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Kidney dialysis is the process of removing excess
water Water is an inorganic compound with the chemical formula . It is a transparent, tasteless, odorless, and Color of water, nearly colorless chemical substance. It is the main constituent of Earth's hydrosphere and the fluids of all known liv ...
,
solutes In chemistry, a solution is defined by IUPAC as "A liquid or solid phase containing more than one substance, when for convenience one (or more) substance, which is called the solvent, is treated differently from the other substances, which are ...
, and
toxins A toxin is a naturally occurring poison produced by metabolic activities of living cells or organisms. They occur especially as proteins, often conjugated. The term was first used by organic chemist Ludwig Brieger (1849–1919), derived ...
from the
blood Blood is a body fluid in the circulatory system of humans and other vertebrates that delivers necessary substances such as nutrients and oxygen to the cells, and transports metabolic waste products away from those same cells. Blood is com ...
in people whose
kidney In humans, the kidneys are two reddish-brown bean-shaped blood-filtering organ (anatomy), organs that are a multilobar, multipapillary form of mammalian kidneys, usually without signs of external lobulation. They are located on the left and rig ...
s can no longer perform these functions naturally. Along with kidney transplantation, it is a type of renal replacement therapy. Dialysis may need to be initiated when there is a sudden rapid loss of kidney function, known as
acute kidney injury Acute kidney injury (AKI), previously called acute renal failure (ARF), is a sudden decrease in renal function, kidney function that develops within seven days, as shown by an increase in serum creatinine or a decrease in urine output, or both. ...
(previously called acute renal failure), or when a gradual decline in kidney function,
chronic kidney failure Chronic kidney disease (CKD) is a type of long-term kidney disease, defined by the sustained presence of abnormal kidney function and/or abnormal kidney structure. To meet criteria for CKD, the abnormalities must be present for at least three mo ...
, reaches stage 5. Stage 5 chronic renal failure is reached when the
glomerular filtration rate Renal functions include maintaining an acid–base balance; regulating fluid balance; regulating sodium, potassium, and other electrolytes; clearance (medicine), clearing toxins; absorption of glucose, amino acids, and other small molecules; reg ...
is less than 15% of the normal,
creatinine Creatinine (; ) is a breakdown product of creatine phosphate from muscle and protein metabolism. It is released at a constant rate by the body (depending on muscle mass). Biological relevance Serum creatinine (a blood measurement) is an impor ...
clearance is less than 10 mL per minute, and
uremia Uremia is the condition of having high levels of urea in the blood. Urea is one of the primary components of urine. It can be defined as an excess in the blood of amino acid and protein metabolism end products, such as urea and creatinine, which ...
is present. Dialysis is used as a temporary measure in either acute kidney injury or in those awaiting kidney transplant and as a permanent measure in those for whom a transplant is not
indicated In medicine, an indication is a valid reason to use a certain test, medication, procedure, or surgery. There can be multiple indications to use a procedure or medication. An indication can commonly be confused with the term diagnosis. A diagnosis ...
or not possible.Pendse S, Singh A, Zawada E. "Initiation of Dialysis". In: ''Handbook of Dialysis''. 4th ed. New York; 2008:14–21 In West European countries, Australia, Canada, the United Kingdom, and the United States, dialysis is paid for by the government for those who are eligible. The first successful dialysis was performed in 1943.


Background

The
kidney In humans, the kidneys are two reddish-brown bean-shaped blood-filtering organ (anatomy), organs that are a multilobar, multipapillary form of mammalian kidneys, usually without signs of external lobulation. They are located on the left and rig ...
s have an important role in maintaining health. When the person is healthy, the kidneys maintain the body's internal equilibrium of water and minerals (sodium, potassium, chloride, calcium, phosphorus, magnesium, sulphate). The acidic
metabolism Metabolism (, from ''metabolē'', "change") is the set of life-sustaining chemical reactions in organisms. The three main functions of metabolism are: the conversion of the energy in food to energy available to run cellular processes; the co ...
end-products that the body cannot get rid of via respiration are also excreted through the kidneys. The kidneys also function as a part of the
endocrine system The endocrine system is a messenger system in an organism comprising feedback loops of hormones that are released by internal glands directly into the circulatory system and that target and regulate distant Organ (biology), organs. In vertebrat ...
, producing
erythropoietin Erythropoietin (; EPO), also known as erythropoetin, haematopoietin, or haemopoietin, is a glycoprotein cytokine secreted mainly by the kidneys in response to cellular hypoxia; it stimulates red blood cell production ( erythropoiesis) in th ...
,
calcitriol Calcitriol is a hormone and the active form of vitamin D, normally made in the kidney. It is also known as 1,25-dihydroxycholecalciferol. It binds to and activates the vitamin D receptor in the nucleus of the cell, which then increases the exp ...
and renin. Erythropoietin is involved in the production of red blood cells and calcitriol plays a role in bone formation. Dialysis is an imperfect treatment to replace kidney function because it does not correct the compromised endocrine functions of the kidney. Dialysis treatments replace some of these functions through
diffusion Diffusion is the net movement of anything (for example, atoms, ions, molecules, energy) generally from a region of higher concentration to a region of lower concentration. Diffusion is driven by a gradient in Gibbs free energy or chemical p ...
(waste removal) and ultrafiltration (fluid removal). Dialysis uses highly purified (also known as "ultrapure") water.


Principle

Dialysis works on the principles of the
diffusion Diffusion is the net movement of anything (for example, atoms, ions, molecules, energy) generally from a region of higher concentration to a region of lower concentration. Diffusion is driven by a gradient in Gibbs free energy or chemical p ...
of solutes and ultrafiltration of fluid across a
semipermeable membrane Semipermeable membrane is a type of synthetic or biologic, polymeric membrane that allows certain molecules or ions to pass through it by osmosis. The rate of passage depends on the pressure, concentration, and temperature of the molecules o ...
. Diffusion is a property of substances in water; substances in water tend to move from an area of high concentration to an area of low concentration.'' Mosby’s Dictionary of Medicine, Nursing, & Health Professions''. 7th ed. St. Louis, MO; Mosby: 2006 Blood flows by one side of a semipermeable membrane, and a dialysate, or special dialysis fluid, flows by the opposite side. A semipermeable membrane is a thin layer of material that contains holes of various sizes, or pores. Smaller solutes and fluid pass through the membrane, but the membrane blocks the passage of larger substances (for example, red blood cells and large proteins). This replicates the filtering process that takes place in the kidneys when the blood enters the kidneys and the larger substances are separated from the smaller ones in the glomerulus. The two main types of dialysis,
hemodialysis Hemodialysis, American and British English spelling differences#ae and oe, also spelled haemodialysis, or simply ''"'dialysis'"'', is a process of filtering the blood of a person whose kidneys are not working normally. This type of Kidney dialys ...
and peritoneal dialysis, remove wastes and excess water from the blood in different ways. Hemodialysis removes wastes and water by circulating blood outside the body through an external filter, called a dialyzer, that contains a
semipermeable membrane Semipermeable membrane is a type of synthetic or biologic, polymeric membrane that allows certain molecules or ions to pass through it by osmosis. The rate of passage depends on the pressure, concentration, and temperature of the molecules o ...
. The blood flows in one direction and the dialysate flows in the opposite. The
counter-current flow Countercurrent exchange is a mechanism between two flowing bodies flowing in opposite directions to each other, in which there is a transfer of some property, usually heat or some chemical. The flowing bodies can be liquids, gases, or even solid ...
of the
blood Blood is a body fluid in the circulatory system of humans and other vertebrates that delivers necessary substances such as nutrients and oxygen to the cells, and transports metabolic waste products away from those same cells. Blood is com ...
and dialysate maximizes the concentration gradient of solutes between the blood and dialysate, which helps to remove more
urea Urea, also called carbamide (because it is a diamide of carbonic acid), is an organic compound with chemical formula . This amide has two Amine, amino groups (–) joined by a carbonyl functional group (–C(=O)–). It is thus the simplest am ...
and
creatinine Creatinine (; ) is a breakdown product of creatine phosphate from muscle and protein metabolism. It is released at a constant rate by the body (depending on muscle mass). Biological relevance Serum creatinine (a blood measurement) is an impor ...
from the blood. The concentrations of solutes normally found in the
urine Urine is a liquid by-product of metabolism in humans and many other animals. In placental mammals, urine flows from the Kidney (vertebrates), kidneys through the ureters to the urinary bladder and exits the urethra through the penile meatus (mal ...
(for example
potassium Potassium is a chemical element; it has Symbol (chemistry), symbol K (from Neo-Latin ) and atomic number19. It is a silvery white metal that is soft enough to easily cut with a knife. Potassium metal reacts rapidly with atmospheric oxygen to ...
,
phosphorus Phosphorus is a chemical element; it has Chemical symbol, symbol P and atomic number 15. All elemental forms of phosphorus are highly Reactivity (chemistry), reactive and are therefore never found in nature. They can nevertheless be prepared ar ...
and urea) are undesirably high in the blood, but low or absent in the dialysis solution, and constant replacement of the dialysate ensures that the concentration of undesired solutes is kept low on this side of the membrane. The dialysis solution has levels of minerals like
potassium Potassium is a chemical element; it has Symbol (chemistry), symbol K (from Neo-Latin ) and atomic number19. It is a silvery white metal that is soft enough to easily cut with a knife. Potassium metal reacts rapidly with atmospheric oxygen to ...
and
calcium Calcium is a chemical element; it has symbol Ca and atomic number 20. As an alkaline earth metal, calcium is a reactive metal that forms a dark oxide-nitride layer when exposed to air. Its physical and chemical properties are most similar to it ...
that are similar to their natural concentration in healthy blood. For another solute,
bicarbonate In inorganic chemistry, bicarbonate (IUPAC-recommended nomenclature: hydrogencarbonate) is an intermediate form in the deprotonation of carbonic acid. It is a polyatomic anion with the chemical formula . Bicarbonate serves a crucial bioche ...
, dialysis solution level is set at a slightly higher level than in normal blood, to encourage the diffusion of
bicarbonate In inorganic chemistry, bicarbonate (IUPAC-recommended nomenclature: hydrogencarbonate) is an intermediate form in the deprotonation of carbonic acid. It is a polyatomic anion with the chemical formula . Bicarbonate serves a crucial bioche ...
into the blood, to act as a pH buffer to neutralize the metabolic acidosis that is often present in these patients. The levels of the components of dialysate are typically prescribed by a nephrologist according to the needs of the individual patient. In peritoneal dialysis, wastes and water are removed from the blood inside the body using the
peritoneum The peritoneum is the serous membrane forming the lining of the abdominal cavity or coelom in amniotes and some invertebrates, such as annelids. It covers most of the intra-abdominal (or coelomic) organs, and is composed of a layer of mesotheli ...
as a natural semipermeable membrane. Waste and excess water move from the blood, across the visceral peritoneum due to its large surface area and into a special dialysis solution, called dialysate, in the peritoneal cavity within the abdomen.


Types

There are three primary and two secondary types of dialysis:
hemodialysis Hemodialysis, American and British English spelling differences#ae and oe, also spelled haemodialysis, or simply ''"'dialysis'"'', is a process of filtering the blood of a person whose kidneys are not working normally. This type of Kidney dialys ...
(primary), peritoneal dialysis (primary), hemofiltration (primary), hemodiafiltration (secondary) and intestinal dialysis (secondary).


Hemodialysis

In
hemodialysis Hemodialysis, American and British English spelling differences#ae and oe, also spelled haemodialysis, or simply ''"'dialysis'"'', is a process of filtering the blood of a person whose kidneys are not working normally. This type of Kidney dialys ...
, the patient's blood is pumped through the blood compartment of a dialyzer, exposing it to a partially permeable membrane. The dialyzer is composed of thousands of tiny hollow
synthetic fiber Synthetic fibers or synthetic fibres (in British English; see spelling differences) are fibers made by humans through chemical synthesis, as opposed to natural fibers that are directly derived from living organisms, such as plants like cott ...
s. The fiber wall acts as the semipermeable membrane. Blood flows through the fibers, dialysis solution flows around the outside of the fibers, and water and wastes move between these two solutions. The cleansed blood is then returned via the circuit back to the body. Ultrafiltration occurs by increasing the hydrostatic pressure across the dialyzer membrane. This usually is done by applying a negative pressure to the dialysate compartment of the dialyzer. This pressure gradient causes water and dissolved solutes to move from blood to dialysate and allows the removal of several litres of excess fluid during a typical 4-hour treatment. In the United States, hemodialysis treatments are typically given in a dialysis center three times per week (due in the United States to Medicare reimbursement rules); however, as of 2005 over 2,500 people in the United States are dialyzing at home more frequently for various treatment lengths. Studies have demonstrated the clinical benefits of dialyzing 5 to 7 times a week, for 6 to 8 hours. This type of hemodialysis is usually called ''nocturnal daily hemodialysis'' and a study has shown it provides a significant improvement in both small and large
molecular weight A molecule is a group of two or more atoms that are held together by Force, attractive forces known as chemical bonds; depending on context, the term may or may not include ions that satisfy this criterion. In quantum physics, organic chemi ...
clearance and decreases the need for phosphate binders. These frequent long treatments are often done at home while sleeping, but home dialysis is a flexible modality and schedules can be changed day to day, week to week. In general, studies show that both increased treatment length and frequency are clinically beneficial. Hemo-dialysis was one of the most common procedures performed in U.S. hospitals in 2011, occurring in 909,000 stays (a rate of 29 stays per 10,000 population).


Peritoneal dialysis

In peritoneal dialysis, a sterile solution containing glucose (called dialysate) is run through a tube into the peritoneal cavity, the abdominal body cavity around the
intestine The gastrointestinal tract (GI tract, digestive tract, alimentary canal) is the tract or passageway of the digestive system that leads from the mouth to the anus. The tract is the largest of the body's systems, after the cardiovascular system. T ...
, where the peritoneal membrane acts as a partially permeable membrane. This exchange is repeated 4–5 times per day; automatic systems can run more frequent exchange cycles overnight. Peritoneal dialysis is less efficient than hemodialysis, but because it is carried out for a longer period of time the net effect in terms of removal of waste products and of salt and water are similar to hemodialysis. Peritoneal dialysis is carried out at home by the patient, often without help. This frees patients from the routine of having to go to a dialysis clinic on a fixed schedule multiple times per week. Peritoneal dialysis can be performed with little to no specialized equipment (other than bags of fresh dialysate).


Hemofiltration

Hemofiltration is a similar treatment to hemodialysis, but it makes use of a different principle. The blood is pumped through a dialyzer or "hemofilter" as in dialysis, but no dialysate is used. A pressure gradient is applied; as a result, water moves across the very permeable membrane rapidly, "dragging" along with it many dissolved substances, including ones with large molecular weights, which are not cleared as well by hemodialysis. Salts and water lost from the blood during this process are replaced with a "substitution fluid" that is infused into the extracorporeal circuit during the treatment.


Hemodiafiltration

Hemodiafiltration is a combination between hemodialysis and hemofiltration, thus used to purify the blood from toxins when the kidney is not working normally and also used to treat
acute kidney injury Acute kidney injury (AKI), previously called acute renal failure (ARF), is a sudden decrease in renal function, kidney function that develops within seven days, as shown by an increase in serum creatinine or a decrease in urine output, or both. ...
(AKI).


Intestinal dialysis

In intestinal dialysis, the diet is supplemented with soluble fibres such as acacia fibre, which is digested by bacteria in the colon. This bacterial growth increases the amount of nitrogen that is eliminated in fecal waste. An alternative approach utilizes the ingestion of 1 to 1.5 liters of non-absorbable solutions of
polyethylene glycol Polyethylene glycol (PEG; ) is a polyether compound derived from petroleum with many applications, from industrial manufacturing to medicine. PEG is also known as polyethylene oxide (PEO) or polyoxyethylene (POE), depending on its molecular wei ...
or
mannitol Mannitol is a type of sugar alcohol used as a sweetener and medication. It is used as a low calorie sweetener as it is poorly absorbed by the intestines. As a medication, it is used to decrease pressure in the eyes, as in glaucoma, and to l ...
every fourth hour.


Indications

The decision to initiate dialysis or hemofiltration in patients with
kidney failure Kidney failure, also known as renal failure or end-stage renal disease (ESRD), is a medical condition in which the kidneys can no longer adequately filter waste products from the blood, functioning at less than 15% of normal levels. Kidney fa ...
depends on several factors. These can be divided into acute or chronic indications. Depression and kidney failure symptoms can be similar to each other. It is important that there is open communication between a dialysis team and the patient. Open communication will allow giving a better quality of life. Knowing the patients' needs will allow the dialysis team to provide more options like: changes in dialysis type like home dialysis for patients to be able to be more active or changes in eating habits to avoid unnecessary waste products.


Acute indications

Indications for dialysis in a patient with
acute kidney injury Acute kidney injury (AKI), previously called acute renal failure (ARF), is a sudden decrease in renal function, kidney function that develops within seven days, as shown by an increase in serum creatinine or a decrease in urine output, or both. ...
are summarized with the vowel mnemonic of "AEIOU": # Acidemia from metabolic acidosis in situations in which correction with
sodium bicarbonate Sodium bicarbonate ( IUPAC name: sodium hydrogencarbonate), commonly known as baking soda or bicarbonate of soda (or simply “bicarb” especially in the UK) is a chemical compound with the formula NaHCO3. It is a salt composed of a sodium cat ...
is impractical or may result in fluid overload. #
Electrolyte An electrolyte is a substance that conducts electricity through the movement of ions, but not through the movement of electrons. This includes most soluble Salt (chemistry), salts, acids, and Base (chemistry), bases, dissolved in a polar solven ...
abnormality, such as severe
hyperkalemia Hyperkalemia is an elevated level of potassium (K+) in the blood. Normal potassium levels are between 3.5 and 5.0 mmol/L (3.5 and 5.0 mEq/L) with levels above 5.5mmol/L defined as hyperkalemia. Typically hyperkalemia does not cause symptoms. Oc ...
, especially when combined with AKI. # Intoxication, that is, acute poisoning with a dialyzable substance. These substances can be represented by the mnemonic SLIME:
salicylic acid Salicylic acid is an organic compound with the formula HOC6H4COOH. A colorless (or white), bitter-tasting solid, it is a precursor to and a active metabolite, metabolite of acetylsalicylic acid (aspirin). It is a plant hormone, and has been lis ...
,
lithium Lithium (from , , ) is a chemical element; it has chemical symbol, symbol Li and atomic number 3. It is a soft, silvery-white alkali metal. Under standard temperature and pressure, standard conditions, it is the least dense metal and the ...
,
isopropanol Isopropyl alcohol (IUPAC name propan-2-ol and also called isopropanol or 2-propanol) is a colorless, flammable, organic compound with a pungent alcoholic odor. Isopropyl alcohol, an organic polar molecule, is miscible in water, ethanol, an ...
,
magnesium Magnesium is a chemical element; it has Symbol (chemistry), symbol Mg and atomic number 12. It is a shiny gray metal having a low density, low melting point and high chemical reactivity. Like the other alkaline earth metals (group 2 ...
-containing laxatives and
ethylene glycol Ethylene glycol ( IUPAC name: ethane-1,2-diol) is an organic compound (a vicinal diol) with the formula . It is mainly used for two purposes: as a raw material in the manufacture of polyester fibers and for antifreeze formulations. It is an odo ...
. # Overload of fluid not expected to respond to treatment with diuretics #
Uremia Uremia is the condition of having high levels of urea in the blood. Urea is one of the primary components of urine. It can be defined as an excess in the blood of amino acid and protein metabolism end products, such as urea and creatinine, which ...
complications, such as
pericarditis Pericarditis () is inflammation of the pericardium, the fibrous sac surrounding the heart. Symptoms typically include sudden onset of sharp chest pain, which may also be felt in the shoulders, neck, or back. The pain is typically less severe whe ...
,
encephalopathy Encephalopathy (; ) means any disorder or disease of the brain, especially chronic degenerative conditions. In modern usage, encephalopathy does not refer to a single disease, but rather to a syndrome of overall brain dysfunction; this syndrome ...
, or
gastrointestinal bleeding Gastrointestinal bleeding (GI bleed), also called gastrointestinal hemorrhage (GIB), is all forms of bleeding in the gastrointestinal tract, from the mouth to the rectum. When there is significant blood loss over a short time, symptoms may includ ...
.


Chronic indications

Chronic dialysis may be indicated when a patient has symptomatic kidney failure and low
glomerular filtration rate Renal functions include maintaining an acid–base balance; regulating fluid balance; regulating sodium, potassium, and other electrolytes; clearance (medicine), clearing toxins; absorption of glucose, amino acids, and other small molecules; reg ...
(GFR < 15 mL/min). Between 1996 and 2008, there was a trend to initiate dialysis at progressively higher estimated GFR, eGFR. A review of the evidence shows no benefit or potential harm with early dialysis initiation, which has been defined by start of dialysis at an estimated GFR of greater than 10 ml/min/1.732. Observational data from large registries of dialysis patients suggests that early start of dialysis may be harmful. The most recent published guidelines from Canada, for when to initiate dialysis, recommend an intent to defer dialysis until a patient has definite kidney failure symptoms, which may occur at an estimated GFR of 5–9 ml/min/1.732.


Impact


Effectiveness

Even though it is not a cure for kidney failure, dialysis is a very effective treatment. Survival rates of kidney failure are generally longer with dialysis than without (having only conservative kidney management). However, from the age of 80 and in elderly patients with comorbidities there is no difference in survival between the two groups.


Quality of life

Dialysis is an intensive treatment that has a serious impact on those treated with it. Being on dialysis usually leads to a poor
quality of life Quality of life (QOL) is defined by the World Health Organization as "an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards ...
. However, there are strategies that can make it more tolerable. Receiving dialysis at home might improve people's quality of life and autonomy.


Scheduling and adherence

Dialysis is typically on a regular schedule of three times a week. Given that dialysis patients have little or no capacity to filtrate solutes and regulate their fluid volume due to kidney dysfunction, missing dialysis is potentially lethal. These patients can be hyperkalaemic leading to cardiac dysrhythmias and potential
cardiac arrest Cardiac arrest (also known as sudden cardiac arrest CA is when the heart suddenly and unexpectedly stops beating. When the heart stops beating, blood cannot properly Circulatory system, circulate around the body and the blood flow to the ...
, as well as fluid in the alveoli of their lungs which can impair breathing. Some medications can be used in the short term to decrease serum potassium and stabilise the cardiac muscle so as to facilitate stabilisation of acute patients in the setting of missed dialysis.
Salbutamol Salbutamol, also known as albuterol and sold under the brand name Ventolin among others, is a medication that opens up the medium and large airways in the lungs. It is a short-acting β2 adrenergic receptor agonist that causes relaxation of ...
and
insulin Insulin (, from Latin ''insula'', 'island') is a peptide hormone produced by beta cells of the pancreatic islets encoded in humans by the insulin (''INS)'' gene. It is the main Anabolism, anabolic hormone of the body. It regulates the metabol ...
can decrease serum potassium by up to 1.0mmol/L each by shifting potassium from the extracellular space into the intracellular spaces within skeletal muscle cells, and calcium gluconate is used to stabilise the myocardium in hyperkalaemic patients, in an attempt to reduce the likelihood of lethal arrhythmias arising from a high serum potassium.


Survival without dialysis

People who decide against dialysis treatment when reaching end-stage chronic kidney disease could survive several years and experience improvements in their mental well-being in addition to sustained physical well-being and overall quality of life until late in their illness course. However, use of acute care services in these cases is common and intensity of end-of-life care is highly variable among people opting out of dialysis.C. K. Liu, M. Kurella Tamura: ''Conservative Care for Kidney Failure-The Other Side of the Coin.'' In: ''JAMA network open.'' Band 5, Nummer 3, März 2022, S. e222252, , PMID 35285925.


Cost

The average annual total cost per dialysis patient varies between countries, for example in South Korea 19,812 USD, in New Zealand 26,479 USD and in Netherlands 89,958 USD, according to an 2021 article.


Pediatric dialysis

Over the past 20 years, children have benefited from major improvements in both technology and clinical management of dialysis.
Morbidity A disease is a particular abnormal condition that adversely affects the structure or function of all or part of an organism and is not immediately due to any external injury. Diseases are often known to be medical conditions that are asso ...
during dialysis sessions has decreased with seizures being exceptional and hypotensive episodes rare. Pain and discomfort have been reduced with the use of chronic internal jugular venous catheters and anesthetic creams for fistula puncture. Non-invasive technologies to assess patient target dry weight and access flow can significantly reduce patient morbidity and health care costs. Mortality in paediatric and young adult patients on chronic hemodialysis is associated with multifactorial markers of nutrition,
inflammation Inflammation (from ) is part of the biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. The five cardinal signs are heat, pain, redness, swelling, and loss of function (Latin ''calor'', '' ...
, anaemia and dialysis dose, which highlights the importance of multimodal intervention strategies besides adequate hemodialysis treatment as determined by Kt/V alone. Biocompatible
synthetic membranes Synthetic may refer to: Science * Synthetic biology * Synthetic chemical or compound, produced by the process of chemical synthesis * Synthetic elements, chemical elements that are not naturally found on Earth and therefore have to be created in ...
, specific small size material dialyzers and new low extra-corporeal volume tubing have been developed for young infants. Arterial and venous tubing length is made of minimum length and diameter, a <80 ml to <110 ml volume tubing is designed for pediatric patients and a >130 to <224 ml tubing are for adult patients, regardless of blood pump segment size, which can be of 6.4 mm for normal dialysis or 8.0mm for high flux dialysis in all patients. All dialysis machine manufacturers design their machine to do the pediatric dialysis. In pediatric patients, the pump speed should be kept at low side, according to patient blood output capacity, and the clotting with heparin dose should be carefully monitored. The high flux dialysis (see below) is not recommended for pediatric patients. In children,
hemodialysis Hemodialysis, American and British English spelling differences#ae and oe, also spelled haemodialysis, or simply ''"'dialysis'"'', is a process of filtering the blood of a person whose kidneys are not working normally. This type of Kidney dialys ...
must be individualized and viewed as an "integrated therapy" that considers their long-term exposure to chronic renal failure treatment. Dialysis is seen only as a temporary measure for children compared with renal transplantation because this enables the best chance of rehabilitation in terms of educational and psychosocial functioning. Long-term chronic dialysis, however, the highest standards should be applied to these children to preserve their future "cardiovascular life"—which might include more dialysis time and on-line hemodiafiltration online hdf with synthetic high flux membranes with the surface area of 0.2 m2 to 0.8 m2 and blood tubing lines with the low volume yet large blood pump segment of 6.4/8.0 mm, if we are able to improve on the rather restricted concept of small-solute urea dialysis clearance.


Dialyzable substances


Characteristics

Dialyzable substances—substances removable with dialysis—have these properties: # Low
molecular mass The molecular mass () is the mass of a given molecule, often expressed in units of daltons (Da). Different molecules of the same compound may have different molecular masses because they contain different isotopes of an element. The derived quan ...
# High water solubility # Low protein binding capacity # Prolonged elimination (long
half-life Half-life is a mathematical and scientific description of exponential or gradual decay. Half-life, half life or halflife may also refer to: Film * Half-Life (film), ''Half-Life'' (film), a 2008 independent film by Jennifer Phang * ''Half Life: ...
) # Small volume of distribution


Substances

*
Ethylene glycol Ethylene glycol ( IUPAC name: ethane-1,2-diol) is an organic compound (a vicinal diol) with the formula . It is mainly used for two purposes: as a raw material in the manufacture of polyester fibers and for antifreeze formulations. It is an odo ...
* Procainamide *
Methanol Methanol (also called methyl alcohol and wood spirit, amongst other names) is an organic chemical compound and the simplest aliphatic Alcohol (chemistry), alcohol, with the chemical formula (a methyl group linked to a hydroxyl group, often ab ...
*
Isopropyl alcohol Isopropyl alcohol (IUPAC name propan-2-ol and also called isopropanol or 2-propanol) is a colorless, flammable, organic compound with a pungent alcoholic odor. Isopropyl alcohol, an organic polar molecule, is miscible in water, ethanol, an ...
* Barbiturates *
Lithium Lithium (from , , ) is a chemical element; it has chemical symbol, symbol Li and atomic number 3. It is a soft, silvery-white alkali metal. Under standard temperature and pressure, standard conditions, it is the least dense metal and the ...
* Bromide * Sotalol *
Chloral hydrate Chloral hydrate is a geminal diol with the formula . It was first used as a sedative and hypnotic in Germany in the 1870s. Over time it was replaced by safer and more effective alternatives but it remained in use in the United States until at ...
*
Ethanol Ethanol (also called ethyl alcohol, grain alcohol, drinking alcohol, or simply alcohol) is an organic compound with the chemical formula . It is an Alcohol (chemistry), alcohol, with its formula also written as , or EtOH, where Et is the ps ...
*
Acetone Acetone (2-propanone or dimethyl ketone) is an organic compound with the chemical formula, formula . It is the simplest and smallest ketone (). It is a colorless, highly Volatile organic compound, volatile, and flammable liquid with a charact ...
*
Atenolol Atenolol is a beta blocker medication primarily used to treat high blood pressure and angina, heart-associated chest pain. Although used to treat high blood pressure, it does not seem to improve mortality rate, mortality in those with the condi ...
* Theophylline * Salicylates * Baclofen


Dialysis in different countries


United Kingdom

The
National Health Service The National Health Service (NHS) is the term for the publicly funded health care, publicly funded healthcare systems of the United Kingdom: the National Health Service (England), NHS Scotland, NHS Wales, and Health and Social Care (Northern ...
provides dialysis in the United Kingdom. In 2022, there were more than 30,000 people on dialysis in the UK. For people who need to travel to dialysis centres, patient transport services are generally provided without charge. Cornwall Clinical Commissioning Group proposed to restrict this provision to people who did not have specific medical or financial reasons in 2018 but changed their minds after a campaign led by Kidney Care UK and decided to fund transport for people requiring dialysis three times a week for a minimum or six times a month for a minimum of three months.


Home dialysis

UK clinical guidelines recommend offering people a choice regarding where they get their dialysis. Research in the UK found that receiving dialysis at home can lead to better quality of life and is less costly than receiving dialysis in hospital. However, many people in the UK prefer to receive dialysis in hospital: In 2022, only 1 in 6 chose receiving it at home. There are various reasons why people do not choose home dialysis. Among these are preferring hospitals as a way of getting regular social contact, being concerned about necessary changes to their homes and their family members becoming carers. Other reasons include a lack of motivation, doubting abilities for self-managed treatment, and not having suitable housing or support at home. Hospital dialysis is also often presented as the norm by healthcare professionals. Encouraging people to have dialysis at home could reduce the impact of dialysis on people's social and professional lives. Some ways to help are offering peer support from other people on home dialysis, better education materials, and professionals being more familiar with home dialysis and its impact. Choosing home dialysis is more likely at kidney centers which have better organisational culture, leadership and attitude.


United States

Since 1972, insurance companies in the United States have covered the cost of dialysis and transplants for all citizens. By 2014, more than 460,000 Americans were undergoing treatment, the costs of which amount to six percent of the entire Medicare budget. Kidney disease is the ninth leading cause of death, and the U.S. has one of the highest mortality rates for dialysis care in the industrialized world. The rate of patients getting kidney transplants has been lower than expected. These outcomes have been blamed on a new for-profit dialysis industry responding to government payment policies. A 1999 study concluded that "patients treated in for-profit dialysis facilities have higher mortality rates and are less likely to be placed on the waiting list for a renal transplant than are patients who are treated in not-for-profit facilities", possibly because transplantation removes a constant stream of revenue from the facility. The insurance industry has complained about kickbacks and problematic relationships between charities and providers.


China

The
Government of China The government of the People's Republic of China is based on a system of people's congress within the parameters of a unitary communist state, in which the ruling Chinese Communist Party (CCP) enacts its policies through people's congresses. ...
provides the funding for dialysis treatment. There is a challenge to reach everyone who needs dialysis treatment because of the unequal distribution of health care resources and dialysis centers. There are 395,121 individuals who receive
hemodialysis Hemodialysis, American and British English spelling differences#ae and oe, also spelled haemodialysis, or simply ''"'dialysis'"'', is a process of filtering the blood of a person whose kidneys are not working normally. This type of Kidney dialys ...
or peritoneal dialysis in China per year. The percentage of the Chinese population with
Chronic Kidney Disease Chronic kidney disease (CKD) is a type of long-term kidney disease, defined by the sustained presence of abnormal kidney function and/or abnormal kidney structure. To meet criteria for CKD, the abnormalities must be present for at least three mo ...
is 10.8%. The Chinese Government is trying to increase the amount of peritoneal dialysis taking place to meet the needs of the nation's individuals with Chronic Kidney Disease.


Australia

Dialysis is provided without cost to all patients through Medicare, with 75% of all dialysis being administered as haemodialysis to patients three times per week in a dialysis facility. The
Northern Territory The Northern Territory (abbreviated as NT; known formally as the Northern Territory of Australia and informally as the Territory) is an states and territories of Australia, Australian internal territory in the central and central-northern regi ...
has the highest incidence rate per population of haemodialysis, with
Indigenous Australians Indigenous Australians are people with familial heritage from, or recognised membership of, the various ethnic groups living within the territory of contemporary Australia prior to History of Australia (1788–1850), British colonisation. The ...
having higher rates of Chronic Kidney Disease and lower rates of functional kidney transplants than the broader population. The remote Central Australian town of
Alice Springs Alice Springs () is a town in the Northern Territory, Australia; it is the third-largest settlement after Darwin, Northern Territory, Darwin and Palmerston, Northern Territory, Palmerston. The name Alice Springs was given by surveyor William ...
, despite having a population of approximately 25000, has the largest dialysis unit in the Southern Hemisphere. Many people must move to Alice Springs from remote Indigenous communities to access health services such as haemodialysis, which results in housing shortages, overcrowding, and poor living conditions.


History

In 1913, Leonard Rowntree and John Jacob Abel of Johns Hopkins Hospital developed the first dialysis system which they successfully tested in animals. A Dutch doctor, Willem Johan Kolff, constructed the first working dialyzer in 1943 during the
Nazi occupation of the Netherlands Despite Dutch neutrality, Nazi Germany invaded the Netherlands on 10 May 1940 as part of '' Fall Gelb'' (Case Yellow). On 15 May 1940, one day after the bombing of Rotterdam, the Dutch forces surrendered. The Dutch government and the royal f ...
. Due to the scarcity of available resources, Kolff had to improvise and build the initial machine using sausage casings, beverage cans, a
washing machine A washing machine (laundry machine, clothes washer, washer, or simply wash) is a machine designed to laundry, launder clothing. The term is mostly applied to machines that use water. Other ways of doing laundry include dry cleaning (which uses ...
and various other items that were available at the time. Over the following two years (1944–1945), Kolff used his machine to treat 16 patients with
acute kidney failure Acute may refer to: Language * Acute accent, a diacritic used in many modern written languages * Acute (phonetic), a perceptual classification Science and mathematics * Acute angle ** Acute triangle ** Acute, a leaf shape in the glossary of leaf m ...
, but the results were unsuccessful. Then, in 1945, a 67-year-old comatose woman regained consciousness following 11 hours of hemodialysis with the dialyzer and lived for another seven years before dying from an unrelated condition. She was the first-ever patient successfully treated with dialysis. Gordon Murray of the
University of Toronto The University of Toronto (UToronto or U of T) is a public university, public research university whose main campus is located on the grounds that surround Queen's Park (Toronto), Queen's Park in Toronto, Ontario, Canada. It was founded by ...
independently developed a dialysis machine in 1945. Unlike Kolff's rotating drum, Murray's machine used fixed flat plates, more like modern designs. Like Kolff, Murray's initial success was in patients with acute renal failure. Nils Alwall of
Lund University Lund University () is a Public university, public research university in Sweden and one of Northern Europe's oldest universities. The university is located in the city of Lund in the Swedish province of Scania. The university was officially foun ...
in Sweden modified a similar construction to the Kolff dialysis machine by enclosing it inside a stainless steel canister. This allowed the removal of fluids, by applying a negative pressure to the outside canister, thus making it the first truly practical device for hemodialysis. Alwall treated his first patient in acute kidney failure on 3 September 1946.


See also

*
Thomas Graham (chemist) Thomas Graham (20 December 1805 – 11 September 1869) was a Scottish chemist known for his pioneering work in dialysis and the diffusion of gases. He is regarded as one of the founders of colloid chemistry. Life Graham was born in Glasgow, S ...
, the founder of dialysis and father of colloid chemistry * Dialysis tubing * List of US dialysis providers * Vitamin and mineral management for dialysis *
Nephrology Nephrology is a specialty for both adult internal medicine and pediatric medicine that concerns the study of the kidneys, specifically normal kidney function (renal physiology) and kidney disease (renal pathophysiology), the preservation of kid ...
* Hepatorenal syndrome


Notes


References


Bibliography

* * * *


Further reading

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External links


"Machine Cleans Blood While You Wait"
��1950 article on early use of dialysis machine at Bellevue Hospital New York City—an example of how complex and large early dialysis machines were
Home Dialysis Museum
��History and pictures of dialysis machines through time
Introduction to Dialysis Machines
��Tutorial describing the main subfunctions of dialysis systems.
"First Nations man conducts own dialysis treatments to avoid move to the city"
��
CBC News CBC News is the division of the Canadian Broadcasting Corporation responsible for the news gathering and production of news programs on the corporation's English-language operations, namely CBC Television, CBC Radio, CBC News Network, and CBC ...
(November 30, 2016) {{Authority control Biochemical separation processes Detoxification Medical mnemonics Membrane technology