AN UNDERSTANDING OF THE NORMAL KIDNEYS

There are three prime functions:

1. Excretion of the waste products of nitrogen metabolism

2. Regulation of water and electrolyte balance
3. Endocrine and metabolic functions

• Production of renin, which affect sodium,fluids volume, and blood pressure.

• Production of erythropoetin, which control red cell production in the bone
marrow.
• Production of prostaglandins.

The normal kidney is a receptor site for several hormone produced by order organs.

• Anti-diuretic hormone (ADH) produced by the pituitary glands, reduces the

excretion of water
• Aldosterone , produced by adrenal cortex, promotes sodium retention and
enhances secretion of potassium and hydrogen ion.
• Parathyroid hormone, which increase phosphorus and bicarbonate excretion and
stimulates conversion of vit D to the active 1,25 vit D form.

The nephron is the functional unit of the kidney. There are over a million such units in
each of the two kidneys.Each nephron has two main parts, the glomerulus and the
tubule.The glomerulus filters water and solutes of molecular weight less than 68,000
daltons (albumin). Such solutes include electrolytes and urea, creatinine, uric
acid,glucose,amino acids, and low molecular weight proteins.This fluid is the glomerular
filtrate, and its rate of production is the glomerular filtration rate (GFR). A man of
average size has about 180 L of filtrate per day, or 100-120 ml/min. 99 % of this filtrate
is reabsorbed in the tubules.

The functions of the tubules are reabsorption and secretion, of the 180 L of glomerular
filtrate each day, about 2 L remain as the final urine. The tubules conserve water and
electrolytes by returning them to the blood.
KIDNEY FAILURE AND TREATMENT OPTIONS IN RRT

Kidney Failure can be divided into:

A. Acute Renal Failure (ARF)/Acute Kidney Injury (AKI )

B. Chronic Renal Failure (CRF)/Chronic Kidney Disease (CKD)

A. Common causes of acute renal failure:

1. Infection, septicaemia.
2. Major trauma / heavy loss of blood.
3. Urinary tract obtruction
4. Drugs induced eg. Pain killer, antibiotics
5. Intrinsic kidney disease.

Note:
Acute renal failure is a sudden loss of kidney function is potentially reversible.
Stages of ARF/AKI
1. Initiating stage - decreased in urine volume
2. Oliguria stage –stage between 5 to 2 weeeks and decreased in urine
production may lead to hyperkalemia
3. Diuretic stage-last from 1 to 2 weeks before become normal
4. Healing stage- renal function if above GFR increase 20 to 40 %

B. Common causes of chronic renal failure:

1. Long standing diabetis mellitus ( Diabetic nephropathy)

2. Inflamation of the kidney (Glomerulonephritis)
3. Infections of the kidney ( Pyelonephritis )
4. Heriditary disease of the kidney ( Polycystic kidney )
5. Long standing uncontrolled high blood pressure ( Hypertensive
nephropathy )
6. Chronic analgesic abuse
7. Obstructive uropathy eg. Renal calculi.

Note:
Chronic renal failure is progressive and irreversible.
Stages in CRF/CKD
1. Stage 1 – GFR above 90% - pts is asymptomatic until GFR least 80%
2. Stage 2 – GFR - reduced to 89 – 70% - mild symptom of azotemia, polyuria
and anaemia
3. Stage 3 – GFR reduced to 69 – 30%- elevated of blood urea, sr creatinine,
hyperphostemia and hypocalcaemia
4. Stage 4 – GFR reduced to 29 – 15% - Preparation for RRT/Vascular acess
5. Stage 5 – GFR below 15 % ( ESRF ) – Permanent RRT
END STAGE RENAL FAILURE ( ESRF)

The level of function of kidneys is measured by its glomerular filtration

rate(GFR).When GFR drops below 5-10% of normal,the patient is said to be in
ESRD. The patient has to choose one of the options of renal replacement therapy
(RRT) to maintain life.The incidence of ESRF is about 100-140 new
patients/million population/year.

Signs and symptom of ESRF include:

1. Nausea ang vomiting

2. Breathlessness.
3. Pallor - anemia
4. Oedema – facial, ascites, swelling of ankle.
5. Tiredness and lethargy.
6. Raised blood pressure.
7. Uraemic skin – sallow discoloration.

Treatment options for ESRF.

1. RENAL TRANSPLANTATION.

The following transplantation is performed in Malaysia:-

Living related renal transplant where one member of the family donata one of
their kidneys.

Emotional related renal transplant where the spouse donate one of their kidney.

Cadaveric transplant where kidneys are removed from a patient who is

pronounced “ brain death” and prior consent from family is obtained.

In Malaysia the renal transplant program started in 1975. Blood grouping,tissue

matching, and many other routine blood and x-ray investigations are done prior to
transplantation.Patients have to be on long term medications after transplantion to
suppress immune response to the transplant kidney.
2. HEMODIALYSIS

This is a process of removing waste products and excess fluid from the blood,
using an artificial “ kidney” also called a dialyser and an artificial kidney
machine also called a hemodialysis machine. This treatment is done three times
aweek , usually four hours per session, for the rest of the patient’s life or until a
renal transplant is done.
Hemo – means blood, Dialysis indicates some form of filtration. Hemodialysis is
an exchange that takes place between a patient’s blood ang a solution termed
dialysate a cross a semipermeable membrane.This exchange removes toxins and
water from the patient’s blood and correct electrolyte imbalances to near
normal.The basic principles involved in hemodialysis include the following:
1. Diffusion
2. Osmosis
3. Ultrafiltration
4. Convection

Diffusion
Molecules in solution are in constant motion and spread uniformly through-out
the solution.The rate of spread depends upon the concentration, size and ionic
status of the molecules in motion. Diffusion can be defined as a flow of solutes
from an area of higher concentration to a lower solute concentration a cross a
semipermeable membrane.

Osmosis
This is defined as the movement of water through a membrane from a higher to a
lower water concentration area. The substance dissolved in water is known as
solute, the water as solvent and the both together is the solution. Different solute
content creates different concentrations of water.

Ultrafiltration
This is the movement of fluid through a membrane caused by a pressure gradient.
In dialysis , both positive and negative pressures on the blood and dialysate sides
contribute to fluid removal.

Convection.
The movement of solutes with a water flow, also known as a “ solvent drag”.In
other words during fluid removal, there is bound to be a small amount of
membrane permeable solute loss together with the ultrafiltrate.

During hemodialysis, solutes such as urea, creatinine, uric acid, phosphates,

electrolytes etc are removed by both diffusion and convection while water is
removed by both osmosis and ultrafiltration.
3. CONTINUOUS AMBULATORY PERITONEAL DIALYSIS ( CAPD )

CAPD uses the same principle of diffusion and is continuous and takes place
within the patients peritoneal cavity.Patient does four exchanges each day and is
more mobile compared to hemodialysis treatment. Each exchange or “ cycle ” has
three phase:
• A “ drain ” phase where the used dialysate is drained from the
peritoneal cavity
• A “ fill ” phase where fresh dialysate is introduced into the peritoneal
cavity.
• A “ dwell ” phase where the fluid remains in the peritoneal cavity, and
during which time the majority of the fluid and solute removal
( dialysis) occur.

The drain an fill phases are undertaken in sequence with the dwell phase
and the whole procedure takes about 20 – 30 minutes. With successful upgrading
of CAPD systems, many patients are able to be safely put onto this program and
there is bound to be an increase in number of new patients being treated on
CAPD.

Ultrafiltration.
Fluid is removed from the blood by ultrafiltration. To attract water the dialysis
fluid contains glucose. The more glucose in the dialysate ( high osmolarity ), the
more fluid can be removed.
During dialysis the dialysate is diluted, and glucose is consumed in the body.
Therefore ultrafiltration ceases, and after some time fluid moves back into the
blood.

Diffusion.
Waste products are removed from the blood by diffusion. Diffusion through a
membrane is called dialysis.
Waste products in the blood move to the cleaner dialysis fluid because of the
difference in concentration.When the concentration of waste products is about the
same in blood and dialysate, no more net transport takes place. The dialysate must
then be exchanged.
 DIALYSATE USED IN HEMODIALYSIS

The function of the dialysate is to correct the the chemical composition of the ureamic
blood to normal physiological level. The means:

- to remove waste products

- to normalize the electrolytes by removing some salt
- to normalize the ph by adding some buffer
- to maintain all vital substances.

Types of Dialysate concentrates.

There are usually five compounds used in the preparation of concentrate. They include
sodium chloride, sodium bicarbonate or sodium acetate, calcium chloride, potassium
chloride and magnesium chloride.

Bicarbonate Concentrate.

When using bicarbonat in dialysis, two practical issues need special attention. The
precipitation of calcium carbonate must be avoided. This is achieved by separating the
calcium ions from the bicarbonat ions during storage. Thus bicarbonta concentre is
prepared in the form of two components, a “ bicarbonate ” component an an “ acid ”
Component. During mixing the ph should be below 7.3 and this is achieved by the
addition of acetic acid in the “ A ” concentrate. The second problem with bicarbonate
concentrate is tha is an excellent growth medium for certain bacteria and should always
be handled aseptically. Both from a microbiological and a chemical point of view,
bicarbonate concentrates should not be stored once the canisters are opened as stability
will be affected due to liberation of carbon dioxide which acts as a stabilizer.

1. Solution “A” ( indicating acidified ) concentrate contains most of the sodium,

calcium, magnesium, potassium, chloride, and a small amount of acetic acid.
Eg. Sodium – 75.00, Potassium – 1.9, Calcium – 1.25, Magnesium – 0.70,
Chloride – 80.80 and Acetate – 4.00 (mmol/L)

2. Solution “ B ” (indicating bicarbonate ) concentrate contains the sodium

bicarbonate and part of the sodium chloride.
Eg. Sodium – 65.00, Chloride – 26.00 and Bicarbonate – 35.00 ( mmol/L )

In the proportioning system, the “ B ” concentrate is usually diluted partially with water,
the “ A ” concentrate is then proportioned into the mixture just before it goes to the
dialyzer. In the closed system, CO2 cannot bubble off, the reaction between sodium
bicarbonate and acetic acid cannot proceed to completion, and the hydrogen ion content
keeps the calcium in solution.
WATER TREATMENT FOR HEMODIALYSIS

Water is used extensively for making the dialysate required for hemodialysis treatment. A
nomal person drinks between 1.5 – 2 litres of water perday and this amount to about not
more than 15 litres perweek.A patient on hemodialysis is exposed indirectly to about 120
litres of water persession ( Dialysate flow rate 500ml x 60 min x 4 hours ) of dialysis
therapy and this amounts to about 400 litres perweek.

The quality of water used is therefore critical to the preparation of a dialysis fluid. It
should be free of contaminant which maybe present in water include suspended
solid,dissolved organics and inorganics, heavy metals, and trace minerals and
microorganisms which have harmful effects on the health of the patient.

Importance of water treatment.

1. To prevent premature damage to the hydraulic parts in the machine.
2. To facilitate production of dialysate with accurate electrolyte content.
3. To prevent long term side effects of inadequately treated water.

Acceptable water content.

1. Calcium and Magnesium < 0.5 ppm ( parts permillion)
2. Free from chlorine.
3. Free from ions.
4. Bacteria count < 200 cfu/ ml (AAMI Standard ),< 0.25EU/ml (EU Standard)
5. Endotoxin level < 2 EU/ml (AAMI Standard), < 0.25EU/ml (EU Standard)

Water treatment system can divided into three section.

1. Pre – treatment consisting :
1. raw water storage tanks – Size should be 1500 to 2000 litres
2. sediment filter ( Sand filter ) – remove large particle ranging 500 micron
down to 5 micron
3. softener – to avoid the “ hard water syndrome”water softener operate on
this principle: resin beads in the tank are coated with sodium. The high
concentration of sodium replace the calcium and magnesium from the
beads.An adjoining salt tank ( brine tank ) replenishes and regenerates the
softener at night by means of a timers.
4. activated carbon filters – to exhaustion ( chlorine / chloramines
breakthrough)
5. microfilters.- remove intermediate sized particles of 5 – 1 micron in
diameter.
2. Primary treatment involving one or two reverse osmosis (R/O) devices.
3. The Distributing loop for reverse osmosis water supply to both the hemodialysis
stations and reprocessing machines.