1. Water Treatment Unit For Hemodialysis machines Hemodialysis Solution

2. Dialysis solution is prepared from Purified water Concentrate +

3. Water – significance for the patient  Needed by a human being app. 500- 800 litres per every treatment  Dialysis patients need app. 20 m 3 /yr  Demands of water for dialysis is very high

4. Types of pollution  Organic pollutants particles, colloids, bacteria, pyrogens, chloramines, pesticides  Inorganic pollutants monovalent/ polyvalent ions, especially calcium, sodium, magnesium, nitrate, copper, aluminium etc. Colloids + + + + + + + + + + + + + + + + - - - - - - - - - - - - - - - -

5. Water contamination is harmful for dialysis patient: Complications:is added for/by: Anemia, dementia, bone disease Flocculating suspended particles Aluminum: Hemolytic anemia Preventing bacterial proliferation Chloramine: Pruritis, Nausea, Atrial fibrillation Reduce tooth decayFluoride: Hemolytic anemia, toxicity Metal pipes Copper, Zinc Lead Pyrogenic reactions Contaminated water Bacteria and Endotoxins

6. Methods of purifying water:  Pretreatment  Primary purification  Distribution  Pretreatment  Primary purification  Distribution

7.  Installation of water pre-treatment and RO system Mechanical Filter Sand filter Softener Water meter Carbon filter Reverse osmosis with mechanical Filter Salt tank

8. Methods of purifying water:  Pretreatment  Primary purification  Distribution  Pretreatment  Primary purification  Distribution

9. pretreatment:  Water softener  Carbon adsorption  Water softener  Carbon adsorption

10. Softener:

11. SOFTENER

12. Carbon adsorption: Adsorption by activated Carbone Is utilized to remove Chlorine and Chloramines Adsorption by activated Carbone Is utilized to remove Chlorine and Chloramines

13. 2-Activated carbon filter for adsorption  principle: *van der Waals forces *high specific surface (100g act. carbon – ca. 100.00 m 2 ) ◊ remove chlorine from drinking water

14. Methods of purifying water:  Pretreatment  Primary purification  Distribution  Pretreatment  Primary purification  Distribution

15. Methods of purifying water:  Pretreatment  Primary purification  Distribution  Pretreatment  Primary purification  Distribution

16. Primary purification:  Reverse osmosis  Deionization  Reverse osmosis  Deionization

17. Reverse osmosis:  It removes more than 95% of ionic contamination and nonionic contaminations  It removes more than 95% of ionic contamination and nonionic contaminations

18. clear water Osmotic pressure saline solution semipermeable membrane Principle of Osmosis

19. pressure saline solutionclear water semipermeable membrane Principle of Reverse Osmosis

20. Reverse osmosis apparatus

21. Direct and indirect water feed distribution system

22. Deionization:

23. Methods of purifying water:  Pretreatment  Primary purification  Distribution  Pretreatment  Primary purification  Distribution

24. Methods of purifying water:  Pretreatment  Primary purification  Distribution  Pretreatment  Primary purification  Distribution

25. The main function of the dialysate, is to remove waste material from the blood and to keep useful material from leaving the blood. Electrolytes and water are some materials included in the dialysate so that their level in the blood can be controlled

26. Dialysis solutions preparation:  Fixed volumes of dialysate concentrate mixed with fix volumes of heated purified water  The final dialysate solution is checked by conductivity  Fixed volumes of dialysate concentrate mixed with fix volumes of heated purified water  The final dialysate solution is checked by conductivity

27. Biff F. Palmer

28. Bicarbonate powder obviates the problem of bicarbonate growth in bicarbonate solutions

29. Hemodialysis solution Concentrations of dialysate components used in hemodialysis : Sodium (meq/L) 135 to 155 Potassium (meq/L) 0 to 4 Calcium (mmol/L) 1.25 to 1.75 (2.5 to 3.5 meq/L) Magnesium (mmol/L) 0 to 0.75 (0 to 1.5 meq/L) Chloride (meq/L) 87 to 120 Bicarbonate (meq/L) 25 to 40 Glucose (g/dL) 0 to 0.20

30. In early 1960s acetate was standard buffer Acetate lead to cardiovascular instability and hypotension during dialysis. Acetate buffer

31. Hemodynamic instability Pts with reduced mass muscle more intolerant to acetate buffer included malnourished Pts,elderly Pts and women.

32. Bicarbonate (meq/L) 25 to 40 Standard solutions have 35 or 38 meq/L In alkalemic pts (metabolic or respiratory) standard solutions must be changed to a solution with 20-28 meq/L of bicarbonate Concentration of base adjusted to a predialysis plasma con of 20-23 meq/L Con beyond 20-23 meq/L increased risk of Ca-P precipatation and cardiac arrhythmia

33. Bicarbonate Concentrate NaHCO3 Bicarbonate Concentrate NaHCO3 Acid Concentrate (acetic acid, citric acid, Na, K, Mg, Cl, dextrose Acid Concentrate (acetic acid, citric acid, Na, K, Mg, Cl, dextrose HCO3 + H+ = H2CO3 PH: 7-7.4 HCO3 + H+ = H2CO3 PH: 7-7.4

34. NaHco3 = 32mmol ± 8 mmol Bicarbonate Concentration for Acidotic Patient =35-38 mEq/L

35. Sodium level:135-145meq/L Dialysate with low Na level predispose to hypotension and cramps because of hypoosmolality and more fluid shifting from extracellular space to intracellular space. Dialysate with high Na level may cause thirst and weight gain and prevent hypotension during dialysis.

36. Standard Dilution 1 + 34 Variable 1 + 25 1 + 37 Acetate 135mmol Base Na Bicarbonate 138mmol NaHco3 + Acid Solution 32mmol + 106 mmol

37. Potassium level :0-4meq/L Usual dialysis K level is 2 meq/L unless predialysis plasma K is less than 4.5 or unless patient is receiving digitalis. In the two instances,dialysis K level is 3 meq/L

38. Calcium level:2.5-3.5 meq/L In pts taking calcium-containing phosphorus Ca level is 2.5 meq/L In pts taking newer phosphate binder which don’t contain Ca, Ca level may increased towards 3.5meq/L

39. Air Detector Blood Leak Detector PT PT = Pressure Transducer PT Venous clamp Anticoagulant Blood from Patient Blood return to Patient Dialysate In Dialysate / UF Out (green / yellow) Informational Display A “Standard” HD Delivery System PT Mixing System Conductivity Meter Water, Acid Concentrate, Bicarbonate Concentrate In Pre-mixed or sorbent regenerated dialysate Saline Drip Chamber

40. غلظت نهایی مایع دیالیز بیکربنات Na :135meq/l K:1 & 2 meq/l Mg:1 meq/l Ca:2.5 meq/l Cl:104 meq/l Acetate :35 meq/l Glucose : 200mg/dl Na :106 + 32 meq/l K:1 & 2 meq/l Mg:1 meq/l Ca:2.5 meq/l Cl:111.5 meq/l Acetate :3.5 meq/l Glucose : 200mg/dl Bicarbonate :32 meq غلظت نهایی مایع دیالیز استات

41. What is sodium modeling in hemodialysis patients? What is sodium modeling in hemodialysis patients?

42. Fluid removal Plasma refilling

43. Low Na 130-135 meq/l Na Fluid removal Na Increased risk of hypotension

44. Historically the dialysate Na was maintained at hyponatremic level, 130-135: To prevent:  Intradialytic hypertension  Thirsty  Interdialytic weight gain To prevent:  Intradialytic hypertension  Thirsty  Interdialytic weight gain

45. Disadvantages of dialysates with low sodium concentration:  Increased risk of hypotension  Increased risk of intradialytic cramps  Increased risk of dialysis disequilibrium syndrome  Increased risk of hypotension  Increased risk of intradialytic cramps  Increased risk of dialysis disequilibrium syndrome

46. Water movement during standard hemodialysis Water movement Intracellular fluidExtracellular fluidDialyzer Osmolality 320 mosm/kg Osmolality 320 mosm/kg Loss of urea and water step1 step2 step3 280 Osmolality 320 mosm/kg Falling to 290mosm/kg as diffusion occurs Compensatory refilling

47. urea removed by dialyzer Effluent Dialysate Inffluent Dialysate urea sequestration in tissue Increased intracellular osmolarity fluid Na fluid

48. Causes of Intradialytic hypotension(IDH) Intradialytic Hypotension Reduced ECV Impaired Vasoconstriction Heart problems Myocardial Infarction Structural heart dis. Arrythmias Pericardial tamponade Dialyzer Rxn Air embolism Hemolysis Hemorrhage Reduced plasma refilling rate Excessive fluid removal Ultrafiltration rate > 0.35 ml/min/kg Decrease in plasma vol. > 20% Patient-related factors Autonomic neuropathy (e.g. DM, Uremia) Antihypertensive medications Sympathetic failure ( 적절한 plasma NE↑ 가 無 ) RAS and arginine-vasopressin syst. sensitivity↓ Food ingestion(splanchnic vasodilation) Tissue ischemia(adenosine mediated) Bacterial sepsis Intradialytic venous pooling Core body temp.↑ Anemia. Dialysis-related factors Acetate dalysate (adenosine-mediated) Low dialysate Na &/or ionized Ca conc. Complemant activation (C3a and C5a-mediated) Cytokine generation(IL-1 and NO-mediated)

49. High dialysate sodium: Advantages:  Decreased risk of hypotension  Decreased risk of intradialytic cramps  Decreased risk of dialysis disequilibrium syndrome Advantages:  Decreased risk of hypotension  Decreased risk of intradialytic cramps  Decreased risk of dialysis disequilibrium syndrome Disadvantages:  Increased rate of hypertension  Interdialytic weight gain  Polydipsia Disadvantages:  Increased rate of hypertension  Interdialytic weight gain  Polydipsia

50. Low Na >145 meq/l Na Fluid removalPlasma refilling Na

51. Different patterns of sodium modeling Na concentration Hours after dialysis initiation 145-155 meq/lit 135-140 meq/lit

52. Dialysate Na should be regulated based on serum Na: hyponatremia:  If Na > 130: Dialysate Na: 140-(140-predialysis Na)  If Na<130: Dialysate Na: Predialysis Na + 15-20 Hypernatremia:  Dialysate Na: Predialysis Na-2 mmol hyponatremia:  If Na > 130: Dialysate Na: 140-(140-predialysis Na)  If Na<130: Dialysate Na: Predialysis Na + 15-20 Hypernatremia:  Dialysate Na: Predialysis Na-2 mmol