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HEMODIALYSIS: TREATMENT AND COMPLICATIONS

NOAH CARPENTER, MD

Dr. Noah Carpenter is a Thoracic and Peripheral Vascular Surgeon. He completed his Bachelor of Science in chemistry and medical school and training at the University of Manitoba. Dr. Carpenter completed surgical residency and fellowship at the University of Edmonton and Affiliated Hospitals in Edmonton, Alberta, and an additional Adult Cardiovascular and Thoracic Surgery fellowship at the University of Edinburgh, Scotland. He has specialized in microsurgical techniques, vascular endoscopy, laser and laparoscopic surgery in Brandon, Manitoba and Vancouver, British Columbia, Canada and in Colorado, Texas, and California. Dr. Carpenter has an Honorary Doctorate of Law from the University of Calgary, and was appointed a Citizen Ambassador to China, and has served as a member of the Indigenous Physicians Association of Canada, the Canadian College of Health Service Executives, the Science Institute of the Northwest Territories, Canada Science Council, and the International Society of Endovascular Surgeons, among others. He has been an inspiration to youth, motivating them to understand the importance of achieving higher education.

DANA BARTLETT, RN, BSN, MSN, MA, CSPI

Dana Bartlett is a professional nurse and author. His clinical experience includes 16 years of ICU and ER experience and over 27 years as a poison control center information specialist. Dana has published numerous CE and journal articles, written NCLEX material, textbook chapters, and more than 100 online CE articles, and done editing and reviewing for publishers such as Elsevier, Lippincott, and Thieme. He has written widely on the subject of toxicology and was a contributing editor, toxicology section, for Critical Care Nurse journal. He is currently employed at the Connecticut Poison Control Center. He lives in Wappingers Falls, NY. ABSTRACT

The kidneys regulate blood pressure, maintain blood pH levels, excrete metabolic by-products, produce erythropoietin, and support bone health. When this function fails, dialysis may be used as treatment following an assessment of the patient’s clinical presentation. Vascular access for hemodialysis can be achieved through arteriovenous fistula, arteriovenous graft, and central venous catheter. Complications of hemodialysis treatment include hypotension, cramps, nausea and vomiting, headache, chest pain, back pain, itching, fever and chills.

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Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. Continuing Education Credit Designation This educational activity is credited for 2.5 hours at completion of the activity. Pharmacology content is 0.5 hours (30 minutes). Statement of Learning Need Hemodialysis provides lifesaving treatment to patients with end-stage renal disease. The risk of hemodialysis complications is influenced by multiple factors, including patient comorbidity, demographics and the availability of hemodialysis services based on geographics and the availability of a trained health team and equipment. A high role of the nephrology health team and interdisciplinary members must include the basic care for renal replacement therapy and associated psychosocial needs of patients and families affected by chronic disease. Course Purpose To provide health team professionals with knowledge of hemodialysis indications, treatment options, and quality of life assessment tools to support patients with end-stage renal disease to achieve quality care outcomes. Target Audience Advanced Practice Registered Nurses, Registered Nurses, and other Interdisciplinary Health Team Members. Disclosures Noah Carpenter, MD, William Cook, PhD, Douglas Lawrence, MA, Jennifer McAnally, DNP, PMHNP-BC, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures. There is no commercial support.

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Self-Assessment of Knowledge Pre-Test:

1. True or False: Hemodialysis normalizes electrolyte levels but it does not normalize the pH level in the blood.

a. True b. False

2. Renal replacement therapy is used for patients with chronic

kidney disease that has not responded to other therapies and

a. who cannot undergo dialysis. b. have just had a kidney transplant. c. who have other complications such as encephalopathy. d. whose kidney function has stabilized.

3. The health clinician’s role when caring for dialysis patients

include(s) which of the following:

a. know the signs and symptoms of infection. b. know what laboratory studies may be ordered. c. understand what body areas to assess for infection. d. All of the above

4. The first choice of vascular access for chronic hemodialysis is the

________________ because it has the best longevity and the lowest association with morbidity and mortality.

a. central venous catheter b. arteriovenous graft (AV graft) c. arteriovenous fistula (AVF) d. prosthetic fistula

5. The hemodialysis catheter often used

a. in place of prosthetic fistulae. b. for long-term, chronic hemodialysis. c. long-term because of its longevity. d. an emergent basis or temporary measure.

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Introduction

Hemodialysis is a lifesaving treatment among patients with reduced kidney function who have not responded to conservative forms of therapy. Most people who have hemodialysis require it to avoid symptoms from the buildup of waste products and toxins in the bloodstream that are normally excreted by the kidneys. Optimal dialysis continues to be an area of research in the treatment of end-stage renal disease. The duration and frequency of hemodialysis has been the goal of research groups focused on treatment outcomes, including morbidity and mortality of hemodialysis patients. Alternative dialysis treatment options relative to quality of life, cost-saving or cost neutral benefits, and the impact of chronic kidney disease treatment upon the health system, patients and their families have been studied. While kidney transplant remains the optimal treatment for end-stage renal disease, dialysis will likely be needed as all options for treatment are considered.

Renal Disease and Replacement Therapy

The kidneys provide several functions that maintain homeostasis by

regulating blood pressure, maintaining blood pH levels, excreting metabolic by-products (creatinine and urea), producing erythropoietin (a hormone that stimulates production of red blood cells), and supporting bone health.1,2 The kidneys also act as a filter for waste products and excess fluid that develops in the bloodstream and as a route for excretion of drug metabolites. Without proper kidney function, sodium, potassium, urea, and other compounds can build up to toxic levels in the bloodstream.1,2

Dialysis is used most often to treat patients who have renal impairment

caused by acute kidney injury and chronic or end-stage renal disease. Acute kidney injury is defined as “an abrupt (within hours) decrease in kidney function, which encompasses both injury (structural damage) and impairment (loss of function). It is a syndrome that rarely has a sole and distinct pathophysiology. Many patients with AKI have a mixed aetiology where the presence of sepsis, ischaemia and nephrotoxicity often coexist and complicate recognition and treatment. Furthermore the syndrome is quite common

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among patients without critical illness and it is essential that healthcare professionals, particularly those without specialisation in renal disorders, detect it easily.”3 The glomerular filtration rate (GFR) is used to identify AKI and is typically associated with an acute rise in serum creatinine (sCr) levels. AKI is also typically seen to include a lowering in urine output (UO).3 Biomarkers

Several biomarkers may be used to diagnose AKI: 1) an increase in

serum creatinine of ≥ 0.3 mg/dL within 48, 2) an increase in serum creatinine of at least 50% of the patient’s baseline, the increase known or presumed to have occurred within the past seven days, 3) a urine volume of < 0.5 mL/kg /hour for six hours. Chronic kidney disease is defined as kidney damage or decreased kidney function – evaluated by the glomerular filtration rate (GFR) and the presence and severity of albuminuria - that is present for ≥ 3 months.3,4

Acute Renal Failure

Acid-base and electrolyte abnormalities unrelated to renal impairment and removal of toxic levels of drugs can be achieved through dialysis. It may be necessary as either an acute or chronic treatment for when the kidneys are not functioning.4,5 Acute dialysis may be necessary for some patients who are significantly ill as a result of acute renal failure or who have taken an overdose of certain drugs, such as lithium.5 It is important that clinicians understand and review regularly their practice guidelines on the benefits and risks of certain medications and renal health. For example, in the case of lithium, not all patients taking lithium will develop glomerular adverse effects; however, some will develop CKD and a small number of patients taking lithium will progress to end-stage renal disease. Age, combination treatment with other psychotropic drugs or comorbid medical/psychiatric illnesses are factors contributing to compromised renal health. Patients on long-term lithium therapy require close monitoring of lithium-associated CKD.5

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Chronic Kidney Disease

Individuals who develop CKD may be hospitalized and receive dialysis where poor kidney function becomes a life-threatening emergency, as in end-stage renal disease. For example, dialysis may be required to correct potassium levels and to avoid cardiac complications from hyperkalemia. Chronic or maintenance dialysis is ordered for patients who need ongoing treatment to correct fluid and electrolyte imbalances as a result of decreased kidney function. Chronic dialysis, often called renal replacement therapy, is used to treat patients who have chronic kidney disease that has not responded to other therapies and who have complications that may include encephalopathy, refractory fluid and electrolyte abnormalities, and uremic pericarditis.6-9

Preparing the Patient for Hemodialysis

Hemodialysis is utilized for renal disease following an assessment of the patient’s clinical presentation. This involves correcting abnormal laboratory parameters and the patient’s presentation. Hemodialysis aims at slowing the rate of kidney disease.9 The process of hemodialysis involves a vascular access device, the dialysate solution, the dialyzer tubing, and the dialysis machine.9,10 Vascular Access Devices

Vascular access (VA) for hemodialysis can be achieved through three main methods: 1) native arteriovenous fistula (AVF), 2) arteriovenous graft (AV graft), and 3) central venous catheter (CVC).9-12 The first choice of vascular access for chronic hemodialysis is AVF because it has the best longevity and the lowest association with morbidity and mortality.12 Prosthetic fistulae are typically the second option for hemodialysis access. Central venous catheters are recognized as an important adjunct to maintain hemodialysis; however, complications from CVCs may range from 5% to 19%.12 Locations for insertion of the hemodialysis catheter that tend to be preferred are the internal jugular and femoral veins.12 The subclavian vein

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carries a high risk of thrombosis and is the third choice of hemodialysis access.12

Vascular access maintenance requires an integrated interdisciplinary health team approach to create a VA team. The VA team typically includes a “nephrologist, radiologist, vascular surgeon, infectious disease consultant, and members of the dialysis staff.”12 The VA team is experienced to provide patients and their families the best options for VA and ongoing care.

Vascular access failure and removal occurs in an approximate 30%–60% of hemodialysis patients with CVCs because of infection, and patients with CVCs have a higher rate of hospitalization than patients with an AVF.12 Increasingly, patients will present with history of implanted pacemakers and defibrillators (inserted via the subclavian vein and superior vena cava into the right heart), therefore these patients require a thorough assessment and informed of the benefits and risks.12 Hemodialysis Catheter

A hemodialysis catheter is an intravenous (IV) catheter that is placed in the central vein by access through a vein in the neck, groin, or upper chest. Hemodialysis catheters are often used on an emergent basis or as a temporary measure until an arteriovenous fistula or graft can be placed or while an arteriovenous fistula or graft is maturing.9-11 Arteriovenous Fistula (AVF) Procedure

An AVF involves surgically creating an anastomosis of an artery to a vein, usually in the non-dominant forearm; creating an anastomosis between the radial artery and the cephalic vein is a common way of performing the procedure.13 The patient should evaluated by the dialysis nurse and the hand that would best be used for dialysis should not be used for phlebotomy or blood pressure measurement. The dialysis nurse should educate the patient to refuse access to the arm where arm veins need to be protected.13 The surgeon should also examine the patient to determine the type and quality of

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the cephalic vein. Veins that are not visualized may need ultrasound testing to map the vein and document vein size.13

An AVF is created through a surgical procedure to connect an artery to a vein; it is typically placed in the lower part of the arm. Once the AVF is working, the blood flow can be felt as a thrill on the skin over the site. Arteriovenous Graft (AV graft) Procedure

An AV graft is done by anastomosing an artery and a vein by use of a synthetic tube, and an AV graft can be placed in the same locations as an AVF.15 The graft is placed under the skin of the lower arm and produces a thrill on the skin over the site. The AV graft does not require as much time to mature as the AVF and generally can be used within several weeks after placement. Adequate cardiac output is needed for needed blood flow in both fistula and graft maturation; adequate vein size and compliance, unobstructed outflow veins (i.e., unscarred or damaged by prior catheter insertions, pacemakers, or cardiac implanted electronic devices) can cause venous stenosis/occlusion that interfere with arteriovenous access creation.16

Vascular Access Selection

Vascular access selection involves several patient algorithms to assist in the appropriate selection of vascular access type. For example, a young patient with good vessel size, low comorbidity and a long life expectancy on hemodialysis should consider fistula as the first access.16 On the other hand, those with high comorbidity and less of a life expectancy on dialysis should consider a graft as more appropriate.16

Arteriovenous fistulas are considered superior to AV grafts because of longer patency after cannulation and dialysis.15 However, an AV graft is suited for the patient who has poor circulation or small, fragile blood vessels, and it can be used within two weeks of placement.15,16

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Arteriovenous fistulas and grafts also have different benefits and disadvantages (i.e., long-term complications, rate of failure, and need to mature) before the access point can be used. The choice of a fistula versus a graft is made on a case-by case basis, but, as mentioned above, the preferred method is the AVF as it has a higher rate of long-term patency and a lower rate of complications.15,16

Dialysate

Dialysate is a type of fluid used with both hemodialysis and peritoneal dialysis.17 Dialysate is fluid that contains ionic compounds, including sodium and chloride, as well as glucose. It is used as part of the cleaning process of the blood that takes place during dialysis.18 For patients undergoing hemodialysis, dialysate is used in the dialysis machine to assist with removing toxins from the blood.19 During peritoneal dialysis, dialysate assists with diffusion of wastes across the peritoneal membrane to collect in the peritoneum.20 In both kinds of dialysis, the dialysate is essential for proper removal of excess fluid and waste from the bloodstream through the dialysis process.

The concentrations of solutes found within dialysate fluid can vary, depending on the patient’s condition, but dialysate usually contains bicarbonate, calcium, chloride, glucose, magnesium, potassium, and sodium.21 For those who have chronic kidney disease and need regular dialysis, the concentration of electrolytes found in the dialysate solution can be adjusted to fit a patient’s individual needs, depending on the patient’s status. Additionally, concentration of dialysate solution can be adjusted to make corrections for other problems that could develop during the dialysis process.21 For example, a dialysate solution with a higher concentration of sodium might be beneficial for a patient who is at risk for hypotension during dialysis. Also, some patients prefer to not undergo dialysis during the day and have better control of fluid retention and related complications.21 Nocturnal hemodialysis typically lasts 8–10 hours with longer diffusion as compared with standard hemodialysis. The longer time of nocturnal hemodialysis required for the mechanism of diffusion applies to all electrolytes. In this setting, “a

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dialysate [Na] higher than plasma water [Na] should be avoided, because Na removal by convection is limited in relation to the large effect of diffusion.”21 In addition, there is a risk of hypokalemia at the end of dialysis.21

Hemodialysis of a shorter duration can cause the opposite problem to

long nocturnal hemodialysis.21 In this situation, “Na is mainly removed by convection, and the time for diffusion to equilibrate Na between plasma water [Na] and dialysate [Na] is too short. This is true for all electrolytes, and the problem is very delicate. A too low dialysate [K] in order to enhance K removal should be avoided because a high [K] gradient between the plasma water and the dialysate could facilitate cardiac arrhythmias. When a high dialysate [Na] is used for improving intradialytic cardiovascular stability, the removal of Na by convection should take into consideration the amount of Na that the patient is receiving by diffusion, in order to avoid the risk of Na and water retention and their related complications.”21

Special dialysis tubing is used for hemodialysis, which is a synthetic

product that carries arterial and venous blood to and from the patient and through the dialysis machine.22 For peritoneal dialysis, the catheter used for insertion in the abdomen is made of a soft, flexible material (i.e., silicone) and has velcro-like cuffs for placement under the skin.23

Dialysis Machine

Dialysis machines are complex and have many components but for the purposes of understanding the basic process of hemodialysis, a dialysis machine consists of: 1) a pump (moving blood from the patient to the dialyzer and back to the patient, 2) a pressurized system (circulating the dialysate solution, and 3) a dialyzer (membrane through which the solutes move and are removed from the blood).24 Hemodialysis using hollow-fiber membranes has been used for an approximate 2 million people who have been diagnosed with end stage renal disease throughout the world.25 The dialyzers are either hollow fibers or flat, parallel sheets of membrane material. The polymer hollow-fiber membrane technology has not changed much in over four decades, and there is newer technology available.25

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The membrane material can be either unmodified cellulose or a synthetic material and aside from the type of material used, dialyzers can differ in terms of blood volume capacity, how well they clear specific substances, and whether or not they can be reused. Cellulose membranes are described as bio-incompatible and increased biocompatibility can be achieved through reuse techniques (avoiding bleach). There is varied biocompatibility in the use of substituted cellulose membranes, and biocompatibility is also increased with reuse techniques.26

Synthetic non-cellulose membranes are described as “more biocompatible than the cellulose membranes.”26 The degree of biocompatibility, interaction of the dialysis membrane with blood components, affects the level of inflammatory response and long-term clinical outcomes for dialysis patients. However, no standard technique exists that measures biocompatibility.26

Some studies are underway that indicate the use of more biocompatible

cellulose membranes (BCMs) lower morbidity and mortality, leading to higher use of BCMs by U.S. nephrologists. Current research studies have suggested that the “biocompatibility of the membrane may influence the accumulation of beta-2 microglobulin, nutritional status, susceptibility to infection, and the loss of residual renal function.”26

One study reported that high-flux hemodialyzer membranes, constructed from polysulfone or polyethersulfone, reportedly has “wide pore-size distribution and long tortuous pore geometries that limit selectivity and permeability.”25 While the hollow fiber configuration allows for efficient use of surface area, exposure to polymer membranes can have detrimental effects on platelet function, increased oxidative stress, inflammation, and biofouling. Another dialyzer product consists of microfabricated silicon membranes that allow surface chemistry modification and limit immunologic reaction and protein fouling; it enables device miniaturization that is not possible with large package size polymer hemodialyzers (with high internal flow resistance).25

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The traditional dialyzer is within the hemodialysis machine and acts as a filter. Within the dialyzer, the patient’s blood flows on one side, while the dialysate solution flows on the other side.22,23 The blood from the patient enters one end of the dialyzer and the dialysate that contains the impurities from the blood is removed through a filter. As the blood moves through the filter, the waste products and toxins are removed while the important blood components remain, such as red blood cells.22,23 Studies are underway using an animal model aimed at the development of a more efficient hemodialysis membrane that can be used in a portable or extended use device, as an alternative to current dialysis modalities. Researchers continue to investigate hemodialysis methods to improve clinical outcomes and quality of life benefits renal patients. The long-term use of new dialyzers that allow for continuous or extended renal replacement therapy is being tested for eventual use in the end stage renal disease patient.25

Process of Hemodialysis

During dialysis, the access site is cannulated, and a needle is placed into the vascular access device to draw the blood out. The needle is connected to dialysis tubing, which carries the blood away from the body and to the dialysis machine; after the toxins have been removed and the blood cleansed, the blood is returned through the dialysis machine to the patient’s body.22,23,27

The dialysis machine uses dialysate solution as part of the cleaning process to remove toxins and extra fluid. The removal of solutes by hemodialysis is done primarily by diffusion. Diffusion is defined as the movement of molecules or particles in a solution such that their concentration becomes uniform throughout the solution.28 The blood and the dialysate are of course different solutions and are not in direct contact. But because they are separated by a semipermeable membrane, they are effectively one solution and the difference in the concentration gradients of molecules between the blood and the dialysate means that passive diffusion occurs, and urea, acids, drugs, and other solutes are moved from the blood to the dialysate and are eliminated.22,23,27

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Dialysis Duration and Frequency

Improved outcomes with longer dialysis treatment times have been observed, and observational studies have suggested that low mortality rates with longer dialysis corresponded with improved blood pressure control and slower ultrafiltration. The international Dialysis Outcomes and Practice Patterns Study (DOPPS) concluded that “patients with the longest treatment time (at least 4 hours) had the lowest risk for all-cause and cardiovascular mortality.”27 Specifically, patients with longer dialysis treatment time were observed to have “lower pre- and post-dialysis systolic blood pressure, greater intradialytic weight loss, higher hemoglobin (for the same erythropoietin dose), serum albumin and potassium and lower serum phosphorus and white blood cell counts.”29

While there are limits to observational studies, it is generally accepted that “a minimum duration for optimum dialysis clearly exists, and is most likely close to 4 hours.”28 As blood and dialysate move through the dialyzer in opposite directions in a counter current fashion, at different speeds, there is efficient removal of the toxins. The removal of solutes depends on many factors: the difference in concentration gradients, the size of the solutes, the properties of the dialyzer membrane, and the rate of blood and dialysate flow.30

Solute removal during hemodialysis is done by convection transport. Convective transport occurs when a solute in fluid is moved through the dialysis membrane by osmotic pressure and hydrostatic pressure.30 Hydrostatic pressure is the pressure exerted by fluid at equilibrium by the force of gravity, and the difference in hydrostatic pressure and osmotic pressure between the blood and the dialysate are maintained so that fluid moves out of the vascular compartment and is removed by the dialysis machine. In the standard hemodialysis procedure this mechanism of action has a negligible role in solute removal, but hemodialysis techniques like ultrafiltration that use a high flow of dialysate rely on convection transport for solute removal.30 Hemodialysis is also used to remove excess fluid; those with chronic renal failure may lack the ability to excrete enough urine to

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maintain the proper fluid balance, or they may be anuric and build-up dangerous levels of fluid.30

Fluid removal during hemodialysis is done by adding osmotic particles in the dialysate, creating a difference in osmotic pressure between the blood and the dialysate, and by creating a difference in hydrostatic pressure between the blood and the dialysate.30 The number of hemodialysis sessions and the length of each session will depend on the patient’s condition and response to hemodialysis, and hemodialysis can be done at home or in a dialysis clinic. In one randomized, cross-over pilot trial involving six adolescents with end stage renal disease were studied to determine if 5 days per week in-center hemodialysis was feasible and associated with improved blood pressure control.31 The researchers evaluated the benefits of “more-frequent treatments over a relatively short follow-up period of 12 weeks.”31

The weekly duration of dialysis was fixed at 12 hours across both 12 week study periods.

The authors of this study noted that as a result of the short trial duration with a short follow-up period and open label design, it was possible to observe improvements in blood pressure corresponding with 12 hours of weekly dialysis for six months. Only the 2 subjects treated in Canada received “12 hours of weekly dialysis pre-study, which was their center’s standard of care.”31 During the 5 days per week period of treatment, the authors reported “a significant reduction in the number of treatments where subjects were ≥4 % fluid overloaded pre-dialysis.”31 Interdialytic fluid overload correlates with a higher risk in children of developing left ventricular hypertrophy. In adults, the authors noted that “dialysis treatment times >4 hours, slower ultrafiltration rates, and lower interdialytic fluid gains have been independently associated with lower mortality rates in observational studies.”31

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TIME Trial

Optimal dialysis duration and frequency continues to be an area of research in the treatment of dialysis. In adults, the Time to Reduce Mortality in End-Stage Renal Disease (TiME) Trial includes a large number of study participants with a goal to determine “if dialysis sessions ≥4.25 hours, provided 3 days per week, decreases mortality in adults.”31 Future studies are needed to evaluate alternative dialysis treatment schedules relative to cost-saving or cost neutral benefits, and the time demands on providers, families, and patients. With regard to pediatric dialysis patients, consideration should be given to the impact of dialysis on school attendance and performance and the cognitive challenges of children diagnosed with end-stage renal disease.31

While kidney transplant remains the optimal treatment for end-stage

renal disease, dialysis will likely be needed at some point for children so that options for treatment and the best studied outcomes will need to be made available by the treatment team. Home Hemodialysis

Home hemodialysis is another option for end-stage renal patients and is often done by using the same total amount of one-week treatment time with more frequent sessions. The standard-hours home for home hemodialysis using standard dialysate flow machines has been identified as 3.0–3.5 sessions/week for a duration of 3.5–5.0 hours with a blood flow rate of 300–400 mL/min.32 Standard-hours regimens for patients just starting hemodialysis with residual renal function “can usually achieve excellent control of fluid, serum parameters, and symptoms with fewer dialysis treatment hours for the first months, and dialysis dose can be gradually titrated upward.”32 Patients can also be supported to develop good dietary and fluid restriction routines that supports blood chemistry and fluid balance during an optimized home dialysis regimen.

Patients may have to gradually increase dialysis hours, so that home placement may be a better way to start a hemodialysis routine.32 Home

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hemodialysis can be more effective at preventing lower risk of hospitalization and complications, however strict infection control and adherence to dialysis protocol should be maintained to avoid higher rates of infection and vascular access complications.32

Nocturnal Hemodialysis

Dialysis session length varies between the type of dialysis performed and the location of dialysis. Dialysis centers offer hemodialysis for patients who need prescribed treatment, and are usually free-standing centers, units within hospitals, or separate clinics, each of which has highly trained physicians and nurses who specialize in dialysis treatment. Some dialysis centers offer hemodialysis as an option overnight, termed nocturnal hemodialysis.33 In this situation, the patient arrives at the dialysis center and is set up to receive dialysis during the evening. The patient then sleeps at the dialysis center and has hemodialysis at the same time. In this method, hemodialysis may take several hours, or the entire night while the patient is sleeping. Similarly, some patients utilize home hemodialysis for treatment and, when used as nocturnal hemodialysis, the process can take between 6 to > 10 hours or the amount of time that a patient will sleep at night.33

Live remote monitoring of patients at home through either regular telephone lines or the internet can be set up through the hemodialysis center. The dialysis machine and trigger alarms are observed by personnel at the center and the patient is contacted. Live monitoring allows for the collection of data during the dialysis procedure, prevents blood clotting in an extracorporeal system, and it reassures the patient and promotes compliance.33

Hemodialysis Complications

Acute complications of hemodialysis treatment may include hypotension (25 to 55%), cramps (5 to 20%), nausea and vomiting (5 to 15%), headache (5%), chest pain (2 to 5%), back pain (2 to 5%), itching (5%), fever and chills (<1%).34 Patients who require hemodialysis often have coronary artery

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disease and left ventricular damage, risk factors that predispose them to the development of arrhythmias, and the electrolyte and fluid shifts that occur during hemodialysis can be arrhythmogenic.34 Atrial and ventricular arrhythmias and brady-arrhythmias and tachyarrhythmias, some quite serious, are common during dialysis. Atrial fibrillation in patients with CKD appears to increase with the degree of disease severity, and is particularly common in patients with end-stage renal disease.35,36 The prevalence of atrial fibrillation in hemodialysis patients is an estimated 8-34% and 7% for patients prescribed peritoneal dialysis treatment.36

Patients who have chronic kidney disease have a significantly increased risk for sudden cardiac death, likely due to arrhythmias, but cardiac arrest is a rare event during hemodialysis.35 A common occurrence during hemodialysis is an event called hemodialysis-induced myocardial stunning, which occurs in approximately 27-64% of cases and coincides with reduced survival rates.35 In such cases left ventricular dysfunction occurs without a personal history of heart disease, although the possibility of underlying coronary artery disease is not ruled out. Some patients with documented hemodialysis-induced myocardial stunning will acquire left ventricular systolic function that worsens over time and is associated with cardiac wall motion abnormalities.35

Hypotension

Hypotension has been reported to occur in hemodialysis patients, and it can be caused by electrolyte imbalances, fluid shifts, hypovolemia, and elevated body temperature.37 While no accepted definition of intradialytic hypotension exists, the Kidney Disease Outcomes Quality Initiative (KDOQI) and European Best Practice Guidelines have defined intradialytic hypotension as “the presence of a decrease in systolic blood pressure ≥20 mmHg or a decrease in mean arterial pressure by 10 mmHg, provided that the decrease in blood pressure is associated with clinical events and need for nursing interventions.”37

In one observational study (2015), the intradialytic hypotension definition of a nadir intradialytic systolic blood pressure < 90 mmHg has been

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found to correspond in 30% of treatments with higher mortality.37 Patients found to have a predialysis BP ≥ 160 mmHg, nadir BP < 100 mmHg were most potently associated with mortality.38 As compared to patient symptom reporting and intervention criteria relative to hypotension during dialysis, the authors of this study suggested that “nadir-based definitions best capture the association between intradialytic hypotension and mortality.”38 The authors of this study elaborated that their findings took into account several factors: provider-to-provider variability in intervention thresholds, patient-to-patient variability in symptom reporting, the varying impetus and the choice of intervention between facilities as well as between provider to provider.38 In addition, patient-reported symptoms were variable, and the authors cited Weisbord et al, who reported that in a hemodialysis patient cohort: “39.0% of patients reported cramping, 23.0% of patients reported dizziness, and 21.0% of patients reported headache.” Other surveys showed higher (varied) symptom frequency: 74.3% of patients reporting cramping, 63.0% of patients reporting dizziness, and 53.6% of patients reporting headache.39 The authors stated that “Such differences may result from reporting bias but may also reflect differences in physiology, because patients experience symptoms at varying thresholds of BP change and nadir. Patient symptoms may be important factors at the individual level, because they plausibly reflect ischemia, but their use in population-level definitions may be questionable because of wide patient-to-patient variation.”38

Chest Pain

Chest pain that occurs during hemodialysis can be caused by an air embolism, angina, the dialysis disequilibrium syndrome, hemolysis, hypotension, hypoxemia, or pulmonary embolism. Dyspnea is likely due to fluid shifts, but other causes like emboli and hemolysis should be considered.40

Serious and potentially fatal complications that occur during dialysis may include air embolism, hemolysis, dialysis disequilibrium syndrome, and pulmonary embolism.40 Fortunately, these are very rare. Air embolism is believed to occur due to human error during the dialysis procedure.

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One retrospective study of 202 patients on home hemodialysis reported an overall incidence of pulmonary embolism of < 1 episode per 30,000 dialysis sessions.40 Inadequate priming or lack of clamping of the catheter or tubing were reported as causes of an air embolism developing.40 A follow-up of 190 patients on home hemodialysis in another study (117,000 total hemodialysis sessions) reported an incidence of < 1 episode per 100,000 hemodialysis sessions.40 Not clamping the arterial line during disconnection was a primary cause of air entry into the tubing.40,41

Dialysis Disequilibrium

Dialysis disequilibrium syndrome usually happens to patients who are new to hemodialysis and have a high baseline blood urea nitrogen (BUN) level.40 The exact mechanism that underpins this complication is not known, but it is thought to be caused by a large drop in BUN levels; this in turn creates a difference in osmotic pressure and a subsequent shift of water from the blood to the brain and a subsequent cerebral edema.40 In most cases the symptoms are mild and self-limiting, i.e., headache and nausea, but coma, seizures, and death can occur. The incidence of dialysis disequilibrium syndrome is not known, but it is considered to be a rare complication of hemodialysis.40 Hemolysis

During hemodialysis erythrocytes are subjected to shear forces, high temperature, osmotic stress, and exposure to dialysate and water contaminants like disinfectants, copper, zinc, and nitrates, all of which can cause hemolysis.40 Additionally, problems with the vascular access device or the hemodialysis equipment can cause hemolysis, and overheated dialysate may cause thermal injury and hemolysis.40 Ham, et al. (1948) had demonstrated changes in RBC morphology, osmotic fragility, and hemolysis at temperatures > 47°C. Berkes, et al. (1975) reported a case study where a patient developed delayed hemolysis 48 hours after exposure to overheated dialysate of 50°C.40 Current hemodialysis machines have alarms at dialysate temperature > 39.5°C and so hyperthermic hemolysis is a rare occurrence.40

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Jepson and Alonso (2009) had discovered that a valve system had led to heated dialysate of 39.8°C, however the attending dialysis nurse noticed the issue and followed protocol, which avoided harm to the patient.40,42

Intradialytic hemolysis symptoms have been reported as nausea, shortness of breath, abdominal/back pain, and chills and initially develop acute hypertension.40 Laboratory results confirming low serum haptoglobin, elevated lactate dehydrogenase, reduction in hematocrit, and pink serum.40 Hemodialysis should be stopped immediately with suspected hemolysis and blood from the extracorporeal circulation should not be returned to the bloodstream to avoid causing severe hyperkalemia, as potassium is released from hemolyzed erythrocytes with a risk of being infused.40

Contamination of the dialysate, faulty tubing, and altered dialysate osmolality should be considered when there are multiple incidents of hemolysis occurring in a hemodialysis unit. In such events a root cause analysis should be performed, and all blood tubing and needle systems retained for investigative procedures.40

Vascular Access Device Complications

Maintaining patency of the vascular access device is paramount. Stenosis and thrombosis frequently occur together, and are well known complications of AV fistulas and AV grafts with potentially serious consequences. Thrombosis often leads to loss of the AV access device, accounting for a vast majority of permanent loss of the access device. Another uncommon complication is hemorrhage from an AV access site. This is a potentially fatal complication without quick recognition and intervention.40 Patients and family members need to be informed of the potential for hemorrhage and educated on how to act when noticing bleeding at the AV access site. Pseudoaneurysm (PSA) results from trauma and repeated cannulation during hemodialysis and aneurysms are typically found at the outflow vein/graft of an AV access where increasing dilation due to high blood flow and vascular damage lead to formation of the aneurysm.40

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The severity of aneurysm formation and decision to proceed with an intervention is best obtained through a physical examination.40 The PSA should be monitored for growth, and any evidence of outflow stenosis, thinning or ulceration of skin over the PSA, pulsatility, or evidence of infection should lead escalate an intervention. Prevention of PSA development is to follow proper cannulation techniques.40

Venous Needle Dislodgement

Venous needle dislodgement (VND) during hemodialysis has been described as “a rare but life-threatening complication.”40 Hemorrhagic shock is the eventual outcome of VND. Shock may occur within minutes because the typical dialysis blood flow is 300–500 ml/min, and this loss leads to an estimated drop of 30%–40% of total blood volume.40 Forty major hemorrhages were reported as a result of VND or disconnection at the dialysis catheter site during 2.5 million dialysis sessions.40 The Veterans Administration (VA) National Center for Patient Safety reported a total of 40 major hemorrhages because of VND or dialysis catheter site disconnection during 2.5 million dialysis sessions. Home dialysis events reported in Canada included VND for one in every 11,000 patients.40

Access site care is important in the prevention of VND. Risk of VND results from “improper taping of access tubing to the skin, loose luer lock tubing connection, bloodlines not being looped loosely, or access site not being visible) and patient factors (i.e., a confused patient).”40 Early detection of blood loss may be done through the use of a venous pressure alarm (set 10 mmHg below the baseline dialysis venous pressure).40 Infection

Hemodialysis patients are often immunocompromised and because hemodialysis requires repeated invasive venous access, they are susceptible to local and bloodstream infections.43 The National Healthcare Safety Network (NHSN) Dialysis Event Surveillance report for 2014 identified 29,516 bloodstream infections that were associated with 4,578,827 dialysis sessions

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(0.64%): 76% of these infections were related to access to the AVF, AV graft, or central venous catheter, and 70% were in the patients who had a central venous catheter.44 Although the rate of bloodstream infections is not high, this is a costly complication that increases morbidity and mortality and the need for hospitalization.54

It is essential for health clinicians who work with dialysis patients to

practice proper hand hygiene, use personal protective equipment, and reduce the risk of patient infection by utilizing hygienic measures when performing cannulation and using needles, syringes, and vials. Clinicians must understand the signs and symptoms of infection that can result during hemodialysis. They need to be able to assess for changes, understand what body areas to assess if infection develops, and know what laboratory studies may be ordered, such as a complete blood count or blood cultures.

Case Study: End-stage Renal Dialysis and Rural Health

The authors of this case study reviewed the development of renal disease in a 42-year-old diabetic male and the socioeconomic impact of chronic renal replacement therapy upon a rural family. The patient reportedly had a 6-year history of type 2 diabetes with recent symptoms of weight loss, fatigue and weakness.45

A physical examination was completed and the patient was described as: cachectic, unable to ambulate and with severe peripheral neuropathy. Body weight was 32.7 kg with the patient’s body mass index documented as 14.5 kg/m2, blood pressure was 90/60 mmHg. Glucose was over 600 mg/mL (normal < 200 mg/mL) by random finger sticks, serum creatinine was 1.1 mg/dL (normal range 0.7–1.2 mg/dL) and urine albumin to creatinine ratio (ACR) was 40 mg/g (normal < 30 mg/g).45

The patient’s medical and surgical history revealed that he had undergone bilateral cataract surgery 2 years previously, and there was no history of retinopathy. Hemoglobin A1c testing was done that showed 7.0%

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(normal range 3.9%–6.5%), which was 12 months following the patient’s presentation. Creatinine levels were repeated and were normal.45

Approximately 18 months after his initial presentation, the patient reported persistent difficulty gaining weight, and severe nausea and anorexia. The patient’s health history was negative for hypertension, urinary tract infections (UTIs), nephrolithiasis or exposure to nephrotoxic agents. Further laboratory testing showed a serum creatinine of 7.57 mg/dL and blood urea nitrogen (BUN) of 68.0 mg/dL. The serum potassium, liver function tests, C-reactive protein, thyrotropin, human immunodeficiency virus (HIV), viral hepatitis antibodies, antinuclear antibodies, serum protein electrophoresis and urinalysis were normal except for the presence of glycosuria.45 The patient had a hemoglobin of 7.3 mg/dL with normal mean corpuscular volume. A renal ultrasound was performed that revealed bilateral atrophic kidneys and kidney stones, but no significant hydronephrosis.45

The patient was diagnosed with end-stage renal disease, cause unknown. Renal replacement therapy was recommended with two options of care for the patient to consider: hemodialysis twice a week at a dialysis center, or continuous ambulatory peritoneal dialysis (CAPD) multiple times daily at home. The patient opted to start CAPD to avoid travel to a dialysis center from his rural home town. An abdominal catheter was placed and a room in his home was set up for sterile dialysis, and CAPD initiated four times per day for 3 years.45

The patient responded well to home-based CAPD and showed more energy, but remained unemployed. He was able to ambulate and gained weight, a total of 10 kg. There were no complications of peritonitis. He did however develop severe peripheral neuropathy and weakness, insomnia and needed assistance to mobilize and for most self-care activities. He also needed help with his dialysis exchanges.45

A social assessment was done and showed that the patient had lost his job as a construction worker, and could no longer afford his prescribed medications or medical fees for diabetes management. He was the father of

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four young children, and developed depression and anxiety over the family’s financial circumstances. He began to feel helpless and ashamed of his chronic disease state, and resources for mental health were limited in his rural town.45 Discussion

The authors of this case study focused on the socioeconomic impact of

end-stage renal disease, emphasizing that it impacts not only the affected patient but whole households and communities.45 In this case, the patient was unable to continue employment and provide support for his family. He became dependent on his family for support and physical care, including assistance with home management of peritoneal dialysis. Additionally, the patient lived in a rural area and the authors raised geographic barriers and health system limitations to continuity of care for people suffering from a chronic illness, such as chronic kidney disease.45

The patient developed end-stage renal disease of unknown origin, and

required urgent renal replacement therapy. Renal transplantation is a preferred option to dialysis, but often the cost of transplantation and the criteria for undergoing a kidney transplant can be limiting, and renal dialysis may be the only feasible option for end-stage renal patients. In this case report, home dialysis was the best option for treatment given the patient’s rural home base and remoteness to a community-based dialysis program.45

Debilitating illnesses like end-stage renal disease often cause economic, social and psychological hardships for patients and their families. A diagnosis of end-stage renal disease requires consistent nephrology care, dialysis and renal transplant. Medical care, mental health and social services are typically needed to support the patients and their families.45

The authors aimed to illustrate the struggle of remote and rural families struggling with the issue of chronic disease, specifically end-stage renal disease. They raised the need to strengthen the rural public health system to prevent and manage chronic disease. In this case, he lacked resources to manage his diabetes safely, and then developed end-stage renal disease.

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Community strategies to provide dialysis services to remote and rural patients with end-stage renal disease is a current and continuing health need within both developed and undeveloped countries worldwide. Further, dialysis patients, as in this case, can survive with symptoms of fatigue, weakness, insomnia, pain, and depression that results in functional impairment.45

Dialysis provides life-supporting treatment, especially for individuals

who may never receive a kidney transplant. Health teams in rural settings need to be aware of how chronic disease and the need for long-standing dialysis treatment can affect a patient’s “physical, mental, spiritual, emotional, social and functional well-being.”45 Standardised treatment instruments need to include not just the basic treatment provision for survival but long-term quality of life discrepancies that can develop and that can impact patient morbidity and mortality. More research is needed related to end-stage renal disease, renal replacement therapy, options for treatment in urban and rural areas, and quality of life indicators that may impact certain variables of treatment outcomes.45

Summary

Dialysis is a life-saving measure for patients who rely on this treatment when their kidney function is no longer adequate to meet their bodies’ needs. Hemodialysis is the most common form of treatment for kidney failure, and is a process that involves removing some blood from the body, cleansing it to remove excess solutes and toxins, and then returning the clean blood back to the body. By getting rid of excess solutes that the kidneys normally filter, hemodialysis maintains a normal pH in the blood, as well as normalize electrolyte levels, preventing buildup of potentially life-threatening levels of certain chemicals.

Arteriovenous fistulas and grafts have different benefits and

disadvantages (i.e., long-term complications, rate of failure, and need to mature) before the access point can be used. The choice of a fistula versus a graft is made on a case-by case basis, but the preferred method is the AVF as it has a higher rate of long-term patency and a lower rate of complications.

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Chronic or maintenance dialysis is ordered for patients who need

ongoing treatment to correct fluid and electrolyte imbalances as a result of decreased kidney function. Most patients who require maintenance dialysis are in end-stage renal disease. Whether dialysis is administered on a short-term basis to correct an acute condition or is needed long term for chronic disease, dialysis has a significant impact on those who use it as well as a great ability to improve the quality of life.

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Self-Assessment of Knowledge Post-Test: Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation. Completing the study questions is optional and is NOT a course requirement. 1. True or False: Hemodialysis normalizes electrolyte levels but it

does not normalize the pH level in the blood.

a. True b. False

2. Renal replacement therapy is used for patients with chronic

kidney disease that has not responded to other therapies and

a. who cannot undergo dialysis. b. have just had a kidney transplant. c. who have other complications such as encephalopathy. d. whose kidney function has stabilized.

3. The health clinician’s role when caring for dialysis patients

include(s) which of the following:

a. know the signs and symptoms of infection. b. know what laboratory studies may be ordered. c. understand what body areas to assess for infection. d. All of the above

4. The first choice of vascular access for chronic hemodialysis is the

________________ because it has the best longevity and the lowest association with morbidity and mortality.

a. central venous catheter b. arteriovenous graft (AV graft) c. arteriovenous fistula (AVF) d. prosthetic fistula

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5. The hemodialysis catheter often used

a. in place of prosthetic fistulae. b. for long-term, chronic hemodialysis. c. long-term because of its longevity. d. an emergent basis or temporary measure.

6. Patients who are taking lithium should know that

a. some long-term lithium therapy may lead to chronic kidney disease. b. even short-term lithium lithium use causes renal disease. c. all patients taking lithium will develop glomerular adverse effects d. acute kidney failure is most often caused by long-term lithium

therapy. 7. True or False: Stenosis and thrombosis frequently occur together.

a. True b. False

8. A common symptom of intradialytic hemolysis is

a. hyperventilation. b. hypokalemia. c. shortness of breath. d. hypertension.

9. Dyspnea is likely caused by

a. renal failure. b. fluid shifts. c. infection. d. hemorrhage.

10. It is essential for health clinicians who work with dialysis

patients to

a. practice proper hand hygiene. b. use personal protective equipment. c. apply hygienic measures when performing cannulation. d. All of the above

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11. _____________ is fluid that contains ionic compounds, including sodium and chloride, as well as glucose.

a. Dialysateb. Solutec. Bicarbonated. Cisplatin

12. True or False: An AV graft is best suited for patients with good circulation.

a. Trueb. False

13. Using ______________ for hemodialysis access carries a high risk of thrombosis and so it is the third choice of hemodialysis access.

a. the external jugularb. the subclavian veinc. a femoral veind. the amoral vein

14. Convective transport removes solutes during hemodialysis by moving the solute in fluid through the dialysis membrane by

a. concentration gradientb. vacuum pressure.c. intradialytic pressure.d. osmotic pressure and hydrostatic pressure.

15. Venous needle dislodgement (VND) can cause hemorrhagic shock within minutes because of

a. hypokalemia.b. infection.c. the loss of total blood volume.d. intradialytic hypertension.

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Reference Section The References below include published works and in-text citations of published works that are intended as helpful material for further reading. 1. Pizzorno J. The Kidney Dysfunction Epidemic, Part 1: Causes. Integr

Med (Encinitas). 2015;14(6):8–13. 2. Inker L and Perrone R. Assessment of kidney function. UpToDate.

2020. Retrieved from https://www.uptodate.com/contents/assessment-of-kidney-function?search=normal%20kidney%20function&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

3. Makris K, Spanou L. Acute Kidney Injury: Definition, Pathophysiology and Clinical Phenotypes. Clin Biochem Rev. 2016;37(2):85–98.

4. Bargman JM and Skorecki KL. Chronic kidney disease. In: Jameson JL, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine, 20th ed. New York, NY: McGraw-Hill Education. 2018. Online edition. Retrieved from www.UCHC.edu.

5. Gupta S, Khastgir U. Drug information update. Lithium and chronic kidney disease: debates and dilemmas. BJPsych Bull. 2017;41(4):216–220.

6. Levey AS and Inker LA. Definition and staging of chronic kidney disease in adults. UpToDate. 2018. Retrieved from https://www.uptodate.com/contents/definition-and-staging-of-chronic-kidney-disease-in-adults?search=Definition%20and%20staging%20of%20chronic%20kidney%20disease%20in%20adults.&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

7. Rosenberg M. Overview of the management of chronic kidney disease in adults. UpToDate. 2019. Retrieved from https://www.uptodate.com/contents/overview-of-the-management-of-chronic-kidney-disease-in-adults?search=Overview%20of%20the%20management%20of%20chronic%20kidney%20disease%20in%20adults.&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

8. Tandukar S, Palevsky PM. Continuous Renal Replacement Therapy: Who, When, Why, and How. Chest. 2019;155(3):626–638.

9. Benjamin O, Lappin SL. End-Stage Renal Disease. [Updated 2019 Nov 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499861/

10. Schmidt R and Holley J. Overview of the hemodialysis apparatus. UpToDate. 2019. Retrieved from https://www.uptodate.com/contents/overview-of-the-hemodialysis-

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apparatus?search=hemodialysis&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2

11. Bander S and Woo K. Central catheters for acute and chronic hemodialysis access. UpToDate. 2018. Retrieved from https://www.uptodate.com/contents/central-catheters-for-acute-and-chronic-hemodialysis-access

12. Santoro D, Benedetto F, Mondello P, et al. Vascular access for hemodialysis: current perspectives. Int J Nephrol Renovasc Dis. 2014;7:281–294.

13. Segal M, Qaja E. Types of Arteriovenous Fistulas. [Updated 2020 Feb 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493195/

14. Salman L. and Beathard G. Interventional Nephrology: Physical Examination as a Tool for Surveillance for the Hemodialysis Arteriovenous Access. CJASN. 2013; 8(7) 1220-1227.

15. Harms JC, Rangarajan S, Young CJ, Barker-Finkel J, Allon M. Outcomes of arteriovenous fistulas and grafts with or without intervention before successful use. J Vasc Surg. 2016;64(1):155–162.

16. MacRae JM, Oliver M, Clark E, et al. Arteriovenous Vascular Access Selection and Evaluation. Can J Kidney Health Dis. 2016;3:2054358116669125.

17. InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. How does dialysis work? 2018 Mar 8. Available from: https://www.ncbi.nlm.nih.gov/books/NBK492981/

18. Alam M and Krause MW. Peritoneal dialysis solution. UpToDate. 2019. Retrieve from https://www.uptodate.com/contents/peritoneal-dialysis-solutions?search=Peritoneal%20dialysis%20solution&source=search_result&selectedTitle=2~54&usage_type=default&display_rank=1

19. Shiran MB, Barzegar Marvasti M, Shakeri-Zadeh A, et al. Enhancement of Toxic Substances Clearance from Blood Equvalent Solution and Human Whole Blood through High Flux Dialyzer by 1 MHz Ultrasound. J Biomed Phys Eng. 2017;7(2):107–116.

20. Saljoughian M. Sifting Through Dialysis Risks and Benefits. US Pharmacist. 2016;41(8):HS-12-HS-16.

21. Locatelli F, La Milia V, Violo L, Del Vecchio L, Di Filippo S. Optimizing haemodialysate composition. Clin Kidney J. 2015;8(5):580–589.

22. Schmidt RJ and Holley JL. Overview of the hemodialysis apparatus. UpToDate. 2019. Retrieved from https://www.uptodate.com/contents/overview-of-the-hemodialysis-apparatus?search=Overview%20of%20the%20hemodialysis%20apparatus&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

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23. Burkert J. Patient education: Peritoneal dialysis (Beyond the Basics). UpToDate. 2020. Retrieved from https://www.uptodate.com/contents/peritoneal-dialysis-beyond-the-basics

24. Nigatie Y. Diffusion in Tube Dialyzer. Biomed Eng Comput Biol. 2017;8:1179597217732006.

25. Moore J, Garcia P, Rohloff P, Flood D. Treatment of end-stage renal disease with continuous ambulatory peritoneal dialysis in rural Guatemala. BMJ Case Rep. 2018;2018:bcr2017223641.

26. Berns J. Clinical consequences of hemodialysis membrane biocompatibility. UpToDate. 2018. Retrieved from https://www.uptodate.com/contents/clinical-consequences-of-hemodialysis-membrane-biocompatibility?search=dialyzer&source=search_result&selectedTitle=4~150&usage_type=default&display_rank=4

27. Ashby, D., Borman, N., Burton, J. et al. Renal Association Clinical Practice Guideline on Haemodialysis. BMC Nephrol. 2019;20, 379.

28. Gaur, Ruchi & Mishra, Lallan & Sen Gupta, Susanta. Diffusion and Transport of Molecules In Living Cells. 2014;10.1007/978-3-319-05657-9_2.

29. Tentori F, Zhang J, Li Y, et al. Longer dialysis session length is associated with better intermediate outcomes and survival among patients on in-center three times per week hemodialysis: results from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Nephrol Dial Transplant. 2012;27(11):4180–4188.

30. Golper TA, Fissell R, Fissell WH, Hartle PM, Sanders ML, Schulman G. Hemodialysis: core curriculum 2014. Am J Kidney Dis. 2014;63(1):153–163.

31. Laskin BL, Huang G, King E, et al. Short, frequent, 5-days-per-week, in-center hemodialysis versus 3-days-per week treatment: a randomized crossover pilot trial through the Midwest Pediatric Nephrology Consortium. Pediatr Nephrol. 2017;32(8):1423–1432.

32. Lockridge R, Cornelis T, Van Eps C. Prescriptions for home hemodialysis. Hemodialysis International. 2015; 19:S112–S127.

33. Pierratos A. Technical aspects of nocturnal hemodialysis. UpToDate. 2019. Retrieved from https://www.uptodate.com/contents/technical-aspects-of-nocturnal-hemodialysis

34. Holley J. Acute complications during hemodialysis. UpToDate. 2020. Retrieved from https://www.uptodate.com/contents/acute-complications-during-hemodialysis

35. deFilippi C and Henrich W. Overview of screening and diagnosis of heart disease in dialysis patients. UpToDate. 2020. Retrieved from https://www.uptodate.com/contents/overview-of-screening-and-

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diagnosis-of-heart-disease-in-dialysis-patients?topicRef=1881&source=related_link

36. Manning W, Singer D, Lip G. Atrial fibrillation: Anticoagulant therapy to prevent thromboembolism. UpToDate. 2019. Retrieved from https://www.uptodate.com/contents/atrial-fibrillation-anticoagulant-therapy-to-prevent-thromboembolism?sectionName=Chronic%20kidney%20disease&topicRef=1846&anchor=H97537302&source=see_link#H97537302

37. Henrich W and Flythe J. Intradialytic hypotension in an otherwise stable patient. UpToDate. 2019. Retrieved from https://www.uptodate.com/contents/intradialytic-hypotension-in-an-otherwise-stable-patient

38. Flythe JE, Xue H, Lynch KE, Curhan GC, Brunelli SM. Association of mortality risk with various definitions of intradialytic hypotension. J Am Soc Nephrol. 2015;26(3):724–734. doi:10.1681/ASN.2014020222

39. Caplin B, Kumar S, Davenport A. Patients' perspective of haemodialysis-associated symptoms. Nephrol Dial Transplant. 2011;26(8):2656–2663.

40. Saha M, Allon M. Diagnosis, Treatment, and Prevention of Hemodialysis Emergencies. Clin J Am Soc Nephrol. 2017;12(2):357–369.

41. Wong B, Zimmerman D, Reintjes F, et al. Procedure-related serious adverse events among home hemodialysis patients: a quality assurance perspective. Am J Kidney Dis. 2014;63(2):251–258.

42. Jepson R, Alonso E. Overheated dialysate: a case study and review. Nephrol Nurs J. 2009;36(5):551–553.

43. Lamarche C, Ioan-Andrei I, Kitzler T. Infectious Disease Risk in Dialysis Patients: A Transdisciplinary Approach. Canadian Journal of Kidney Health and Disease. 2019; Vol. 6.

44. Nguyen DB, Shugart A, Lines C, et al. National Healthcare Safety Network (NHSN) Dialysis Event Surveillance Report for 2014. Clin J Am Soc Nephrol. 2017;12(7):1139–1146.

45. Moore J, Garcia P, Rohloff P, Flood D. Treatment of end-stage renal disease with continuous ambulatory peritoneal dialysis in rural Guatemala. BMJ Case Rep. 2018;2018:bcr2017223641.

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