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Water Treatment Equipment for In-Center Hemodialysis

Introduction During the provision of contemporary hemodialysis, the dialysate flows through the dialysate chamber of a dialyzer, which separates the toxic substances from the bloodstream into the dialysate via diffusion. The dialysate is composed of solute electrolytes in solvent water. In order to produce the final dialysate solution, a concentrated electrolyte solution is mixed with water. The ratio of concentrated electrolyte solution to water can vary…

Selecting a Dialyzer: Technical and Clinical Considerations

Introduction During hemodialysis (HD), solutes and water are removed through a semipermeable membrane using different separation mechanisms (diffusion, convection, adsorption, and ultrafiltration). The traditional classification scheme for dialysis membranes has been based broadly on composition and water permeability. However, advances in biomaterials and improved fiber production (spinning) technology have led to consideration of several other parameters for membrane characterization, especially new permeability indices. While the dialysis…

The Dialysis Prescription

Perhaps the most fundamental prescriptive question is how much dialysis is enough? On the surface, this question seems simple. However, this veneer of simplicity is misleading and belies myriad complexities and nuances. The question’s apparent simplicity stems from its bounded nature: on the low end, zero dialysis is insufficient and leads to death; on the high end, there exists a finite number of hours per week…

Urea Kinetic Modeling for Guiding Hemodialysis Therapy in Adults

Introduction Dialysis is arguably a successful life-sustaining therapy. This unique, extracorporeal therapy has granted millions of people years of life after kidney failure. Hemodialysis (HD) is presently the most utilized form of renal replacement therapy around the globe. Even as technology improves, the method through which HD provides its therapy remains little changed over the last few decades. The removal of low-molecular-weight, water- soluble, and minimally…

Initiation of Dialysis Therapy

Acknowledgments Some data reported in this chapter have been supplied by the USRDS. The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy or interpretation of the U.S. government. Dr. Rivara is supported in part by funding from the Extramural Grant Program (EGP) by Satellite Healthcare, a not-for-profit renal care provider. Introduction…

Uremic Toxicity

Introduction The progressive loss of kidney function in chronic kidney disease (CKD) is accompanied by the retention of a host of metabolites due to a decrease in kidney clearance and sometimes in nonkidney clearance that is accompanied by unaltered, if not increased, generation and/or transport. Many of these solutes have been shown to exert biological activity, hence affecting the functioning of cells and organs, resulting in…

Demographics of the End-Stage Renal Disease Patient

Introduction End-stage kidney disease (ESKD) constitutes an ever-increasing threat to public health. Since the publication of the last edition of this book in 2015, complex trends have continued to evolve in the epidemiology of ESKD and maintenance dialysis. In this chapter, we highlight how incidence rates of treated ESKD have increased globally, a phenomenon that will almost certainly continue as low- and middle-income countries undergo economic…

Hyperglycemia

Introduction Because hyperglycemia due to poorly controlled diabetes mellitus is a common disorder associated with a number of disturbances in fluid and electrolyte balances, we thought it would be useful to have a separate chapter on hyperglycemia to address these different issues. Abbreviations P Glucose , concentration of glucose in plasma GFR, glomerular filtration rate ECF, extracellular fluid ICF, intracellular fluid DKA, diabetic ketoacidosis P Creatinine…

Hyperkalemia

Introduction Hyperkalemia is usually defined as a concentration of potassium ions (K + ) in plasma (P K ) that is greater than 5 mmol Hyperkalemia is a common electrolyte disorder that may be present in a number of disease states. Hyperkalemia may have detrimental effects, the most serious of which is a cardiac arrhythmia. Therefore, the first step in the clinical approach to the patient…

Hypokalemia

Introduction Hypokalemia, usually defined as a concentration of potassium (K + ) ions in plasma (P K ) of less than 3.5 mmol/L, is a common electrolyte disorder both in the outpatient and the inpatient setting. When faced with a patient with hypokalemia, the first step is to determine whether an emergency is present. The most serious emergency due to hypokalemia is a cardiac arrhythmia. The…

Potassium Physiology

Introduction Regulation of total body potassium (K + ) ion homeostasis is vital for survival. Changes in the concentration of K + ions in plasma (P K ) are associated with changes in the negative voltage across cell membranes and the resting membrane potential (RMP). This may have dangerous consequences (e.g., altered cardiac impulse conduction causing an arrhythmia). Abbreviations P K , concentration of potassium (K…

Polyuria

Introduction Polyuria is caused by either a water diuresis or an osmotic diuresis. Many patients who present with polyuria also have hypernatremia because they excrete a large volume of urine with a low concentration of sodium (Na + ) plus potassium (K + ) ions (e.g., patients with diabetes insipidus [DI] or patients with a urea-induced osmotic diuresis). Therefore, there are areas of overlap between this…

Hypernatremia

Introduction Hypernatremia is defined as a concentration of sodium (Na + ) ions in plasma (P Na ) that is greater than 145 mmol Hypernatremia is not a diagnosis; rather it is a laboratory finding that may be the result of a number of disorders of diverse etiology. Hence, one must determine its underlying cause. The first step in the clinical approach to the patient with…

Hyponatremia

Introduction Hyponatremia is defined as a concentration of sodium (Na + ) ions in plasma (P Na ) that is less than 135 mmol Hyponatremia is the most common electrolyte disorder encountered in clinical practice. It can be associated with considerable morbidity and even mortality. The initial step in the clinical approach to the patient with hyponatremia must focus on what the danger is to the…

Sodium and Water Physiology

Introduction It is important to understand the physiology of sodium (Na + ) and of water homeostasis to determine the pathophysiology that leads to alteration in the extracellular fluid (ECF) volume and/or the concentration of sodium ions (Na + ) in plasma (P Na ), and what is the optimal therapy to deal with these disorders. This chapter is divided into four sections. The first section…

Respiratory Acid–Base Disturbances

Introduction Respiratory acidosis is characterized by an increased arterial blood PCO 2 and H + ion concentration. The major cause of respiratory acidosis is alveolar hypoventilation. The expected physiologic response is an increased PHCO3 P HCO 3 . The increase in concentration of bicarbonate ions (HCO 3 ) in plasma ( PHCO3 P HCO 3 ) is tiny in patients with acute respiratory acidosis, but is…

Metabolic Alkalosis

Introduction Metabolic alkalosis is principally an electrolyte disorder that is accompanied by changes in acid–base parameters in plasma, namely an elevated concentration of bicarbonate ( HCO3− HCO 3 − ) ions ( PHCO3 P HCO 3 ) and elevated pH. Most patients with metabolic alkalosis have a deficit of chloride (Cl − )-containing compounds: sodium chloride (NaCl), potassium chloride (KCl) and/or hydrochloric acid (HCl). A deficit…

Metabolic Acidosis: Acid Gain Types

Introduction The focus in this chapter is on metabolic acidosis due to the accumulation of acids. Two disorders that can cause this type of metabolic acidosis are not discussed in this chapter. Ketoacidosis was discussed in Chapter 5 . Metabolic acidosis caused by hippuric acid production from the metabolism of toluene in patients who sniff glue was discussed in Chapter 4 , because the hippurate anion…

Ketoacidosis

Introduction Although ketoacidosis is a form of metabolic acidosis because of the addition of acids, it is discussed separately in this chapter to emphasize the metabolic and biochemical issues required to understand the clinical aspects of this disorder (see margin note). We discuss the metabolic setting that is required to allow for the formation of ketoacids in the liver at a high rate and what sets…