There are three primary and two secondary types of dialysis:
hemodialysis (primary),
peritoneal dialysis (primary),
hemofiltration (primary),
hemodiafiltration (secondary) and intestinal dialysis (secondary).
Hemodialysis In
hemodialysis, 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 fibers. 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 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, 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 (AKI).
Intestinal dialysis In healthy humans, the intestines both remove uremic toxins (urea, creatine, uric acid) from blood and add uremic toxins (indoxyl sulfate, ammonia, etc.) to blood. More uremic toxins are excreted through the gut (as feces) than through the kidneys (as urine). This exchange of substances is enabled by the massive surface area of the intestinal capillary network and intestinal mucus, together serving as a large semipermeable membrane. In patients with kidney failure, the intestines receive a larger influx of uremic toxins due to a higher concentration in blood, but this does not automatically translate to a benefit in reducing blood toxin levels as gut bacteria use these toxins as food, producing more toxins in the process. The goal of
intestinal dialysis is to maximize the removal of uremic toxins into the intestines while minimizing the production of new toxin molecules in the intestines. It serves as a more conservative renal replacement therapy for those unable to tolerate conventional dialysis. There are a few forms of intestinal dialysis: • Small bowel/intestinal dialysis puts the dialysate in the small intestines through a surgical opening (
ileostomy), using the intestinal walls as the semipermeable membrane for removing toxins. It did not show any actual survival benefit overall and was replaced by modern dialysis methods. • Colonic dialysis puts the dialysate in the colon, which can be done without a surgical opening: an anal catheter inserted through the anus can reach the ascending colon and inject the dialysate there. The clinical use of colonic dialysis is still in its early stages (as of 2020), being studied mainly in Iran and China. • Oral adsorbents are used in hope that they will absorb toxins as they pass through the gut. One of them, AST-120, has undergone two multinational randomized controlled trials in which it failed to show a benefit in slowing CKD progression. However, a post-hoc analysis find some benefit in a subgroup of patients. ==Indications==