular
diseases are usually diagnosed with a biopsy—a procedure that involves taking a piece
of kidney tissue for examination with a microscope. Treatments for glomerular diseases
may include immunosuppressive drugs or steroids to reduce inflammation and
proteinuria, depending on the specific disease.

Inherited and Congenital Kidney Diseases

Some kidney diseases result from hereditary factors. Polycystic kidney disease (PKD),
for example, is a genetic disorder in which many cysts grow in the kidneys. PKD cysts
can slowly replace much of the mass of the kidneys, reducing kidney function and
leading to kidney failure.

Some kidney problems may show up when a child is still developing in the womb.
Examples include autosomal recessive PKD, a rare form of PKD, and other
developmental problems that interfere with the normal formation of the nephrons. The
signs of kidney disease in children vary. A child may grow unusually slowly, vomit
often, or have back or side pain. Some kidney diseases may be silent—causing no signs
or symptoms—for months or even years.

If a child has a kidney disease, the child’s doctor should find it during a regular
checkup. The first sign of a kidney problem may be high blood pressure; a low number
of red blood cells, called anemia; proteinuria; or hematuria. If the doctor finds any of
these problems, further tests may be necessary, including additional blood and urine
tests or radiology studies. In some cases, the doctor may need to perform a biopsy.

Some hereditary kidney diseases may not be detected until adulthood. The most
common form of PKD was once called “adult PKD” because the symptoms of high
blood pressure and renal failure usually do not occur until patients are in their twenties
or thirties. But with advances in diagnostic imaging technology, doctors have found
cysts in children and adolescents before any symptoms appear.

Other Causes of Kidney Disease

Poisons and trauma, such as a direct and forceful blow to the kidneys, can lead to
kidney disease.

Some over-the-counter medicines can be poisonous to the kidneys if taken regularly

over a long period of time. Anyone who takes painkillers regularly should check with a
doctor to make sure the kidneys are not at risk.

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How do kidneys fail?

Many factors that influence the speed of kidney failure are not completely understood.
Researchers are still studying how protein in the diet and cholesterol levels in the blood
affect kidney function.

Acute Kidney Injury

Some kidney problems happen quickly, such as when an accident injures the kidneys.
Losing a lot of blood can cause sudden kidney failure. Some drugs or poisons can
make the kidneys stop working. These sudden drops in kidney function are called acute
kidney injury (AKI). Some doctors may also refer to this condition as acute renal
failure (ARF).

AKI may lead to permanent loss of kidney function. But if the kidneys are not
seriously damaged, acute kidney disease may be reversed.

Chronic Kidney Disease

Most kidney problems, however, happen slowly. A person may have “silent” kidney
disease for years. Gradual loss of kidney function is called chronic kidney disease
(CKD) or chronic renal insufficiency. People with CKD may go on to develop
permanent kidney failure. They also have a high risk of death from a stroke or heart
attack.

End-stage Renal Disease

Total or nearly total and permanent kidney failure is called end-stage renal disease
(ESRD). People with ESRD must undergo dialysis or transplantation to stay alive.

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What are the signs of chronic kidney disease (CKD)?

People in the early stages of CKD usually do not feel sick at all.

People whose kidney disease has gotten worse may

• need to urinate more often or less often

• feel tired
• lose their appetite or experience nausea and vomiting
• have swelling in their hands or feet
• feel itchy or numb
• get drowsy or have trouble concentrating
• have darkened skin
• have muscle cramps
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What medical tests detect kidney disease?

Because a person can have kidney disease without any symptoms, a doctor may first
detect the condition through routine blood and urine tests. The National Kidney
Foundation recommends three simple tests to screen for kidney disease: a blood
pressure measurement, a spot check for protein or albumin in the urine, and a
calculation of glomerular filtration rate (GFR) based on a serum creatinine
measurement. Measuring urea nitrogen in the blood provides additional information.

Blood Pressure Measurement

High blood pressure can lead to kidney disease. It can also be a sign that the kidneys
are already impaired. The only way to know whether a person’s blood pressure is high
is to have a health professional measure it with a blood pressure cuff. The result is
expressed as two numbers. The top number, which is called the systolic pressure,
represents the pressure in the blood vessels when the heart is beating. The bottom
number, which is called the diastolic pressure, shows the pressure when the heart is
resting between beats. A person’s blood pressure is considered normal if it stays below
120/80, stated as “120 over 80.” The NHLBI recommends that people with kidney
disease use whatever therapy is necessary, including lifestyle changes and medicines,
to keep their blood pressure below 130/80.

Microalbuminuria and Proteinuria

Healthy kidneys take wastes out of the blood but leave protein. Impaired kidneys may
fail to separate a blood protein called albumin from the wastes. At first, only small
amounts of albumin may leak into the urine, a condition known as microalbuminuria, a
sign of deteriorating kidney function. As kidney function worsens, the amount of
albumin and other proteins in the urine increases, and the condition is called
proteinuria. A doctor may test for protein using a dipstick in a small sample of a
person’s urine taken in the doctor’s office. The color of the dipstick indicates the
presence or absence of proteinuria.

A more sensitive test for protein or albumin in the urine involves laboratory
measurement and calculation of the protein-to-creatinine or albumin-to-creatinine ratio.
Creatinine is a waste product in the blood created by the normal breakdown of muscle
cells during activity. Healthy kidneys take creatinine out of the blood and put it into the
urine to leave the body. When the kidneys are not working well, creatinine builds up in
the blood.

The albumin-to-creatinine measurement should be used to detect kidney disease in

people at high risk, especially those with diabetes or high blood pressure. If a person’s
first laboratory test shows high levels of protein, another test should be done 1 to 2
weeks later. If the second test also shows high levels of protein, the person has
persistent proteinuria and should have additional tests to evaluate kidney function.

Glomerular Filtration Rate (GFR) Based on Creatinine Measurement

GFR is a calculation of how efficiently the kidneys are filtering wastes from the blood.
A traditional GFR calculation requires an injection into the bloodstream of a substance
that is later measured in a 24-hour urine collection. Recently, scientists found they
could calculate GFR without an injection or urine collection. The new calculation—the
eGFR—requires only a measurement of the creatinine in a blood sample.

In a laboratory, a person’s blood is tested to see how many milligrams of creatinine are
in one deciliter of blood (mg/dL). Creatinine levels in the blood can vary, and each
laboratory has its own normal range, usually 0.6 to 1.2 mg/dL. A person whose
creatinine level is only slightly above this range will probably not feel sick, but the
elevation is a sign that the kidneys are not working at full strength. One formula for
estimating kidney function equates a creatinine level of 1.7 mg/dL for most men and
1.4 mg/dL for most women to 50 percent of normal kidney function. But because
creatinine values are so variable and can be affected by diet, a GFR calculation is more
accurate for determining whether a person has reduced kidney function.

The eGFR calculation uses the patient’s creatinine measurement along with age and
values assigned for sex and race. Some medical laboratories may make the eGFR
calculation when a creatinine value is measured and include it on the lab report. The
National Kidney Foundation has determined different stages of CKD based on the
value of the eGFR. Dialysis or transplantation is needed when the eGFR is less than 15
milliliters per minute (mL/min).

Blood Urea Nitrogen (BUN)

Blood carries protein to cells throughout the body. After the cells use the protein, the
remaining waste product is returned to the blood as urea, a compound that contains
nitrogen. Healthy kidneys take urea out of the blood and put it in the urine. If a
person’s kidneys are not working well, the urea will stay in the blood.

A deciliter of normal blood contains 7 to 20 milligrams of urea. If a person’s BUN is

more than 20 mg/dL, the kidneys may not be working at full strength. Other possible
causes of an elevated BUN include dehydration and heart failure.

Additional Tests for Kidney Disease

If blood and urine tests indicate reduced kidney function, a doctor may recommend
additional tests to help identify the cause of the problem.

Kidney imaging. Methods of kidney imaging—taking pictures of the kidneys—

include ultrasound, computerized tomography (CT) scan, and magnetic resonance
imaging (MRI). These tools are most helpful in finding unusual growths or blockages
to the flow of urine.

Kidney biopsy. A doctor may want to examine a tiny piece of kidney tissue with a
microscope. To obtain this tissue sample, the doctor will perform a kidney biopsy—a
hospital procedure in which the doctor inserts a needle through the patient’s skin into
the back of the kidney. The needle retrieves a strand of tissue less than an inch long.
For the procedure, the patient lies facedown on a table and receives a local anesthetic to
numb the skin. The sample tissue will help the doctor identify problems at the cellular
level.

For more information, see the fact sheet Kidney Biopsy from the National Kidney and
Urologic Diseases Information Clearinghouse.

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What are the stages of CKD?

A person’s eGFR is the best indicator of how well the kidneys are working. An eGFR
of 90 or above is considered normal. A person whose eGFR stays below 60 for 3
months or longer has CKD. As kidney function declines, the risk of complications
rises.

Moderate decrease in eGFR (30 to 59). At this stage of CKD, hormones and minerals
can be thrown out of balance, leading to anemia and weak bones. A health care
provider can help prevent or treat these complications with medicines and advice about
food choices.

Severe reduction in eGFR (15 to 29). The patient should continue following the
treatment for complications of CKD and learn as much as possible about the treatments
for kidney failure. Each treatment requires preparation. Those who choose
hemodialysis will need to have a procedure to make veins in their arms larger and
stronger for repeated needle insertions. For peritoneal dialysis, one will need to have a
catheter placed in the abdomen. A catheter is a thin, flexible tube used to fill the
abdominal cavity with fluid. A person may want to ask family or friends to consider
donating a kidney for transplantation.

Kidney failure (eGFR less than 15). When the kidneys do not work well enough to
maintain life, dialysis or a kidney transplant will be needed.

In addition to tracking eGFR, blood tests can show when substances in the blood are
out of balance. If phosphorus or potassium levels start to climb, a blood test will
prompt the health care provider to address these issues before they permanently affect
the person’s health.

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What can be done about CKD?

Unfortunately, CKD often cannot be cured. But people in the early stages of CKD may
be able to make their kidneys last longer by taking certain steps. They will also want to
minimize the risks for heart attack and stroke because CKD patients are susceptible to
these problems.

• People with reduced kidney function should see their doctor regularly. The
primary doctor may refer the patient to a nephrologist, a doctor who specializes
in kidney disease.
• People who have diabetes should watch their blood glucose levels closely to
keep them under control. They should ask their health care provider about the
latest in treatment.
• People with reduced renal function should avoid pain pills that may make their
kidney disease worse. They should check with their health care provider before
taking any medicine.

Controlling Blood Pressure

People with reduced kidney function and high blood pressure should control their
blood pressure with an ACE inhibitor or an ARB. Many people will require two or
more types of medication to keep their blood pressure below 130/80. A diuretic is an
important addition when the ACE inhibitor or ARB does not meet the blood pressure
goal.

Changing the Diet

People with reduced kidney function need to be aware that some parts of a normal diet
may speed their kidney failure.

Protein. Protein is important to the body. It helps the body repair muscles and fight
disease. Protein comes mostly from meat but can also be found in eggs, milk, nuts,
beans, and other foods. Healthy kidneys take wastes out of the blood but leave in the
protein. Impaired kidneys may fail to separate the protein from the wastes.

Some doctors tell their kidney patients to limit the amount of protein they eat so the
kidneys have less work to do. But a person cannot avoid protein entirely. People with
CKD can work with a dietitian to create the right food plan.

Cholesterol. Another problem that may be associated with kidney failure is high
cholesterol. High levels of cholesterol in the blood may result from a high-fat diet.

Cholesterol can build up on the inside walls of blood vessels. The buildup makes
pumping blood through the vessels harder for the heart and can cause heart attacks and
strokes.

Sodium. Sodium is a chemical found in salt and other foods. Sodium in the diet may
raise a person’s blood pressure, so people with CKD should limit foods that contain
high levels of sodium. High-sodium foods include canned or processed foods like
frozen dinners and hot dogs.

Potassium. Potassium is a mineral found naturally in many fruits and vegetables, such
as oranges, potatoes, bananas, dried fruits, dried beans and peas, and nuts. Healthy
kidneys measure potassium in the blood and remove excess amounts. Diseased kidneys
may fail to remove excess potassium. With very poor kidney function, high potassium
levels can affect the heart rhythm.

Not Smoking

Smoking not only increases the risk of kidney disease, but it also contributes to deaths
from strokes and heart attacks in people with CKD.

Treating Anemia

Anemia is a condition in which the blood does not contain enough red blood cells.
These cells are important because they carry oxygen throughout the body. A person
who is anemic will feel tired and look pale. Healthy kidneys make the hormone EPO,
which stimulates the bones to make red blood cells. Diseased kidneys may not make
enough EPO. A person with CKD may need to take injections of a form of EPO.

Preparing for End-stage Renal Disease (ESRD)

As kidney disease progresses, a person needs to make several decisions. People in the
later stages of CKD need to learn about their options for treating the last stages of
kidney failure so they can make an informed choice between hemodialysis, peritoneal
dialysis, and transplantation.

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What happens if the kidneys fail completely?

Total or nearly total and permanent kidney failure is called ESRD. If a person’s
kidneys stop working completely, the body fills with extra water and waste products.
This condition is called uremia. Hands or feet may swell. A person will feel tired and
weak because the body needs clean blood to function properly.

Untreated uremia may lead to seizures or coma and will ultimately result in death. A
person whose kidneys stop working completely will need to undergo dialysis or kidney
transplantation.

Dialysis

The two major forms of dialysis are hemodialysis and peritoneal dialysis.
Hemodialysis uses a special filter called a dialyzer that functions as an artificial kidney
to clean a person’s blood. The dialyzer is a canister connected to the hemodialysis
machine. During treatment, the blood travels through tubes into the dialyzer, which
filters out wastes, extra salt, and extra water. Then the cleaned blood flows through
another set of tubes back into the body. The hemodialysis machine monitors blood
flow and removes wastes from the dialyzer. Hemodialysis is usually performed at a
dialysis center three times per week for 3 to 4 hours. A small but growing number of
clinics offer home hemodialysis in addition to standard in-clinic treatments. The patient
first learns to do treatments at the clinic, working with a dialysis nurse. Daily home
hemodialysis is done 5 to 7 days per week for 2 to 3 hours at a time. Nocturnal dialysis
can be performed for 8 hours at night while a person sleeps. Research as to which is the
best method for dialysis is under way, but preliminary data indicate that daily dialysis
schedules such as short daily dialysis or nocturnal dialysis may be the best form of
dialysis therapy.

Hemodialysis

In peritoneal dialysis, a fluid called dialysis solution is put into the abdomen. This fluid
captures the waste products from a person’s blood. After a few hours when the fluid is
nearly saturated with wastes, the fluid is drained through a catheter. Then, a fresh bag
of fluid is dripped into the abdomen to continue the cleansing process. Patients can
perform peritoneal dialysis themselves. Patients using continuous ambulatory
peritoneal dialysis (CAPD) change fluid four times a day. Another form of peritoneal
dialysis, called continuous cycling peritoneal dialysis (CCPD), can be performed at
night with a machine that drains and refills the abdomen automatically.

Peritoneal dialysis

Transplantation

A donated kidney may come from an anonymous donor who has recently died or from
a living person, usually a relative. The kidney must be a good match for the patient’s
body. The more the new kidney is like the person receiving the kidney, the less likely
the immune system is to reject it. The immune system protects a person from disease
by attacking anything that is not recognized as a normal part of the body. So the
immune system will attack a kidney that appears too “foreign.” The patient will take
special drugs to help trick the immune system so it does not reject the transplanted
kidney. Unless they are causing infection or high blood pressure, the diseased kidneys
are left in place. Kidneys from living, related donors appear to be the best match for
success, but kidneys from unrelated people also have a long survival rate. Patients
approaching kidney failure should ask their doctor early about starting the process to
receive a kidney transplant.

Kidney transplantation

Points to Remember

• The kidneys are two vital organs that keep the blood clean and chemically
balanced.
• Kidney disease can be detected through a spot check for protein or albumin in
the urine and a calculation of glomerular filtration rate (GFR) based on a blood
test.
• The progression of kidney disease can be slowed, but it cannot always be
reversed.
• End-stage renal disease (ESRD) is the total or nearly total and permanent loss
of kidney function.
• Dialysis and transplantation can extend the lives of people with kidney failure.
• Diabetes and high blood pressure are the two leading causes of kidney failure.
• People with reduced kidney function should see their doctor regularly. Doctors
who specialize in kidney disease are called nephrologists.
• Chronic kidney disease (CKD) increases the risk of heart attacks and strokes.
• People in the early stages of CKD may be able to save their remaining kidney
function for many years by
o controlling their blood glucose
o controlling their blood pressure
o following a low-protein diet
o maintaining healthy levels of cholesterol in the blood
o taking an angiotensin-converting enzyme (ACE) inhibitor or an
angiotensin receptor blocker (ARB)
o not smoking

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Hope through Research

As understanding of the causes of kidney failure increases, so does the ability to predict
and prevent these diseases. Recent studies have shown that intensive control of
diabetes and high blood pressure can prevent or delay the onset of kidney disease.

In the area of genetics, researchers supported by the National Institute of Diabetes and
Digestive and Kidney Diseases (NIDDK) have located two genes that cause the most
common form of PKD and learned that a person must have two defective copies of the
PKD1 gene to develop PKD. Researchers have also found a gene in the roundworm
that is identical to the PKD1 gene. This new knowledge will be used in the search for
effective therapies to prevent or treat PKD.

In the area of transplantation, new drugs to help the body accept foreign tissue increase
the likelihood that a transplanted kidney will survive and function properly. Scientists
at the NIDDK are also developing new techniques to induce a person’s tolerance for
foreign tissue before receiving a transplanted organ. This technique will eliminate or
reduce the need for immunosuppressive drugs and thereby reduce expense and
complications. In the future, scientists may develop an artificial kidney for
implantation.

Participants in clinical trials can play a more active role in their own health care, gain
access to new research treatments before they are widely available, and help others by
contributing to medical research. For information about current studies, visit
www.ClinicalTrials.gov.

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For More Information

American Association of Kidney Patients

3505 East Frontage Road, Suite 315
Tampa, FL 33607
Phone: 1–800–749–2257 or 813–636–8100
Fax: 813–636–8122
Email: info@aakp.org
Internet: www.aakp.org

American Kidney Fund

6110 Executive Boulevard, Suite 1010
Rockville, MD 20852
Phone: 1–800–638–8299 or 1–866–300–2900
Fax: 301–881–0898
Email: helpline@kidneyfund.org
Internet: www.kidneyfund.org

Life Options
c/o Medical Education Institute, Inc.
414 D’Onofrio Drive, Suite 200
Madison, WI 53719
Phone: 1–800–468–7777
Fax: 608–833–8366
Email: lifeoptions@MEIresearch.org
Internet: www.lifeoptions.org
www.kidneyschool.org

National Kidney Foundation

30 East 33rd Street
New York, NY 10016
Phone: 1–800–622–9010 or 212–889–2210
Internet: www.kidney.org

The NephCure Foundation

15 Waterloo Avenue, Suite 200
Berwyn, PA 19312
Phone: 1–866–NEPHCURE
(1–866–637–4287) or 610–540–0186
Fax: 610–540–0190
Email: info@nephcure.org
Internet: www.nephcure.org

Polycystic Kidney Disease (PKD) Foundation

8330 Ward Parkway, Suite 510
Kansas City, MO 64114–2000
Phone: 1–800–PKD–CURE
(1–800–753–2873) or 816–931–2600
Fax: 816–931–8655
Email: pkdcure@pkdcure.org
Internet: www.pkdcure.org

You may also find additional information about this topic by visiting MedlinePlus at
www.medlineplus.gov.

This publication may contain information about medications. When prepared, this
publication included the most current information available. For updates or for
questions about any medications, contact the U.S. Food and Drug Administration toll-
free at 1–888–INFO–FDA (1–888–463–6332) or visit www.fda.gov. Consult your
doctor for more information.

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Acknowledgments

Publications produced by the Clearinghouse are carefully reviewed by both NIDDK

scientists and outside experts. This publication was reviewed by William McClellan,
M.D., Emory University, Atlanta, and Bessie Young, M.D., University of Washington,
Seattle.

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National Kidney Disease Education Program

3 Kidney Information Way

Bethesda, MD 20892
Phone: 1–866–4–KIDNEY (1–866–454–3639)
TTY: 1–866–569–1162
Fax: 301–402–8182
Email: nkdep@info.niddk.nih.gov
Internet: www.nkdep.nih.gov

The National Kidney Disease Education Program (NKDEP) is an initiative of the

National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes
of Health, U.S. Department of Health and Human Services. The NKDEP aims to raise
awareness of the seriousness of kidney disease, the importance of testing those at high
risk, and the availability of treatment to prevent or slow kidney disease.

National Kidney and Urologic Diseases Information

Clearinghouse
3 Information Way
Bethesda, MD 20892–3580
Phone: 1–800–891–5390
TTY: 1–866–569–1162
Fax: 703–738–4929
Email: nkudic@info.niddk.nih.gov
Internet: www.kidney.niddk.nih.gov

The National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) is

a service of the National Institute of Diabetes and Digestive and Kidney Diseases
(NIDDK). The NIDDK is part of the National Institutes of Health of the U.S.
Department of Health and Human Services. Established in 1987, the Clearinghouse
provides information about diseases of the kidneys and urologic system to people with
kidney and urologic disorders and to their families, health care professionals, and the
public. The NKUDIC answers inquiries, develops and distributes publications, and
works closely with professional and patient organizations and Government agencies to
coordinate resources about kidney and urologic diseases.
Publications produced by the Clearinghouse are carefully reviewed by both NIDDK
scientists and outside experts.

This publication is not copyrighted. The Clearinghouse encourages users of this

publication to duplicate and distribute as many copies as desired.

NIH Publication No. 09–3195

February 2009

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http://kidney.niddk.nih.gov/kudiseases/pubs/yourkidneys/

Hemodialysis
From Wikipedia, the free encyclopedia
Jump to: navigation, search

Hemodialysis in progress
Hemodialysis machine

In medicine, hemodialysis (also haemodialysis) is a method for removing waste products such
as creatinine and urea, as well as free water from the blood when the kidneys are in renal failure.
Hemodialysis is one of three renal replacement therapies (the other two being renal transplant;
peritoneal dialysis).

Hemodialysis can be an outpatient or inpatient therapy. Routine hemodialysis is conducted in a

dialysis outpatient facility, either a purpose built room in a hospital or a dedicated, stand alone
clinic. Less frequently hemodialysis is done at home. Dialysis treatments in a clinic are initiated
and managed by specialized staff made up of nurses and technicians; dialysis treatments at home
can be self initiated and managed or done jointly with the assistance of a trained helper who is
usually a family member.[1]

Contents
[hide]

• 1 Principle
• 2 History
• 3 Prescription
• 4 Side effects and complications
• 5 Access
o 5.1 Catheter
o 5.2 AV fistula
o 5.3 AV graft
 o 5.4 Fistula First project
• 6 Types
o 6.1 Conventional hemodialysis
o 6.2 Daily hemodialysis
o 6.3 Nocturnal hemodialysis
• 7 Advantages and disadvantages
o 7.1 Advantages
o 7.2 Disadvantages
• 8 Equipment
o 8.1 Water system
o 8.2 Dialyzer
• 9 Membrane and flux
o 9.1 Membrane flux and outcome
o 9.2 Membrane flux and beta-2-microglobulin amyloidosis
o 9.3 Dialyzer size and efficiency
o 9.4 Reuse of dialyzers
• 10 Nursing care for hemodialysis patient
• 11 See also
• 12 References

• 13 External links

[edit] Principle

Semipermeable membrane

The principle of hemodialysis is the same as other methods of dialysis; it involves diffusion of
solutes across a semipermeable membrane. Hemodialysis utilizes counter current flow, where the
dialysate is flowing in the opposite direction to blood flow in the extracorporeal circuit. Counter-
current flow maintains the concentration gradient across the membrane at a maximum and
increases the efficiency of the dialysis.

Fluid removal (ultrafiltration) is achieved by altering the hydrostatic pressure of the dialysate
compartment, causing free water and some dissolved solutes to move across the membrane along
a created pressure gradient.
The dialysis solution that is used may be a sterilized solution of mineral ions or comply with
Britich Pharmacopea. Urea and other waste products, potassium, and phosphate diffuse into the
dialysis solution. However, concentrations of sodium and chloride are similar to those of normal
plasma to prevent loss. Sodium bicarbonate is added in a higher concentration than plasma to
correct blood acidity. A small amount of glucose is also commonly used.

Note that this is a different process to the related technique of hemofiltration.

[edit] History
Many have played a role in developing dialysis as a practical treatment for renal failure, starting
with Thomas Graham of Glasgow, who first presented the principles of solute transport across a
semipermeable membrane in 1854.[2] The artificial kidney was first developed by Abel, Rountree
and Turner in 1913,[3] the first hemodialysis in a human being was by Hass (February 28, 1924)[4]
and the artificial kidney was developed into a clinically useful apparatus by Kolff in 1943 - 1945.
[5]
This research showed that life could be prolonged in patients dying of renal failure.

Dr. Willem Kolff was the first to construct a working dialyzer in 1943. The first successfully
treated patient was a 67-year-old woman in uremic coma who regained consciousness after 11
hours of hemodialysis with Kolff’s dialyzer in 1945. At the time of its creation, Kolff’s goal was
to provide life support during recovery from acute renal failure. After World War II ended, Kolff
donated the five dialyzers he had made to hospitals around the world, including Mount Sinai
Hospital, New York. Kolff gave a set of blueprints for his hemodialysis machine to George
Thorn at the Peter Bent Brigham Hospital in Boston. This led to the manufacture of the next
generation of Kolff’s dialyzer, a stainless steel Kolff-Brigham dialysis machine.

By the 1950s, Willem Kolff’s invention of the dialyzer was used for acute renal failure, but it
was not seen as a viable treatment for patients with stage 5 chronic kidney disease (CKD). At the
time, doctors believed it was impossible for patients to have dialysis indefinitely for two reasons.
First, they thought no man-made device could replace the function of kidneys over the long term.
In addition, a patient undergoing dialysis suffered from damaged veins and arteries, so that after
several treatments, it became difficult to find a vessel to access the patient’s blood.

Dr. Nils Alwall: The original Kolff kidney was not very useful clinically, because it did not
allow for removal of excess fluid. Dr. Nils Alwall [6] encased a modified version of this kidney
inside a stainless steel canister, to which a negative pressure could be applied, in this way
effecting the first truly practical application of hemodialysis, which was done in 1946 at the
University of Lund. Alwall also was arguably the inventor of the arteriovenous shunt for dialysis.
He reported this first in 1948 where he used such an arteriovenous shunt in rabbits. Subsequently
he used such shunts, made of glass, as well as his canister-enclosed dialyzer, to treat 1500
patients in renal failure between 1946 and 1960, as reported to the First International Congress of
Nephrology held in Evian in September 1960. Alwall was appointed to a newly-created Chair of
Nephrology at the University of Lund in 1957. Subsequently, he collaborated with Swedish
businessman Holger Crafoord to found one of the key companies that would manufacture
dialysis equipment in the past 50 years, Gambro. The early history of dialysis has been reviewed
by Stanley Shaldon.[7]
Dr. Belding H. Scribner working with a surgeon, Dr. Wayne Quinton, modified the glass shunts
used by Alwall by making them from Teflon. Another key improvement was to connect them to
a short piece of silicone elastomer tubing. This formed the basis of the so-called Scribner shunt,
perhaps more properly called the Quinton-Scribner shunt. After treatment, the circulatory access
would be kept open by connecting the two tubes outside the body using a small U-shaped Teflon
tube, which would shunt the blood from the tube in the artery back to the tube in the vein.[8]

In 1962, Scribner started the world’s first outpatient dialysis facility, the Seattle Artificial Kidney
Center, later renamed the Northwest Kidney Centers. Immediately the problem arose of who
should be given dialysis, since demand far exceeded the capacity of the six dialysis machines at
the center. Scribner decided that the decision about who would receive dialysis and who
wouldn’t, would not be made by him. Instead, the choices would be made by an anonymous
committee, which could be viewed as one of the first bioethics committees.

For a detailed history of successful and unsuccessful attempts at dialysis, including pioneers such
as Abel and Roundtree, Haas, and Necheles, see this review by Kjellstrand.[9]

[edit] Prescription
A prescription for dialysis by a nephrologist (a medical kidney specialist) will specify various
parameters for a dialysis treatment. These include frequency (how many treatments per week),
length of each treatment, and the blood and dialysis solution flow rates, as well as the size of the
dialyzer. The composition of the dialysis solution is also sometimes adjusted in terms of its
sodium and potassium and bicarbonate levels. In general, the larger the body size of an
individual, the more dialysis he/she will need. In the North America and UK, 3-4 hour treatments
(sometimes up to 5 hours for larger patients) given 3 times a week are typical. Twice-a-week
sessions are limited to patients who have a substantial residual kidney function. Four sessions per
week are often prescribed for larger patients, as well as patients who have trouble with fluid
overload. Finally, there is growing interest in short daily home hemodialysis, which is 1.5 - 4 hr
sessions given 5-7 times per week, usually at home. There also is interest in nocturnal dialysis,
which involves dialyzing a patient, usually at home, for 8–10 hours per night, 3-6 nights per
week. Nocturnal in-center dialysis, 3-4 times per week is also offered at a handful of dialysis
units in the United States.

[edit] Side effects and complications

Hemodialysis often involves fluid removal (through ultrafiltration), because most patients with
renal failure pass little or no urine. Side effects caused by removing too much fluid and/or
removing fluid too rapidly include low blood pressure, fatigue, chest pains, leg-cramps, nausea
and headaches. These symptoms can occur during the treatment and can persist post treatment;
they are sometimes collectively referred to as the dialysis hangover or dialysis washout. The
severity of these symptoms is usually proportionate to the amount and speed of fluid removal.
However, the impact of a given amount or rate of fluid removal can vary greatly from person to
person and day to day. These side effects can be avoided and/or their severity lessened by
limiting fluid intake between treatments or increasing the dose of dialysis e.g. dialyzing more
often or longer per treatment than the standard three times a week, 3–4 hours per treatment
schedule.

Since hemodialysis requires access to the circulatory system, patients undergoing hemodialysis
may expose their circulatory system to microbes, which can lead to sepsis, an infection affecting
the heart valves (endocarditis) or an infection affecting the bones (osteomyelitis). The risk of
infection varies depending on the type of access used (see below). Bleeding may also occur,
again the risk varies depending on the type of access used. Infections can be minimized by
strictly adhering to infection control best practices.

Heparin is the most commonly used anticoagulant in hemodialysis, as it is generally well

tolerated and can be quickly reversed with protamine sulfate. Heparin allergy can infrequently be
a problem and can cause a low platelet count. In such patients, alternative anticoagulants can be
used. In patients at high risk of bleeding, dialysis can be done without anticoagulation.

First Use Syndrome is a rare but severe anaphylactic reaction to the artificial kidney. Its
symptoms include sneezing, wheezing, shortness of breath, back pain, chest pain, or sudden
death. It can be caused by residual sterilant in the artificial kidney or the material of the
membrane itself. In recent years, the incidence of First Use Syndrome has decreased, due to an
increased use of gamma irradiation, steam sterilization, or electron-beam radiation instead of
chemical sterilants, and the development of new semipermeable membranes of higher
biocompatibility. New methods of processing previously acceptable components of dialysis must
always be considered. For example, in 2008, a series of first-use type or reactions, including
deaths occurred due to heparin contaminated during the manufacturing process with oversulfated
chondroitin sulfate.[10]

Longterm complications of hemodialysis include amyloidosis, neuropathy and various forms of

heart disease. Increasing the frequency and length of treatments have been shown to improve
fluid overload and enlargement of the heart that is commonly seen in such patients.[11][12]

Listed below are specific complications associated with different types of hemodialysis access.

[edit] Access
In hemodialysis, three primary methods are used to gain access to the blood: an intravenous
catheter, an arteriovenous (AV) fistula and a synthetic graft. The type of access is influenced by
factors such as the expected time course of a patient's renal failure and the condition of his or her
vasculature. Patients may have multiple accesses, usually because an AV fistula or graft is
maturing and a catheter is still being used. The creation of all these three major types of vascular
accesses requires surgery.[13]

[edit] Catheter

Catheter access, sometimes called a CVC (Central Venous Catheter), consists of a plastic
catheter with two lumens (or occasionally two separate catheters) which is inserted into a large
vein (usually the vena cava, via the internal jugular vein or the femoral vein) to allow large flows
of blood to be withdrawn from one lumen, to enter the dialysis circuit, and to be returned via the
other lumen. However, blood flow is almost always less than that of a well functioning fistula or
graft.

Catheters are usually found in two general varieties, tunnelled and non-tunnelled.

Non-tunnelled catheter access is for short-term access (up to about 10 days, but often for one
dialysis session only), and the catheter emerges from the skin at the site of entry into the vein.

Tunnelled catheter access involves a longer catheter, which is tunnelled under the skin from the
point of insertion in the vein to an exit site some distance away. It is usually placed in the
internal jugular vein in the neck and the exit site is usually on the chest wall. The tunnel acts as a
barrier to invading microbes, and as such, tunnelled catheters are designed for short- to medium-
term access (weeks to months only), because infection is still a frequent problem.

Aside from infection, venous stenosis is another serious problem with catheter access. The
catheter is a foreign body in the vein and often provokes an inflammatory reaction in the vein
wall. This results in scarring and narrowing of the vein, often to the point of occlusion. This can
cause problems with severe venous congestion in the area drained by the vein and may also
render the vein, and the veins drained by it, useless for creating a fistula or graft at a later date.
Patients on long-term hemodialysis can literally 'run out' of access, so this can be a fatal problem.

Catheter access is usually used for rapid access for immediate dialysis, for tunnelled access in
patients who are deemed likely to recover from acute renal failure, and for patients with end-
stage renal failure who are either waiting for alternative access to mature or who are unable to
have alternative access.

Catheter access is often popular with patients, because attachment to the dialysis machine doesn't
require needles. However, the serious risks of catheter access noted above mean that such access
should be contemplated only as a long-term solution in the most desperate access situation.

[edit] AV fistula
A radiocephalic fistula.

AV (arteriovenous) fistulas are recognized as the preferred access method. To create a fistula, a
vascular surgeon joins an artery and a vein together through anastomosis. Since this bypasses the
capillaries, blood flows rapidly through the fistula. One can feel this by placing one's finger over
a mature fistula. This is called feeling for "thrill" and produces a distinct 'buzzing' feeling over
the fistula. One can also listen through a stethoscope for the sound of the blood "whooshing"
through the fistula, a sound called bruit.

Fistulas are usually created in the nondominant arm and may be situated on the hand (the
'snuffbox' fistula'), the forearm (usually a radiocephalic fistula, or so-called Brescia-Cimino
fistula, in which the radial artery is anastomosed to the cephalic vein), or the elbow (usually a
brachiocephalic fistula, where the brachial artery is anastomosed to the cephalic vein). A fistula
will take a number of weeks to mature, on average perhaps 4–6 weeks. During treatment, two
needles are inserted into the fistula, one to draw blood and one to return it.

The advantages of the AV fistula use are lower infection rates, because no foreign material is
involved in their formation, higher blood flow rates (which translates to more effective dialysis),
and a lower incidence of thrombosis. The complications are few, but if a fistula has a very high
blood flow and the vasculature that supplies the rest of the limb is poor, a steal syndrome can
occur, where blood entering the limb is drawn into the fistula and returned to the general
circulation without entering the limb's capillaries. This results in cold extremities of that limb,
cramping pains, and, if severe, tissue damage. One long-term complication of an AV fistula can
be the development of an aneurysm, a bulging in the wall of the vein where it is weakened by the
repeated insertion of needles over time. To a large extent the risk of developing an aneurysm can
be reduced by carefully rotating needle sites over the entire fistula, or using the
"buttonhole"(constant site) technique. Aneurysms may necessitate corrective surgery and may
shorten the useful life of a fistula. To prevent damage to the fistula and aneurysm or
pseudoaneurysm formation, it is recommended that the needle be inserted at different points in a
rotating fashion. Another approach is to cannulate the fistula with a blunted needle, in exactly the
same place. This is called a 'buttonhole' approach. Often two or three buttonhole places are
available on a given fistula. This also can prolong fistula life and help prevent damage to the
fistula.

[edit] AV graft

An arteriovenous graft.

AV (arteriovenous) grafts are much like fistulas in most respects, except that an artificial vessel
is used to join the artery and vein. The graft usually is made of a synthetic material, often PTFE,
but sometimes chemically treated, sterilized veins from animals are used. Grafts are inserted
when the patient's native vasculature does not permit a fistula. They mature faster than fistulas,
and may be ready for use several weeks after formation (some newer grafts may be used even
sooner). However, AV grafts are at high risk to develop narrowing, especially in the vein just
downstream from where the graft has been sewn to the vein. Narrowing often leads to clotting or
thrombosis. As foreign material, they are at greater risk for becoming infected. More options for
sites to place a graft are available, because the graft can be made quite long. Thus a graft can be
placed in the thigh or even the neck (the 'necklace graft').

[edit] Fistula First project

AV fistulas have a much better access patency and survival than do venous catheters or grafts.
They also produce better patient survival and have far fewer complications compared to grafts or
venous catheters. For this reason, the Centers for Medicare & Medicaid (CMS) has set up a
Fistula First Initiative,[14] whose goal is to increase the use of AV fistulas in dialysis patients.

There is ongoing research to make bio-engineered blood vessels, which may be of immense
importance in creating AV fistulas for patients on hemodialysis, who do not have good blood
vessels for creation of one. It involves growing cells which produce collagen and other proteins
on a biodegradable micromesh tube followed by removal of those cells to make the 'blood
vessels' storable in refrigerators.[15]

[edit] Types
There are three types of hemodialysis: conventional hemodialysis, daily hemodialysis, and
nocturnal hemodialysis. Below is the adaption and summary from a brochure of The Ottawa
Hospital.

[edit] Conventional hemodialysis

Chronic hemodialysis is usually done three times per week, for about 3–4 hours for each
treatment, during which the patient's blood is drawn out through a tube at a rate of 3-400 cc/min.
The tube is connected to a 15, 16, or 17 gauge needle inserted in the dialysis fistula or graft, or
connected to one port of a dialysis catheter. The blood is then pumped through the dialyser, and
then the processed blood is pumped back into the patient's bloodstream through another tube
(connected to a second needle or port). During the procedure, the patient's blood pressure is
closely monitored, and if it becomes low, or the patient develops any other signs of low blood
volume such as nausea, the dialysis attendant can administer extra fluid through the machine.
During the treatment, the patient's entire blood volume (about 5000 cc) circulates through the
machine every 15 minutes.

[edit] Daily hemodialysis

Daily hemodialysis is typically used by those patients who do their own dialysis at home. It is
less stressful (more gentle) but does require more frequent access. This is simple with catheters,
but more problematic with fistulas or grafts. The "buttonhole technique" can be used for fistulas
requiring frequent access. Daily hemodialysis is usually done for 2 hours six days a week.

[edit] Nocturnal hemodialysis

the procedure of nocturnal hemodialysis is similar to conventional hemodialysis except it is

performed six nights a week and six-ten hours per session while the patient sleeps.[16]

[edit] Advantages and disadvantages

[edit] Advantages

• Low mortality rate

• Better control of blood pressure and abdominal cramps
• Less diet restriction
• Better solute clearance effect for the daily hemodialysis: better tolerance and fewer
complications with more frequent dialysis [17]
[edit] Disadvantages

• Restricts independence, as people undergoing this procedure cannot travel around

because of supplies’ availability
• Requires reliable technology such as high water quality and electricity
• Requires more supplies like dialysis machines
• The procedure is complicated and requires that care givers have more knowledge
• Requires time to set up and clean dialysis machines, and expense with machines and
associated staff[17]

[edit] Equipment

Schematic of a hemodialysis circuit

The hemodialysis machine pumps the patient's blood and the dialysate through the dialyzer. The
newest dialysis machines on the market are highly computerized and continuously monitor an
array of safety-critical parameters, including blood and dialysate flow rates; dialysis solution
conductivity, temperature, and pH; and analysis of the dialysate for evidence of blood leakage or
presence of air. Any reading that is out of normal range triggers an audible alarm to alert the
patient-care technician who is monitoring the patient. Manufacturers of dialysis machines
include companies such as Fresenius, Gambro, Baxter, B. Braun, NxStage and Bellco.

[edit] Water system

A hemodialysis unit's dialysate solution tanks

An extensive water purification system is absolutely critical for hemodialysis. Since dialysis
patients are exposed to vast quantities of water, which is mixed with dialysate concentrate to
form the dialysate, even trace mineral contaminants or bacterial endotoxins can filter into the
patient's blood. Because the damaged kidneys cannot perform their intended function of
removing impurities, ions introduced into the bloodstream via water can build up to hazardous
levels, causing numerous symptoms or death. Aluminum, chloramine, fluoride, copper, and zinc,
as well as bacterial fragments and endotoxins, have all caused problems in this regard.

For this reason, water used in hemodialysis is carefully purified before use. Initially it is filtered
and temperature-adjusted and its pH is corrected by adding an acid or base. Then it is softened.
Next the water is run through a tank containing activated charcoal to adsorb organic
contaminants. Primary purification is then done by forcing water through a membrane with very
tiny pores, a so-called reverse osmosis membrane. This lets the water pass, but holds back even
very small solutes such as electrolytes. Final removal of leftover electrolytes is done by passing
the water through a tank with ion-exchange resins, which remove any leftover anions or cations
and replace them with hydroxyl and hydrogen molecules, respectively, leaving ultrapure water.

Even this degree of water purification may be insufficient. The trend lately is to pass this final
purified water (after mixing with dialysate concentrate) through a dialyzer membrane. This
provides another layer of protection by removing impurities, especially those of bacterial origin,
that may have accumulated in the water after its passage through the original water purification
system.

Once purified water is mixed with dialysate concentrate, its conductivity increases, since water
that contains charged ions conducts electricity. During dialysis, the conductivity of dialysis
solution is continuously monitored to ensure that the water and dialysate concentrate are being
mixed in the proper proportions. Both excessively concentrated dialysis solution and excessively
dilute solution can cause severe clinical problems.

[edit] Dialyzer

The dialyzer is the piece of equipment that actually filters the blood. Almost all dialyzers in use
today are of the hollow-fiber variety. A cylindrical bundle of hollow fibers, whose walls are
composed of semi-permeable membrane, is anchored at each end into potting compound (a sort
of glue). This assembly is then put into a clear plastic cylindrical shell with four openings. One
opening or blood port at each end of the cylinder communicates with each end of the bundle of
hollow fibers. This forms the "blood compartment" of the dialyzer. Two other ports are cut into
the side of the cylinder. These communicate with the space around the hollow fibers, the
"dialysate compartment." Blood is pumped via the blood ports through this bundle of very thin
capillary-like tubes, and the dialysate is pumped through the space surrounding the fibers.
Pressure gradients are applied when necessary to move fluid from the blood to the dialysate
compartment.

[edit] Membrane and flux

Dialyzer membranes come with different pore sizes. Those with smaller pore size are called
"low-flux" and those with larger pore sizes are called "high-flux." Some larger molecules, such
as beta-2-microglobulin, are not removed at all with low-flux dialyzers; lately, the trend has been
to use high-flux dialyzers. However, such dialyzers require newer dialysis machines and high-
quality dialysis solution to control the rate of fluid removal properly and to prevent backflow of
dialysis solution impurities into the patient through the membrane.

Dialyzer membranes used to be made primarily of cellulose (derived from cotton linter). The
surface of such membranes was not very biocompatible, because exposed hydroxyl groups
would activate complement in the blood passing by the membrane. Therefore, the basic,
"unsubstituted" cellulose membrane was modified. One change was to cover these hydroxyl
groups with acetate groups (cellulose acetate); another was to mix in some compounds that
would inhibit complement activation at the membrane surface (modified cellulose). The original
"unsubstituted cellulose" membranes are no longer in wide use, whereas cellulose acetate and
modified cellulose dialyzers are still used. Cellulosic membranes can be made in either low-flux
or high-flux configuration, depending on their pore size.

Another group of membranes is made from synthetic materials, using polymers such as
polyarylethersulfone, polyamide, polyvinylpyrrolidone, polycarbonate, and polyacrylonitrile.
These synthetic membranes activate complement to a lesser degree than unsubstituted cellulose
membranes. Synthetic membranes can be made in either low- or high-flux configuration, but
most are high-flux.

Nanotechnology is being used in some of the most recent high-flux membranes to create a
uniform pore size. The goal of high-flux membranes is to pass relatively large molecules such as
beta-2-microglobulin (MW 11,600 daltons), but not to pass albumin (MW ~66,400 daltons).
Every membrane has pores in a range of sizes. As pore size increases, some high-flux dialyzers
begin to let albumin pass out of the blood into the dialysate. This is thought to be undesirable,
although one school of thought holds that removing some albumin may be beneficial in terms of
removing protein-bound uremic toxins.

[edit] Membrane flux and outcome

Whether using a high-flux dialyzer improves patient outcomes is somewhat controversial, but
several important studies have suggested that it has clinical benefits. The NIH-funded HEMO
trial compared survival and hospitalizations in patients randomized to dialysis with either low-
flux or high-flux membranes. Although the primary outcome (all-cause mortality) did not reach
statistical significance in the group randomized to use high-flux membranes, several secondary
outcomes were better in the high-flux group.[18][19] A recent Cochrane analysis concluded that
benefit of membrane choice on outcomes has not yet been demonstrated.[20] A collaborative
randomized trial from Europe, the MPO (Membrane Permeabilities Outcomes) study,[21]
comparing mortality in patients just starting dialysis using either high-flux or low-flux
membranes, found a nonsignificant trend to improved survival in those using high-flux
membranes, and a survival benefit in patients with lower serum albumin levels or in diabetics.

[edit] Membrane flux and beta-2-microglobulin amyloidosis

High-flux dialysis membranes and/or intermittent on-line hemodiafiltration (IHDF) may also be
beneficial in reducing complications of beta-2-microglobulin accumulation. Because beta-2-
microglobulin is a large molecule, with a molecular weight of about 11,600 daltons, it does not
pass at all through low-flux dialysis membranes. Beta-2-M is removed with high-flux dialysis,
but is removed even more efficiently with IHDF. After several years (usually at least 5-7),
patients on hemodialysis begin to develop complications from beta-2-M accumulation, including
carpal tunnel syndrome, bone cysts, and deposits of this amyloid in joints and other tissues. Beta-
2-M amyloidosis can cause very serious complications, including spondyloarthropathy, and often
is associated with shoulder joint problems. Observational studies from Europe and Japan have
suggested that using high-flux membranes in dialysis mode, or IHDF, reduces beta-2-M
complications in comparison to regular dialysis using a low-flux membrane.[22][23][24][25][26]

[edit] Dialyzer size and efficiency

Dialyzers come in many different sizes. A larger dialyzer with a larger membrane area (A) will
usually remove more solutes than a smaller dialyzer, especially at high blood flow rates. This
also depends on the membrane permeability coefficient K0 for the solute in question. So dialyzer
efficiency is usually expressed as the K0A - the product of permeability coefficient and area.
Most dialyzers have membrane surface areas of 0.8 to 2.2 square meters, and values of K0A
ranging from about 500 to 1500 mL/min. K0A, expressed in mL/min, can be thought of as the
maximum clearance of a dialyzer at very high blood and dialysate flow rates.

[edit] Reuse of dialyzers

The dialyzer may either be discarded after each treatment or be reused. Reuse requires an
extensive procedure of high-level disinfection. Reused dialyzers are not shared between patients.
There was an initial controversy about whether reusing dialyzers worsened patient outcomes.
The consensus today is that reuse of dialyzers, if done carefully and properly, produces similar
outcomes to single use of dialyzers.[27]

Dialyzer Reuse is a practice that has been around since the invention of the product. This
practice includes the cleaning of a used dialyzer in order to be reused multiple times for the same
patient. Dialysis clinics reuse dialyzers to become more economical and reduce the high costs of
“single-use” dialysis which can be extremely expensive and wasteful. Single used dialyzers are
initiated just once and then thrown out creating a large amount of bio-medical waste with no
mercy for cost savings. If done right, dialyzer reuse can be very safe for dialysis patients.

There are two ways of reusing dialyzers. Firstly, there is manual reuse, which involves the
cleaning of the used dialyzer by hand. The dialyzer is semi-disassembled then flushed repeatedly
before being rinsed with water. It is then stored with a liquid disinfectant for 18+ hours until its
next use. Secondly, there is the newer method of automated reuse by means of a medical device.
These devices are beneficial to dialysis clinics that practice reuse – especially for large dialysis
clinical entities – because they allow for several back to back cycles per day. The dialyzer is
automatically cleaned by machine then filled with liquid disinfectant for storage. Automated
reuse is more effective than manual reuse, but when reused over 15 times with current
methodology, the dialyzer can lose B2m, middle molecule clearance and fiber pore structure
integrity, reducing the effectiveness of the patients dialysis session.

[edit] Nursing care for hemodialysis patient

Adapt from nephrology nursing practice recommendations developed by Canadian Association
of Nephrology and Technology (CANNT) based on best available evidence and clinical practice
guidelines, a nephrology nurse should perform [28]:

Hemodialysis Vascular Access: Assess the fistula/graft and arm before, after each dialysis or
every shift: the access flow, complications Assess the complication of central venous catheter:
the tip placement, exit site, complications document and notify appropriate health care provider
regarding any concerns. educates the patient with appropriate cleaning of fistula/graft and exit
site; with recognizing and reporting signs and symptoms of infection and complication.

Hemodialysis adequacy: Assesses patient constantly for signs and symptoms of inadequate
dialysis. Assesses possible causes of inadequate dialysis. Educations patients the importance of
receiving adequate dialysis.

Hemodialysis treatment and complications: Performs head to toe physical assessment before,
during and after hemodialysis regarding complications and access’s security. Confirm and
deliver dialysis prescription after review most update lab results. Address any concerns of the
patient and educate patient when recognizing the learning gap.

Medication management and infection control practice: Collaborate with the patient to develop
a medication regimen. Follow infection control guidelines as per unit protocol.

[edit] See also

• Dialysis
• Dialysis disequilibrium syndrome
• Home hemodialysis
• Peritoneal dialysis
• Hemofiltration
 • Extracorporeal therapies
• Renal replacement therapy
• Step-by-step description of hemodialysis

[edit] References
1. ^ National Kidney and Urologic Diseases Information Clearinghouse guidance
Kidney Failure: Choosing a Treatment That’s Right for You
2. ^ Graham T. The Bakerian lecture: on osmotic force. Philosophical Transactions
of the Royal Society in London. 1854;144:177–228.
3. ^ Abel, J. J., Rountree, L. G., and Turner, B. B. The removal of diffusible
substances from the circulating blood by means of dialysis. Tn. Assoc. Am. Phys., 28:51,
1913.
4. ^ Georg Haas (1886–1971): The Forgotten Hemodialysis Pioneer (PDF)
5. ^ Kolff, W. J., and Berk, H. T. J. Artificial kidney, dialyzer with great area.
Geneesk. gids., 21:1944.
6. ^ University of Lund website: Nils Alwall.
7. ^ Shaldon S. Development of Hemodialysis, From Access to Machine
(presentation given during a symposium entitled: Excellence in Dialysis: Update in
Nephrology; Karachi, Pakistan. October, 2002, as archived on HDCN
8. ^ NIDDK Contributions to Dialysis
9. ^ Kjellstrand CM. History of Dialysis, Men and Ideas. Talk given to the Nordic
Nephrology Days Symposium, Lund, 1997, as archived on HDCN.
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[edit] External links

Wikimedia Commons has media related to: Hemodialysis

• Your Kidneys and How They Work - (American) National Institute of Diabetes and
Digestive and Kidney Diseases (NIDDK), NIH.
• Treatment Methods for Kidney Failure - (American) National Institute of Diabetes and
Digestive and Kidney Diseases (NIDDK), NIH.
 • Treatment Methods for Kidney Failure: Hemodialysis - (American) National Kidney and
Urologic Diseases Information Clearinghouse, NIH.
• Online Community for Dialysis Patients by Dialysis Patients
• What is dialysis? - Kidney Foundation of Canada
• European Kidney Patients' Federation (CEAPIR)
• ARCH Project - European research project for development of a model to simulate

•
• This page was last modified on 22 April 2011 at 07:20.

http://en.wikipedia.org/wiki/Hemodialysis