Composition of Dialysate,Sodium and Ultrafiltration Modeling

Ranjith Kumar InbasekaranB.Sc in Renal Dialysis TechnologyClinical Instructor and Dialysis

TechnologistB N Patel Institute of Paramedical and

Science

Use of DialysateRemove uremic waste material from the blood

but to keep the useful materials in the blood.The restoration of normal electrolyte

concentrations in the blood.Acid base balance.

Composition of DialysateDialysate as it is used today was

patented by Itoh Nobuo of Nikkiso Japan in 1990.

Composition in dialysate after bicarb and acid concentrates mix together in the ratio of 1:1.83:34 parts (Acid: bicarb: water)

Composition of DialysateCompositionAcetate Dialysate

mEq/LBicarb Dialysate mEq/L

Citrate Dialysate mEq/L

Sodium 135-145135-145135-145

Potassium 0-4.00-4.00-4.0

Calcium 2.5-3.52.5-3.52.5-3.5

Magnesium 0.5-1.00.5-1.00.5-1.0

Chloride 100-119100-124100-124

Acetate 35-382-40.3

Citrate--2.4

Bicarbonate 030-3830-38

Dextrose 111111

PCO2 mmHg 40-10040-10040-100

pH 7.1-7.37.1-7.37.1-7.3

Acetate dialysisAdvantages of Acetate concentrate:1.The concentrate is stable during storage and is

not prone for bacterial contamination

2.The delivery systems are simpler and less costly.

Disadvantages of Acetate concentrate:1.The patients serum bicarbonate may decrease

early during dialysis

2.Acetate accumulation contributes to cardiovascular instability

3.Also causes complications such as Nausea, vomiting, post dialysis fatigue, etc.

4.High risk of developing amyloidosis

Bicarb dialysisAdvantages:1.Rapid positive effect on acid base balance

2.No loss of bicarbonate to dialysate

3.More stable blood pressure

Disadvantages:1.Cannot be stored as concentrate in solution

with positive ions such as calcium and magnesium or it will precipitate

2.Powdered bicarbonate once mixed has limited shelf life (Should be used within 24 hours)

3.As bicarbonate solution is not bactericidal disinfection of the container is very important 

Citrate DialysisAdvantagesAnticoagulation without heparin those who

with allergy to heparin or no effect of heparinDisadvantagesRisk of Hypocalcemia

Complications During Hemodialysis

Possible complications preventable by modelingHypotensionMuscle CrampsIntradialytic/Post dialytic hypertensionInterdialytic hypertensionFluid overloadHead ache (Hypertension induced)Nausea, Vomiting (Hypotension induced)

Purpose of Using ProfilesTo Prevent hypovolemia To counter act rapid osmotic

changes Sodium and water balance free of

complicationsTo eliminate or reduce the

frequency and severity of complications.

MethodsIsolated UltrafiltrationExtended Duration (Slow Continuous UF)Ultrafiltration and Sodium profiling

Standard Hemodialysis Water Movement

Movement of Water During Iso UF

Extended Time (Slow C UF)The increase in time cause dicrease in

ultrafiltration rate, thus there will be a requirement of slow refilling rate from intracellular compartment to extracellular compartmnt.

Profiling/ModelingA Machine controlled Conductivity change is

called Sodium profilingA Machine controlled Ultrafiltration rate is

called Ultrafiltration profiling

Types of Ultrafiltration and Sodium Modeling1. Standard (Non Altered/Linear)2. Linear decreasing 3. Increasing4. Step down5. Alternating6. Step down and Alternating mixed

These types for both Sodium and Ultrafiltration, each of them can be applied separately or with the other.

1. Standard / Linear

2. Linear Decreasing Profile

3. Increasing Profile

4. Step down profiles

5. Alternating

6. Step down and Alternating Mixed

Machines with Sodium and UF profiling facility

CompanyModelSodium Profile

UF Profile

Baxter1550YesYes

Baxter550YesYes

CobeCentry-3YesNo

Fresenius4008 BYesYes

Fresenius4008 SYesYes

Fresenius2008 DYesYes

Fresenius2008 EYesYes

GambroAK 96YesYes

Hospal MonitralYesYes

In Fresenius 4008 S

Principles of UF ProfilingFluid gain between dialysis session is mainly

stored in the interstitial spaceFluid withdrawn from the Vascular space

during UF refills from interstitial space Rate of refilling is likely to be at its maximum

at the beginning of the HD session – this is the basis of UF profiles

UF Profiles seek to optimize the patient’s response to UF to prevent hypotension and symptoms induced by hypovolemia

TO FIX UF Profile In MachineSteps:1.Go to UF Menu2.Fix the ultrafiltration goal and time3.Rate need not be changed by us4.Next select any one of the Profiles from 6 pre

programmed profiles5.Confirm & On the UF (If Na+ Profile is

Required Set it First and Switch on the UF)

To Fix UF Profile In Machine

To Set Sodium ProfileSteps:1.Go to Dialysate menu2.Dilution is fixed for our Part A&B System3.Base Na+ is fixed and needs no change4.Prescribed Na+ can be adjusted from 132-

138 mmol/L (Sodium at end of the dialysis)5.Bicarbonate as prescribed by Nephrologist

±8, if no orders then 0

To Set Sodium Profile6. Temperature and flow are preset to 37 C

and 500 ml respectively. Can be changed if required.

7. Next is the Na+ Profile, one of the 6 profiles can be selected

8. Select the starting Sodium 140-150 mmol/L9. Confirm and Start the Ultrafiltration

To Set Sodium Profile

ReferenceSodium & UF profiling with Fresenius 4008 S –

Dr. Thiagarajan.Acid concentrates – Monica AbelesDialysate made from dry chemicals usind citric

acid increases dialyses dose - Ahmad S et al, AJKD 2000; 35 : 493-499

Hand book of Dialysis – DaugirdasText book of Dialysis Therapy - Nissessenson &

Fine

Thank You