Technical Issues in Dialysis

By Alex R. Constantinescu, for the American Society of Nephrology Practicing Nephrologists Advisory Group

What are some of the most important challenges facing nephrologists in prescribing dialysis therapy for their patients? Ever since dialysis therapy has proved to be lifesaving, we have been challenged to decrease the mortality and increase the safety of the procedure (1). Advances in technology have led to increasingly complex equipment, resulting in a steep learning curve for both clinicians and patients alike. Clinicians must evaluate whether the dialysis prescription is actually translating into adequate treatments, and constantly adjust the dose to meet the goals of the Kidney Disease Outcome Quality Initiative (2,3). In addition, we need to be assured that the assessment of dialysis outcomes is based on reliable data and adequate sampling of blood and solutions (4). Patients have to be proficient in certain basic skills for home therapies, both peritoneal dialysis (PD) and hemodialysis (HD), and they must be reassured that backup support is available around the clock at all times (5,6).

What are the most common technical issues encountered during dialysis therapy? Despite efforts to minimize the risks and complications, we face many technical issues, some of which are difficult to overcome. Technical issues may be related first to patient characteristics and then, in short order, access problems, dialysis solutions, drug administration, equipment and operator problems, and other issues not yet well defined (Table 1).

table-commontechissues-dialysis.png

How important is choosing a dialysis modality in minimizing the risk of complications? Choosing a dialysis modality is one of our most challenging first steps (7,8). We are reminded time and again that each patient is unique, especially with respect to vascular anatomy (an important determining factor in longevity of HD access). Not only is vessel caliber a major issue in HD (a real challenge in the smallest of our patients), but also comorbid conditions (i.e., obesity, diabetes, vasculitides) can create technical difficulties from the start. The same holds true for PD in patients with prior abdominal surgical procedures, malnutrition, obesity, or extreme prematurity in infants, to name a few. For patients contemplating home dialysis therapies, those with back pain, arthritis, or amputation may not be able to cannulate vessels, perform connections, or open packages or medication bottles. In essence, they may not be capable of performing their own treatment.

How can dialysis solutions affect the outcome of dialysis therapy? Regarding solutions, the composition is constantly optimized to ensure minimal disruption of the metabolic homeostasis, maximal removal of uremic toxins, and ultrafiltration capabilities. Nevertheless, temperature of the dialysate, conductivity, osmotic pressure, buffer capacity, and electrolyte and dextrose concentrations in both HD and PD solutions are a few of the factors that can affect the success of the dialysis treatment in the short or long term.

Given that drug metabolism is affected by dialysis, what can be done to improve the safety of drug treatment in patients receiving dialysis? Drug administration can be challenging with regard to bioavailability and clearance, especially with respect to the mode of delivery in patients with limited access. Many new drugs have yet to be studied in the dialysis population (with regard to age, body size, dialysis modality, dialyzer size, and clearance) to ensure their safety and their maximal therapeutic effects. Elimination of medication errors and avoidance of patient complications must remain a central focus of our practice (9).

What are the most common equipment and operator issues encountered during dialysis therapy? Programming the treatments into the automated cycler (for PD) or the HD or continuous renal replacement therapy machines has to be made by specialized personnel, requires training, and is still subject to the human factor and to mechanical, electrical, or hardware-software failures. In addition, water treatment systems—reverse osmosis and carbon tanks being the most common—need to be installed when some home HD therapies are desired, and backup plans are needed to anticipate power failure or mechanical failure. Troubleshooting and backup plans are essential in bridging these difficult situations. Architectural alterations and infrastructure setup need to be evaluated and agreed upon before the initiation of home HD. A few attached references deal with these issues in detail (6,7,10).

What are the most common technical issues encountered during dialysis therapy based on the modality chosen? Table 1 depicts a few important technical issues in both HD and PD. These issues have a significant impact on the adequacy of the dialysis dose prescribed, and the problems shown in Table 1 need to be rectified to improve outcomes. The more we learn about the complexity of our patients, the more we realize that there are newer obstacles to overcome. Research and innovations will continue to help pave the way to safer patient care.

Alex R. Constantinescu, MD, is medical director of the Pediatric Nephrology and Hypertension Program at Joe DiMaggio Children’s Hospital in Hollywood, FL.

References

  1. Wathen R, Keshaviah P, Shapiro F. Unsolved technical problems of maintenance dialysis. Clin Nephrol 1978; 9:174–178.
  2. Clinical practice guidelines for hemodialysis adequacy; update 2006. Am J Kidney Dis 2006; 48:S2–S90.
  3. Clinical practice guidelines for peritoneal dialysis adequacy. Am J Kidney Dis 2006; 48:S91–S158.
  4. Mehta AN, Fenves AZ. Hemodialysis adequacy: a review. Dial Transplant 2010; 39:1–3.
  5. Alhomayeed B, Lindsay RM. Technical aspects of home hemodialysis. Saudi J Kidney Dis Transpl 2009; 20:185–191.
  6. Ponson L, Arkouche W, Laville M. Home hemodialysis: the technical overview. A 2010 survey. Nephrol Ther 2012; 8:81–86.
  7. Walters S, Porter C, Brophy PD. Dialysis and pediatric acute kidney injury: choice of renal support modality. Pediatr Nephrol 2009; 24:37–48.
  8. Verrina E, Cappelli V, Perfumo F. Selection of modalities, prescription and technical issues in children on peritoneal dialysis. Pediatr Nephrol 2009; 24:1453–1464.
  9. Barletta JF, et al. Medication errors and patient complications with continuous renal replacement therapy. Pediatr Nephrol 2006; 21:842–845.
  10. Goretti Penido M, editor. Technical Problems in Patients on Hemodialysis, Rijecka, Croatia, Intech Press, 2011.
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What are some of the most important challenges facing nephrologists in prescribing dialysis therapy for their patients? Ever since dialysis therapy has proved to be lifesaving, we have been challenged to decrease the mortality and increase the safety of the procedure (1). Advances in technology have led to increasingly complex equipment, resulting in a steep learning curve for both clinicians and patients alike. Clinicians must evaluate whether the dialysis prescription is actually translating into adequate treatments, and constantly adjust the dose to meet the goals of the Kidney Disease Outcome Quality Initiative (2,3). In addition, we need to be assured that the assessment of dialysis outcomes is based on reliable data and adequate sampling of blood and solutions (4). Patients have to be proficient in certain basic skills for home therapies, both peritoneal dialysis (PD) and hemodialysis (HD), and they must be reassured that backup support is available around the clock at all times (5,6).

What are the most common technical issues encountered during dialysis therapy? Despite efforts to minimize the risks and complications, we face many technical issues, some of which are difficult to overcome. Technical issues may be related first to patient characteristics and then, in short order, access problems, dialysis solutions, drug administration, equipment and operator problems, and other issues not yet well defined (Table 1).

table-commontechissues-dialysis.png

How important is choosing a dialysis modality in minimizing the risk of complications? Choosing a dialysis modality is one of our most challenging first steps (7,8). We are reminded time and again that each patient is unique, especially with respect to vascular anatomy (an important determining factor in longevity of HD access). Not only is vessel caliber a major issue in HD (a real challenge in the smallest of our patients), but also comorbid conditions (i.e., obesity, diabetes, vasculitides) can create technical difficulties from the start. The same holds true for PD in patients with prior abdominal surgical procedures, malnutrition, obesity, or extreme prematurity in infants, to name a few. For patients contemplating home dialysis therapies, those with back pain, arthritis, or amputation may not be able to cannulate vessels, perform connections, or open packages or medication bottles. In essence, they may not be capable of performing their own treatment.

How can dialysis solutions affect the outcome of dialysis therapy? Regarding solutions, the composition is constantly optimized to ensure minimal disruption of the metabolic homeostasis, maximal removal of uremic toxins, and ultrafiltration capabilities. Nevertheless, temperature of the dialysate, conductivity, osmotic pressure, buffer capacity, and electrolyte and dextrose concentrations in both HD and PD solutions are a few of the factors that can affect the success of the dialysis treatment in the short or long term.

Given that drug metabolism is affected by dialysis, what can be done to improve the safety of drug treatment in patients receiving dialysis? Drug administration can be challenging with regard to bioavailability and clearance, especially with respect to the mode of delivery in patients with limited access. Many new drugs have yet to be studied in the dialysis population (with regard to age, body size, dialysis modality, dialyzer size, and clearance) to ensure their safety and their maximal therapeutic effects. Elimination of medication errors and avoidance of patient complications must remain a central focus of our practice (9).

What are the most common equipment and operator issues encountered during dialysis therapy? Programming the treatments into the automated cycler (for PD) or the HD or continuous renal replacement therapy machines has to be made by specialized personnel, requires training, and is still subject to the human factor and to mechanical, electrical, or hardware-software failures. In addition, water treatment systems—reverse osmosis and carbon tanks being the most common—need to be installed when some home HD therapies are desired, and backup plans are needed to anticipate power failure or mechanical failure. Troubleshooting and backup plans are essential in bridging these difficult situations. Architectural alterations and infrastructure setup need to be evaluated and agreed upon before the initiation of home HD. A few attached references deal with these issues in detail (6,7,10).

What are the most common technical issues encountered during dialysis therapy based on the modality chosen? Table 1 depicts a few important technical issues in both HD and PD. These issues have a significant impact on the adequacy of the dialysis dose prescribed, and the problems shown in Table 1 need to be rectified to improve outcomes. The more we learn about the complexity of our patients, the more we realize that there are newer obstacles to overcome. Research and innovations will continue to help pave the way to safer patient care.

Alex R. Constantinescu, MD, is medical director of the Pediatric Nephrology and Hypertension Program at Joe DiMaggio Children’s Hospital in Hollywood, FL.

References

  1. Wathen R, Keshaviah P, Shapiro F. Unsolved technical problems of maintenance dialysis. Clin Nephrol 1978; 9:174–178.
  2. Clinical practice guidelines for hemodialysis adequacy; update 2006. Am J Kidney Dis 2006; 48:S2–S90.
  3. Clinical practice guidelines for peritoneal dialysis adequacy. Am J Kidney Dis 2006; 48:S91–S158.
  4. Mehta AN, Fenves AZ. Hemodialysis adequacy: a review. Dial Transplant 2010; 39:1–3.
  5. Alhomayeed B, Lindsay RM. Technical aspects of home hemodialysis. Saudi J Kidney Dis Transpl 2009; 20:185–191.
  6. Ponson L, Arkouche W, Laville M. Home hemodialysis: the technical overview. A 2010 survey. Nephrol Ther 2012; 8:81–86.
  7. Walters S, Porter C, Brophy PD. Dialysis and pediatric acute kidney injury: choice of renal support modality. Pediatr Nephrol 2009; 24:37–48.
  8. Verrina E, Cappelli V, Perfumo F. Selection of modalities, prescription and technical issues in children on peritoneal dialysis. Pediatr Nephrol 2009; 24:1453–1464.
  9. Barletta JF, et al. Medication errors and patient complications with continuous renal replacement therapy. Pediatr Nephrol 2006; 21:842–845.
  10. Goretti Penido M, editor. Technical Problems in Patients on Hemodialysis, Rijecka, Croatia, Intech Press, 2011.