II. Indications: Renal Failure

  1. End Stage Renal Disease
    1. Refractory volume overload (e.g. Pulmonary Edema)
    2. Refractory Metabolic Acidosis, Hyperkalemia, Hyperphosphatemia
    3. Uncontrolled Hypertension
    4. Significant Uremia Signs and Symptoms
      1. Anorexia, Nausea, Protein calorie Malnutrition and wasting, altered taste and smell
      2. Hypothermia
      3. Confusion or encephalopathy
      4. Seizures
      5. Myalgias or restless legs
      6. Lethargy or Somnolence
      7. Pruritus
  2. Acute Renal Failure with uremic complications
    1. Encephalopathy
    2. Pericarditis
    3. Uncontrolled bleeding
    4. BUN >100-150
    5. Persistent Nausea and Vomiting
    6. Anuria (minimal Urine Output in 6 hours) or Severe Oliguria (<200 ml in 12 hours)
    7. Hyperkalemia (seen below)

III. Indications: Toxins and Overdose substances cleared by Hemodialysis

  1. General
    1. Low Protein binding (<80%)
    2. Small volumes of distribution (<1 L/kg)
    3. High water solubility
    4. Low Molecular weight (<100 daltons)
    5. Non-ionized
    6. Unstable Overdose patient of Unknown Ingestion
  2. Specific (Mnemonic: "I STUMBLED")
    1. Isopropanol
    2. Salicylates
    3. Theophylline, Tenormin (Atenolol)
    4. Uremia
    5. Methanol
    6. Barbiturates (e.g. Phenobarbital)
    7. Lithium
    8. Ethylene Glycol
    9. Depakote (esp. if level >500)

IV. Indications: Fluid and Electrolyte Abnormalities

  1. Serum Potassium >6.5 mEq/L (or Hyperkalemia Related EKG Changes)
  2. Serum Uric Acid >10 mg/dl
  3. Serum Creatinine >10 mg/dl
  4. Serum Phosphate >10 mg/dl
  5. Symptomatic Hypocalcemia
  6. Significant Fluid Overload (e.g. Pulmonary Edema with Hypoxia refractory to Diuretics)
  7. Severe Metabolic Acidosis (pH <7.1 despite normal or low arterial pCO2)

V. Background: Hemodialysis

  1. Duration of Hemodialysis: 3.5 hour (average)
  2. Frequency of Hemodialysis: 3 times weekly
  3. Total hours of Dialysis per week: 9 to 12 hours (depending on calculation below)
  4. Dialysis adequacy estimation
    1. Where
      1. Dialyzer clearance = K
      2. Dialysis duration = t
      3. Urea volume of distribution = V
    2. Calculation
      1. Kt/V >1.2 per session suggests adequate Dialysis
  5. Alternatives in End Stage Renal Disease (90% use in-center Hemodialysis)
    1. In-Home Hemodialysis
    2. Peritoneal Dialysis

VI. Preparations: Shunt types

  1. Precautions in ESRD
    1. Early referral in ESRD to prepare for Vascular Access before Hemodialysis is needed
    2. Preserve venous access sites in CKD Stage 3 and CKD Stage 4 patients
      1. Avoid excessive venipuncture and PICC Lines
      2. Avoid subclavian venous catheters
  2. Fistulas (autogenous subcutaneous shunts)
    1. Most common Dialysis permanent shunts in United States
    2. Preferred long-term Dialysis shunt
      1. Lower risk of infection (no artificial material as contrasted with grafts)
      2. Lower risk of thrombosis than with other shunts
      3. Higher Blood Flow rates than with other shunts
    3. Internal Radiocephalic AV fistula (wrist)
      1. Radial artery to cephalic vein anastomosis at the wrist (1966, Brescia and Cimino)
    4. Internal Brachiobasilic fistula (proximal to elbow)
      1. Brachial artery to cephalic vein anastomosis proximal to the elbow
  3. Grafts (Internal subcutaneous shunts
    1. Indicated when a patient in need of longterm Dialysis does not have native vessels amenable to fistula placement
    2. Intermediate life span (2 years)
    3. Typically made of Dacron and polytetrafluoroethylene (Gortex)
    4. Synthetic shunts require 3-6 weeks to mature
      1. Fastest with polytetrafluoroethylene
      2. Contrast with fistulas (autogenous shunts) which require at least 3-6 months to mature
  4. Percutaneous catheters
    1. Highest rate of complications including infection
    2. Non-tunneled-Lines
      1. Very short-term access of <10 days and typically only one Dialysis run
      2. Indicated for emergent Dialysis until surgical tunneled-line placement
        1. Examples: Toxin Ingestion, Acute Renal Failure
    3. Tunneled-Lines (e.g. Hickman Catheters)
      1. Temporary lines for Acute Renal Failure, or while awaiting fistula maturity
      2. Tunnel-cuffed catheters in the internal Jugular Vein or the subclavian vein
  5. External Arteriovenous Shunt (historical)
    1. First Dialysis shunt developed (1960, Quinton and Scribner)
    2. Highest shunt survival rate (75% at 2 years)

VII. Precautions

  1. Hemodialysis catheters are at risk for clotting, infection and failure
    1. Hemodialysis catheters are very large bore (>12 F) to move large Blood Volumes
    2. Infection risk is high with access and should be performed only with specifically trained precautions
    3. Hemodialysis catheters are primed with Heparin to prevent clotting
  2. Venipuncture
    1. Avoid drawing blood from nondominant arm
    2. Avoid drawing blood from dominant upper arm
    3. Avoid draw blood from Central DIalysis line or fistula (unless emergency without other access)
      1. High risk of complication (shunt injury, infection, bleeding)
      2. Immature shunts risk pseudoaneurysm development with venipuncture
  3. Blood Pressure readings
    1. Avoid obtaining Blood Pressure on the shunt arm

VIII. Technique: Emergency access of the shunt for venipuncture (avoid if at all possible, especially in immature shunts)

  1. Carefully cleanse access site with topical disinfectant before venipuncture
  2. Apply firm, non-occlusive pressure to site for 10 minutes or more
  3. Document palpable thrill over shunt before and after access

IX. Complications: Acute

  1. Hypotension (very common)
    1. See Hypotension in the Dialysis Patient
    2. Most commonly related to excessive ultrafiltration volume or rate
    3. Critical to exclude other serious causes (e.g. bleeding, Electrolyte disturbance, infection)
  2. Hypersensitivity Reaction
    1. Reactions include Anaphylaxis
    2. Reactions to Dialysis membrane
    3. Phthalate (in PVC tubing)
    4. Ethylene oxide (sterilizing solution)
    5. Polyacrylonitrile (in membrane)
  3. Hemolysis (associated with dialysate components or overheated)
  4. Air Embolism (rare now in U.S. with current technology)
  5. Electrolyte abnormalities (Sodium, Potassium, Calcium, Magnesium, osmolality)
  6. Dialysis Disequilibrium Syndrome (rare, but potentially lethal)
  7. Bloodstream Infections in Hemodialysis

X. Complications: Chronic

  1. See Dialysis Emergencies
  2. Graft Occlusion (common)
    1. Flow may be assessed via Ultrasound
    2. Access salvage techniques
      1. Embolectomy balloon
      2. Mechanical Thrombolysis
      3. Pulsed urokinase
  3. Calciphylaxis
    1. Vascular calcification secondary to abnormal metabolism of Calcium and Phosphorus
    2. Exclusive to Dialysis patients (may require cessation of Dialysis)
    3. Severe generalized pain
    4. Skin ischemia may progress to skin necrosis

XI. References

  1. Glauser (2013) Crit Dec Emerg Med 27(10): 2-12
  2. Mallemat, Swaminathan and Egan in Herbert (2014) EM:Rap 14(10): 5

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Related Studies

Ontology: Dialysis procedure (C0011946)

Definition (MEDLINEPLUS)

When your kidneys are healthy, they clean your blood. They also make hormones that keep your bones strong and your blood healthy. When your kidneys fail, you need treatment to replace the work your kidneys used to do. Unless you have a kidney transplant, you will need a treatment called dialysis.

There are two main types of dialysis. Both types filter your blood to rid your body of harmful wastes, extra salt, and water.

  • Hemodialysis uses a machine. It is sometimes called an artificial kidney. You usually go to a special clinic for treatments several times a week.
  • Peritoneal dialysis uses the lining of your abdomen, called the peritoneal membrane, to filter your blood.

NIH: National Institute of Diabetes and Digestive and Kidney Diseases

Definition (NCI) A procedure to remove toxic substances from the blood that is used in patients with end-stage chronic kidney disease or acute kidney failure. This includes hemodialysis and peritoneal dialysis.
Definition (NCI_NCI-GLOSS) The process of cleansing the blood when the kidneys are not able to filter the blood.
Definition (NCI_CDISC) A procedure to remove toxic substances from the blood that is used in patients with end-stage chronic kidney disease or acute kidney failure. This includes hemodialysis and peritoneal dialysis.
Definition (MSH) Therapy for the insufficient cleansing of the BLOOD by the kidneys based on dialysis and including hemodialysis, PERITONEAL DIALYSIS, and HEMODIAFILTRATION.
Definition (CSP) dialysis fluid being introduced into and removed from the peritoneal cavity or kidneys as either a continuous or an intermittent procedure.
Concepts Therapeutic or Preventive Procedure (T061)
MSH D006435
SnomedCT 151048001, 180267005, 266809003, 108241001, 265764009, 27392003
CPT 1012740
LNC LA7216-0
English Dialyses, Renal, Renal Dialyses, Renal Dialysis, Dialysis, Renal, Dialysis procedure, dialysis therapy, dialysis, dialysis (treatment), Dialysis NOS, therapy dialysis, kidney dialysis, dialysis procedure, Dialysis - renal, renal dialysis (treatment), renal dialysis, Dialysis Services and Procedures, Dialysis, Kidney dialysis, Renal dialysis, Dialysis procedure (procedure), Renal dialysis (procedure), Artificial kidney dialysis, Kidney dialysis, NOS, Renal dialysis, NOS, Artificial kidney dialysis, NOS, Dialysis Procedure, Dialysis Therapy
Italian Dialisi, Dialisi NAS, Dialisi renale
Dutch dialyse NAO, nierdialyse, dialyse, Dialyse, nier-, Nierdialyse, Dialyse, hemo-
French Dialyse SAI, Dialyse, Dialyse rénale, Épuration extrarénale
German Dialyse NNB, Dialyse, Nierendialyse, Dialyse, Nieren-
Portuguese Diálise NE, Diálise renal, Diálise, Diálise Renal
Spanish Diálisis NEOM, Diálisis renal, diálisis artificial del riñón, procedimiento de diálisis (procedimiento), procedimiento de diálisis, Diálisis, diálisis renal, diálisis de riñón, diálisis renal (procedimiento), diálisis renal artificial, Diálisis Renal
Japanese 透析, 透析NOS, ジントウセキ, トウセキNOS, トウセキ, 体外血液透析, 腎透析, 血液透析-体外, 透析-治療的, 体外透析, 治療的透析, 血液浄化法(透析), 血液透析
Swedish Njurdialys
Czech hemodialýza, Dialýza, Dialýza NOS, Renální dialýza
Finnish Hemodialyysi
Polish Dializa nerkowa, Hemodializa, Dializa krwi, Dializa pozaustrojowa
Hungarian Vese dialysis, Dialysis, Dialysis k.m.n.
Norwegian Nyredialyse, Dialyse, nyre

Ontology: Hemodialysis (C0019004)

Definition (NCI) A therapeutic procedure used in patients with kidney failure. It involves the extracorporeal removal of harmful wastes and fluids from the blood using a dialysis machine. Following the dialysis, the blood is returned to the body.
Definition (CSP) therapy for the insufficient cleansing of the blood by the kidneys based on dialysis.
Definition (MSH) Removal of certain elements from the blood based on the difference in their rates of diffusion through a semipermeable membrane.
Definition (NIC) Management of extracorporeal passage of the patient's blood through a dialyzer
Concepts Therapeutic or Preventive Procedure (T061)
MSH D006435
ICD9 39.95
ICD10 1059 , 13100-00
SnomedCT 309432002, 151048001, 27392003, 266809003, 302497006
CPT 1012752
LNC LP149600-1, LP173518-4, LA9975-9
English Hemodialyses, Hemodialysis, Extracorporeal Dialysis, Renal Dialysis, Artificial Kidney Dialysis, Kidney Dialysis, Hemodialysis Therapy, hemodialysis (treatment), hemodialysis, Haemodialysed, hemodialysis procedure, hemodialyses, Haemodialysis procedure (procedure), Hemodialyzed, Hemodialysis Procedures, HD - Haemodialysis, HD - Hemodialysis, Haemodialysis, Haemodialysis procedure, Hemodialysis procedure, Extracorporeal haemodialysis, Extracorporeal hemodialysis, Hemodialysis (procedure), dialysis; renal, kidney; dialysis, Hemodialysis, NOS, Extracorporeal hemodialysis, NOS, Hemodialysis (procedure) [Ambiguous], haemodialysis
French Hémodyalisé(e), Hémodialyse
German einer Haemodialyse unterzogen, Hämodialyse, Haemodialyse
Italian Emodializzato, Emodialisi
Portuguese Hemodialisado, Hemodiálise
Spanish Hemodialisis, Hemodializado, Hemodiálisis, hemodiálisis extracorporal, hemodiálisis (concepto no activo), hemodiálisis (procedimiento), hemodiálisis extracorpórea, hemodiálisis, procedimiento de hemodiálisis
Japanese 血液透析, ケツエキトウセキ
Czech Hemodialýza, Hemodialyzovaný
Hungarian Hemodialysis, Haemodialysis, Hemodialyzált
Norwegian Hemodialyse
Dutch gehemodialyseerd, dialyse; nier, nier; dialyse, hemodialyse, Hemodialyse