Hemodialysis

The Northern Alberta Renal Program manages approximately 600 patients on hemodialysis in settings which include an in-centre unit, assisted self-care, satellite units and home hemodialysis. These units provide over 80,000 treatments per year, providing abundant opportunities for exposure to this modality.

Terminal Objectives

  1. The resident should be familiar with the clinical manifestations and pathophysiology of chronic renal failure and be able to describe the clinical presentation of uremia, including symptoms and signs of uremic toxicity.
  2. The resident should demonstrate knowledge of the history of hemodialysis treatment (Baxter video available).
  3. The resident should be familiar with the principles and biophysics of hemodialysis treatment and be able to describe the principles of diffusion, ultrafiltration, convective solute transfer, flux and dialysance.
  4. The resident should demonstrate knowledge of these mechanical aspects of hemodialysis:
    • types of blood access, including their complications, tools useful for monitoring the function of the access, the role and complications of temporary hemodialysis catheters
    • types of dialyser membranes available (cellulosic, modified cellulose, and synthetic), including membrane characteristics and their performance measures, biocompatibility, and clinical issues pertaining to dialyser reuse
    • hemodialysis machine and the circuit, monitoring of performance, sterilization, regulation of ultrafiltration, new advances in on-line monitoring
    • requirements for appropriate dialysate, including water pre-treatment, water quality standards, dialysate composition
    • anticoagulation, including the options available for individual patients
  5. The resident should be able to demonstrate an understanding of the dialysis prescription and measures of its adequacy, including the NCDS and HEMO studies, urea kinetic modelling, determination of Kt/V and PCR, the use of PRU/URR, and non-urea based indices of adequacy.
  6. The resident should be able to demonstrate an understanding of the following complications of hemodialysis and their management:
    • the solute and fluid dynamics during hemodialysis, including ways to maximize patient tolerance of ultrafiltration
    • the differential diagnosis of hypotension during hemodialysis
    • other common symptoms such as muscle cramps, nausea, headache, chest pain, back, pain, fever, arrhythmias, hemolysis, seizures
    • the dialysis disequilibrium syndrome
    • pericarditis and cardiac tamponade
    • air embolism
    • dialyser reactions, including Type A reactions (anaphylactic), Type B (nonspecific) reactions and the influence of factors such as membrane type, complement activation, sterilants, dialysate contamination, high flux, and medication interactions (AN 69 and ACEI)
  7. The resident should be able to describe the pathophysiology and management of the long-term complications of hemodialysis including: anemia, hypertension, renal osteodystrophy and hypercalcemia, dialysis amyloid syndrome, hyperlipidemia, aluminum toxicity, and cardiac dysfunction
  8. The resident should be able to discuss social, ethical and legal issues such as the criteria for patient suitability for hemodialysis, stopping therapy, the medically unsuitable patient, the non-compliant patient
  9. The resident must have sufficient experience with the hemodialysis unit to be capable of fully supervising the care of acute and chronic hemodialysis patients. This includes knowledge of technical aspects of dialysis (above), infection control standards including HIV, hepatitis, VRE, and MRSA control and technical aspects of dialyzer reuse
  10. The resident should be able to discuss each of the following issues in the management of acute renal failure with hemodialysis:
    • the dialysis prescription, including access
    • continuous forms of hemodialysis or ultrafiltration
    • the influence of modality or membrane on outcome of acute renal failure and patient morbidity or mortality
  11. The resident should be able to outline the role of hemodialysis in treating certain intoxications and drug overdoses, including methanol, ethylene glycol, salicylates, lithium etc.
  12. The resident should be able to demonstrate competence at placing temporary hemodialysis catheters
  13. The resident should be able to appropriately prescribe medications in hemodialysis patients
  14. The resident should be experienced in providing care for satellite hemodialysis patients, including those treated at a distance from Edmonton

Clinical Experience

The resident will be provided opportunities to meet the objectives in a variety of clinical settings. These include:

  1. Management of acute and chronic hemodialysis in inpatients admitted to the University Hospital
  2. Developing the ability to work smoothly within the multi-disciplinary team, interacting with nurses, social workers, dieticians, pharmacists, and other physicians
  3. At least one month spent in the in-centre hemodialysis unit (5B1/5C2) where the focus will be on the management of acute medical complications in this high-acuity population
  4. Participating in the chronic hemodialysis coverage of a satellite hemodialysis unit and rural nephrology clinics
  5. Participating in the on-call chronic hemodialysis coverage of the in-centre hemodialysis unit (5B1/5C2)