BASICS OF DIALYSIS

Basics of Dialysis
Healthy Kidney
Location and Structure Functions

Physical Basis
Transport through Membranes

Situation in a healthy human?

Functioning of solute transport?

Diseased Kidney
Causes Symptoms and Sequelae Renal Failure

Renal Replacement
Hemodialysis Peritonealdialysis Kidney Transplantation

Situation with a diseased kidney?

Functioning of replacement therapy?

Location and Structure

Location of the Kidneys inside of the Body

Superior Vena Cava

Lung
Liver

Heart Aorta Spleen

Right Kidney
Large Intestine
Right Ureter

Left Kidney
Small Intestine
Left Ureter Bladder

Healthy Kidney

Diseased Kidney

Physical Basis

Renal Replacement

Location and Structure

Cross-Section of the Kidney

Nephron

Renal Medulla Papilla

Renal Vein Renal Artery Renal Pelvis Ureter

Renal Cortex
Branch of the Renal Vein

Branch of the Renal Artery

Healthy Kidney

Diseased Kidney

Physical Basis

Renal Replacement

Location and Structure

Nephron - Functional Unit of the Kidney

Distal Tubule Proximal Tubule

Collecting Duct Capillary Network

Plasma Ultrafiltrate Glomerulus Afferent Arteriole Efferent Venule

Urinary Outflow
Henles Loop

Healthy Kidney

Diseased Kidney

Physical Basis

Renal Replacement

Location and Structure

Details of a Glomerulus - The Membrane for Filtration

Proximal Tubule
Inside of the Capillary - Blood Side -

Bowmans Capsule Capillary Loops Efferent Arteriole Afferent Arteriole

Detail of the Capillary Wall

Capillary Wall - Filter-

Outside of the Capillary - Urine Side -

Healthy Kidney

Diseased Kidney

Physical Basis

Renal Replacement

Functions of the Kidney

Manifold Tasks of the Kidney

Bone Structure

Metabolic End Products

Blood Formation

Calcium Balance

Vitamin D Activation
Erythropoietin Synthesis

Removal of Urea, Creatinine etc.

Functions
Water Balance

Potassium Balance
Recovery of Bicarbonate Cardiac Activity Regulation of Blood pH
Healthy Kidney Diseased Kidney Physical Basis Renal Replacement

Sodium Removal Blood Pressure

Functions of the Kidney

Water Balance
0,3 l Water from metabolism 0,9 l Water contained in solid food 1,3 l Beverages

Water intake and water excretion must be balanced. This task is done by the kidneys and by thirst.

2,5 l Intake

0,1 l Water bound in stool 0,9 l Sweating and respiration 1,5 l Urine
2,5 l Removal

Healthy Kidney

Diseased Kidney

Physical Basis

Renal Replacement

Functions of the Kidney

Filtration and Reabsorption

60 l urine per day at the end of the proximal tubules 20 l urine per day at the beginning of the distal tubules 10 l urine per day at the end of the distal tubules

180 l filtrate per day in the glomeruli

1,5 l urine per day at the end of the collecting ducts real removal: 1,5 l urine

1500 l blood per day through the renal arteries

Healthy Kidney

Diseased Kidney

Physical Basis

Renal Replacement

Causes for Kidney Failure

Examples
Hypertension

Cysts, Anomalies

Diabetes

Autoimmune Diseases

Kidney Failure

Heavy Blood Loss

Nephritis
Accident / Trauma

Neurogenic Problems

Healthy Kidney

Diseased Kidney

Physical Basis

Renal Replacement

Causes for Kidney Failure

Location of the Cause?

Upstream of the Kidney - prerenal Heavy Blood Loss Stenosis of the Renal Artery ...

Within the Kidney - intrarenal Drugs Diabetes Inflammatory Diseases ...

Downstream of the Kidney - postrenal Prostatic Hypertrophy Renal Calculus ...

Healthy Kidney

Diseased Kidney

Physical Basis

Renal Replacement

Causes for Kidney Failure

Risk Factors of Renal Failure

Overweight Smoking

High Cholesterol
Hypertension Diabetes

Atherosclerosis

Kidney Failure

Healthy Kidney

Diseased Kidney

Physical Basis

Renal Replacement

Symptoms and Signs of Renal Diseases

Early Signs of Renal Disease

Blood in the Urine Protein in the Urine (Heavily Frothing Urine)

Fatigue

Signs and Symptoms at the beginning of renal disease are not specific, i.e. they occur also in other circumstances. A medical examination and simple tests are able to diagnose a renal disease early. Thus the progress of the renal disease can be stopped or at least slowed down.
Edema

Very Little Urin or Very Much Urine

Feeling of Weakness

Healthy Kidney

Diseased Kidney

Physical Basis

Renal Replacement

Symptoms and Signs of Renal Diseases

Renal Failure, e.g. Water Removal

Reduced Water Removal Peripheral Edema Fluid Overload in the Body Hypertension Fluid Lung

Reduction of Oxygen Intake

Reduction of Cardiac Performance

Without therapy the fluid overload of the body and its consequences are progressing, leading finally to the death of the patient. Renal replacement therapy is life-saving.
Healthy Kidney Diseased Kidney Physical Basis Renal Replacement

Renal Failure

Acute Renal Failure

Dialysis Treatments
Creatinine M/l Urine l/day

Time / days

Zllner, Innere Medizin, modified

1. Damage Damage to Renal Tissue (minutes to days)

Healthy Kidney

2. Oliguria / Anuria Complete Loss of Renal Function (up to 6 weeks)

3. Polyuria Uncontrolled Urine Quantities (1 - 2 weeks)

4. Recovery slow Recovery of Renal Function (several months)

Diseased Kidney

Physical Basis

Renal Replacement

Renal Failure

Chronic Renal Failure - Stages

1
Renal Insufficiency
only minor clinical symptoms residual renal function is sufficient without treatment further deterioration

Renal Failure

increasing clinical symptoms multiple and serious deviations in blood chemistries residual renal function is borderline possible decompensation, e.g. due to a cold

severe clinical symptoms Acute-on-Chronic residual renal function is suddenly insufficient Renal Failure with adequate therapy a recompensation is often possible (return to stage 2)

Uremia

severe clinical symptoms renal replacement therapy is permanently needed, if untreated patient will die

Healthy Kidney

Diseased Kidney

Physical Basis

Renal Replacement

Physical Basis of Dialysis

Semipermeable Membrane

Erythrocyte, Red Blood Cell

Albumin, as Example of a Big Protein Molecule Electrolytes

Medium sized Molecules, e.g. b2-Microglobulin

Water Flow is Easily Possible

The semipermeable membrane functions similar to a fine sieve, only molecules that are small enough can pass.

Healthy Kidney

Diseased Kidney

Physical Basis

Renal Replacement

Physical Basis of Dialysis

Diffusion
Start: Different Concentrations End:

Time

Equal Concentrations

Diffusion is a consequence of the random movement of all molecules (Brownian Movement).

Healthy Kidney

Diseased Kidney

Physical Basis

Renal Replacement

Physical Basis of Dialysis

Ultrafiltration
Time
Pressure

Exertion of pressure on one side of the membrane produces filtration of water with solutes, as long as they can pass the membrane.

Healthy Kidney

Diseased Kidney

Physical Basis

Renal Replacement

Physical Basis of Dialysis

Osmosis
Time

Different to diffusion the dissolved particles cannot pass the membrane, nevertheless the concentrations tend to equal out, thus water passes the membrane.

Healthy Kidney

Diseased Kidney

Physical Basis

Renal Replacement

Physical Basis of Dialysis

Reverse Osmosis
Time Pressure

Similar to ultrafiltration pressure is applied to one side of the membrane. Reverse osmosis is especially important for the purification of water for the production of dialysate.
Healthy Kidney Diseased Kidney Physical Basis Renal Replacement

Hemodialysis

Flow Scheme Hemodialysis

Dialyzer Anti-Coagulation Blood Pump

Blood to the Patient Fresh Dialysate

Used Dialysate

Blood from the Patient

Healthy Kidney

Diseased Kidney

Physical Basis

Renal Replacement

Hemodialysis

Flow Scheme Hemofiltration

Dialyzer Sterile Infusion Solution Blood from the Patient Anti-Coagulation Blood Pump

Ultrafiltrate

An exact balancing of infused and ultrafiltrated volumes is mandatory when using Hemofiltration !

Blood to the Patient

Healthy Kidney

Diseased Kidney

Physical Basis

Renal Replacement

Hemodialysis

Vascular access
Dilated Vein - Shunt Twinlumen Catheter Jugular Vein (V. jugularis interna) Aorta

Connection: Vein and Artery Closure of the Distal End of the Vein

The vascular access using peripheral veins of the forearm has the big advantage of long usage, but it needs some weeks waiting time after the operation before the first use.
Healthy Kidney Diseased Kidney

The access by a catheter inserted in a central vein can be immediately used, but its lifetime is limited to a few weeks.

Physical Basis

Renal Replacement

Hemodialysis

Dialyzer
Bundle of Capillaries in the Housing Dialysate Inflow

Dialysate Outflow

Blood Outflow Solute Transfer across the Capillary Walls

Blood Inflow

The dialysate flows outside of the capillaries, blood within the capillaries countercurrently.

Healthy Kidney

Diseased Kidney

Physical Basis

Renal Replacement

Peritoneal Dialysis

How is Peritoneal Dialysis Done?

Bag with Fresh Solution

Peritoneal dialysis is done by filling specially composed peritoneal dialysis solution into the abdominal cavity.
The solute transfer between blood and the solution happens by diffusion. The water removal from the patient is an osmotic process.

Peritoneum

Implanted Catheter

Peritoneal Dialysis Solution Bag for Used Solution

Healthy Kidney

Diseased Kidney

Physical Basis

Renal Replacement

Peritoneal Dialysis

Peritoneum as Semipermeable Membrane

Transport from the Blood into the Solution Capillary Peritoneum

Connective Tissue Epithelial Layer Transport from the Solution into the Blood

Peritoneal Dialysis Solution

The solute transfer across the Peritoneum takes place in both directions, e.g. metabolic end products from the blood into the solution and e.g. buffers in the opposite direction.
Healthy Kidney Diseased Kidney Physical Basis Renal Replacement

Kidney Transplantation

Location of a Kidney Transplant

Liver Aorta

Kidney Transplant in the Fossa Iliaca, Not at the Position of Healthy Kidneys Connection of Renal Artery and Vein to the Pelvic Vessels

Connection of the Ureter to the Bladder of the Recipient

Healthy Kidney

Diseased Kidney

Physical Basis

Renal Replacement

Kidney Transplantation

Advantages of Kidney Transplantation

Continuous Treatment No Fixed Time Schedule

Advantages of Kidney Transplantation

Less Sequelae

Mobility

Healthy Kidney

Diseased Kidney

Physical Basis

Renal Replacement

Kidney Transplantation

Problems of Kidney Transplantation

Rejection Immunosuppression

Compatibility of Tissues

Disadvantages of Kidney Transplantation

Suitability of the Recipient

Shortage of Organ Donors

Healthy Kidney

Diseased Kidney

Physical Basis

Renal Replacement

Which Mode of Renal Replacement Therapy?

Kidney Transplantation Hemodialysis Peritoneal Dialysis

Each mode has its advantages and disadvantages. The selection is made in a discussion between patient and physician.

Healthy Kidney

Diseased Kidney

Physical Basis

Renal Replacement

Thank you for your kind attention.