Nephrology & Dialysis Nursing

Haemodialysis, peritoneal dialysis, renal replacement therapy — GCC nephrology practice

DHA / DOH / SCFHS CNN Prep GCC Renal Burden Updated 2025
Transport Principles
DiffusionSolute movement down concentration gradient
UltrafiltrationFluid removal by hydrostatic pressure gradient
ConvectionSolvent drag — solutes carried with fluid flux
OsmosisWater movement across semi-permeable membrane
Standard HD Parameters
Blood Flow Rate (Qb)300–400 mL/min
Dialysate Flow (Qd)500 mL/min
Session duration4 hours × 3/week
Kt/V (adequacy)Target >1.2 / session
URR target>65%
Temperature35–37°C (cool = 35.5°C)
Dialyser Types
TypeMembrane FluxMiddle Molecule ClearanceUse CaseNote
High-FluxHigh hydraulic permeabilityExcellent (β2-microglobulin)Standard modern HDPreferred in GCC centres
Low-FluxLow hydraulic permeabilityLimitedResource-limited settingsLess effective long-term
HDFVery highSuperior (online HDF)HaemodiafiltrationRequires ultra-pure water
Anticoagulation Options
UFH (Unfractionated Heparin) ▼
  • Loading bolus: 1,000–5,000 IU IV at start
  • Infusion: 500–1,500 IU/hr throughout session
  • Stop 30–60 min before end of session
  • Monitor aPTT (target 1.5–2× baseline)
  • Reversal: Protamine sulphate 1mg per 100 IU heparin
Nadroparin (LMWH) ▼
  • Single pre-dialysis IV bolus (weight-based)
  • Less monitoring required (anti-Xa if needed)
  • Caution in residual renal function (accumulation)
  • Not reversible with protamine
Citrate Anticoagulation ▼
  • Regional anticoagulation — calcium chelation in circuit
  • Monitor ionised Ca²⁺ pre/post filter & systemic
  • Calcium chloride infusion returns Ca²⁺ to patient
  • Preferred in bleeding risk patients
  • Citrate toxicity: rising total:ionised Ca ratio (>2.5)
Heparin-Free HD ▼
  • Pre-rinse circuit with 500 mL heparinised saline, discard
  • High Qb (>350 mL/min) to reduce clotting risk
  • Intermittent saline flushes (100 mL every 30 min)
  • Monitor TMP — rising TMP signals filter clotting
Vascular Access Assessment
AV Fistula / Graft
  • Palpate for thrill (vibration) — absence = emergency
  • Auscultate for bruit (swishing sound)
  • Assess distal pulses, warmth, capillary refill
  • Steal syndrome: cold/numb/painful hand distal to access
  • Aneurysm: focal sac-like dilation — avoid cannulation site
  • Stenosis: high venous pressure, prolonged post-needling bleeding
  • Thrombosis: loss of thrill/bruit — urgent Doppler ultrasound
Tunnelled Cuffed Catheter (TCC) Care
  • Aseptic technique ALWAYS — mask and gloves mandatory
  • Exit site assessment: redness, swelling, discharge, pain
  • Heparin lock post-session (per lumen volume)
  • Never use for blood draws unless absolutely necessary
  • Fibrin sheath = poor flow, high pressures — may need urokinase
  • Signs of bacteraemia: fever, rigors — blood cultures x2 sets
Adequacy Monitoring
Kt/V Calculation
📐
Kt/V = -ln(R - 0.008×t) + (4 - 3.5×R) × UF/V
R = post/pre BUN, t = session time (hrs), UF = ultrafiltration (L), V = volume distribution
  • Target: >1.2 per session
  • Weekly standard Kt/V target >2.0
URR (Urea Reduction Ratio)
📊
URR = (Pre-BUN − Post-BUN) / Pre-BUN × 100
Target: >65%
  • Monthly BUN pre & post session
  • Sample post-BUN from arterial line — slow flow 15 sec before
Other Adequacy Markers
  • Monthly: eKt/V, URR, blood chemistry panel
  • Haemoglobin: target 10–12 g/dL (ESA therapy)
  • Ferritin >200 µg/L, TSAT >20% (iron status)
  • PTH: 2–9× upper normal (CKD-MBD management)
  • Albumin >3.5 g/dL (nutritional marker)
Haemodialysis Session Safety Checklist & Complication Identifier
Complication Identifier — Select Symptom
⚠️
Emergency Protocol: For any life-threatening complication — STOP blood pump, clamp lines, return blood to patient (if safe), call physician, monitor vitals continuously.
COMMONEST Intradialytic Hypotension (IDH) ▼
Definition & Causes
  • SBP drop >20 mmHg OR SBP <90 mmHg
  • Excessive ultrafiltration rate (UFR >13 mL/kg/hr)
  • Autonomic neuropathy (diabetic patients — GCC common)
  • Low osmolality dialysate, high-flux membranes
  • Cardiac dysfunction, hypoalbuminaemia
Management Steps
  • Trendelenburg position (legs up)
  • Reduce or pause ultrafiltration rate
  • Normal saline 100–200 mL bolus IV
  • Cool dialysate (35–35.5°C reduces vasodilation)
  • Sodium profiling (higher early, taper late)
  • Midodrine 5–10 mg orally 30 min pre-dialysis
  • Reassess dry weight if recurrent
Muscle Cramps ▼
Causes
  • Rapid fluid removal / low dry weight
  • Hyponatraemia, hypokalaemia
  • Reduced tissue perfusion
Management
  • Hypertonic saline (23.4%) 10 mL IV bolus
  • Hypertonic glucose (50%) 40 mL IV
  • Reduce UFR temporarily
  • Local heat application
  • Stretch affected muscle
  • Quinine sulphate (if persistent — prescriber order)
Disequilibrium Syndrome ▼
🧠
Pathophysiology: Rapid urea removal creates osmotic gradient → cerebral oedema. Risk: first sessions, very high pre-dialysis BUN, paediatric patients.
Symptoms
  • Mild: headache, nausea, restlessness
  • Severe: confusion, seizures, coma
  • Typically occurs late in session or post-session
Prevention & Management
  • Short initial sessions (2 hrs first HD)
  • Low blood flow rate (200 mL/min first session)
  • IV mannitol 20% (1 g/kg) to equalise osmolality
  • Raise dialysate Na+ (145–150 mEq/L)
  • Treat seizures with IV benzodiazepine
EMERGENCY Air Embolism ▼
🚨
IMMEDIATELY: Clamp venous line → Stop blood pump → Do NOT return blood → Call emergency
Signs
  • Sudden dyspnoea, cough, chest pain
  • Foam/bubbles visible in venous line
  • Hypotension, cardiovascular collapse
  • "Mill-wheel" murmur on auscultation
Emergency Actions
  • Left lateral decubitus + Trendelenburg (Durant's manoeuvre)
  • 100% oxygen by non-rebreather mask
  • Hyperbaric oxygen if available
  • Aspiration via central venous catheter (if trained)
  • CPR if cardiac arrest
EMERGENCY Haemolysis ▼
🚨
IMMEDIATELY: STOP session — DO NOT return blood — discard circuit blood
Signs & Causes
  • Blood turns green/dark red (cherry red if severe)
  • Back/flank pain, burning at access site
  • Hypotension, dyspnoea
  • Causes: hypotonic dialysate, overheated dialysate, contaminated water, kinked blood lines, formaldehyde residue
Management
  • STOP pump, clamp arterial & venous lines
  • DO NOT reinfuse circuit blood (high potassium)
  • Oxygen therapy, IV access
  • Monitor K+ (hyperkalaemia risk — cardiac arrhythmia)
  • May require emergency RBC transfusion
  • Urgent physician notification
  • Investigate water treatment system
Pyrexia & Rigors (CVC Infection) ▼
Assessment
  • Temperature >38°C or rigors during session
  • Assess CVC exit site for redness/pus
  • Check for other infection sources
  • TCC-related bacteraemia most common organism: Staph. aureus / CONS
Management
  • Blood cultures × 2 sets (peripheral + catheter lumen)
  • Start empirical Vancomycin IV (TCC-related bacteraemia)
  • Add gentamicin if Gram-negative suspected
  • Duration: 2–4 weeks depending on organism
  • Consider catheter removal if persistent bacteraemia >72h
  • Antibiotic lock therapy (unresolved catheter infection)
First-Use Syndrome (Anaphylactoid Reaction) ▼
Presentation
  • Type A: anaphylactic — dyspnoea, burning, urticaria, hypotension within 20 min of start
  • Type B: non-specific — back/chest pain, later onset
  • Associated with: ETO-sterilised dialysers, AN69 membrane + ACEi
Management
  • Type A: STOP session, DO NOT return blood, epinephrine 0.3 mg IM, antihistamine, IV steroids
  • Type B: symptom management, session may continue
  • Prevention: pre-rinsing dialyser with saline, change dialyser brand
  • Stop ACE inhibitors if using AN69 membrane
PD Modalities
CAPD3–4 manual exchanges/day, 4–6h dwell
APD (CCPD)Automated nocturnal cycling, 8–10h
Dwell time (CAPD)4–6 hours
Fill volume1.5–2.5 L per exchange
Glucose concentration1.36%, 2.27%, 3.86%
IcodextrinLong dwell (8–12h) — colloid osmosis
Tenckhoff Catheter Care
  • Exit site cleaning: sterile technique daily
  • Use prescribed antiseptic (mupirocin/gentamicin cream)
  • Keep exit site dry — avoid immersion baths
  • Secure catheter to prevent traction
  • Flush with saline if poor flow — check for constipation
  • Break-in period: 2–4 weeks before full exchanges
🚨
PERITONITIS RULE: Cloudy effluent = peritonitis until proved otherwise. Act immediately — do not wait for culture results.
PD Peritonitis
Diagnostic Criteria (ISPD)
  • Cloudy effluent (cardinal sign)
  • Effluent WBC >100/mm³ with >50% neutrophils
  • Positive effluent culture
  • Abdominal pain, fever (may be absent)
  • At least 2 criteria required for diagnosis
Common Organisms
  • Gram-positive: S. epidermidis (touch contamination)
  • S. aureus: serious — risk catheter loss
  • Gram-negative: enteric organisms — bowel source?
  • Culture negative: ~20% of episodes
  • Fungal peritonitis: STOP PD — switch to HD
Empirical Treatment (IP Antibiotics)
💊
Empirical IP therapy:
Vancomycin 15–30 mg/kg IP (Gram-positive coverage) PLUS
Gentamicin 0.6 mg/kg IP (Gram-negative coverage)
Adjust per culture & sensitivity at 48h
  • Intraperitoneal route preferred (IP)
  • Continue therapy 14–21 days (organism-dependent)
  • Monitor residual renal function (aminoglycoside caution)
  • Catheter removal if: refractory >5 days, fungal, tunnel infection with peritonitis
Exit Site vs Tunnel Infection
Exit site infectionPurulent discharge ± erythema ≤2 cm from exit
Tunnel infectionErythema/oedema/tenderness along subcutaneous tunnel
DiagnosisClinical ± ultrasound of tunnel
TreatmentOral antibiotics 2+ weeks; systemic if tunnel involved
Catheter removalIf concurrent peritonitis or unresponsive >3 weeks
Encapsulating Peritoneal Sclerosis (EPS)
⚠️
Rare but life-threatening long-term complication of PD (>5–8 years). Fibrous encasement of bowel.
  • Presentation: recurrent peritonitis, malnutrition, bowel obstruction
  • CT scan: peritoneal calcification, bowel encasement
  • Management: stop PD, switch to HD, immunosuppression (tamoxifen)
  • Surgery (peritonectomy) in severe cases
Sterile Connection Technique — PD Exchange Procedure
Preparation
  • Wash hands — 6-step technique, 20 seconds
  • Mask on (patient & helper)
  • Gather: new bag, transfer set, clamps
  • Inspect bag: clear fluid, no leaks, expiry date
  • Warm bag to body temp (warming cabinet)
Drain Phase
  • Open transfer set — allow full drainage
  • Normal drain: clear/pale yellow, 1.5–2.5 L
  • Drain time: 20–30 minutes
  • Inspect drained effluent — note colour/turbidity
  • Measure volume drained (ultrafiltration assessment)
Fill Phase
  • Connect new bag using STRICT aseptic technique
  • Flush system (discard first 5 mL into drain bag)
  • Allow fill to complete (~10 min)
  • Clamp, disconnect, apply new cap
  • Record: time, fill volume, drain volume, UF, effluent appearance
CRRT Modalities Comparison
ModeFull NamePrimary MechanismSolute RemovalMain Indication
CVVHDFContinuous Venovenous HaemodiafiltrationDiffusion + ConvectionSmall + MiddlePreferred AKI in ICU
CVVHFContinuous Venovenous HaemofiltrationConvection onlyMiddle moleculesSepsis/inflammatory mediators
CVVHDContinuous Venovenous HaemodialysisDiffusion onlySmall solutesElectrolyte/metabolic control
Effluent Dose & Fluid Balance
💧
AKI-Net Trial target: 20–25 mL/kg/hr effluent dose
Higher doses (35 mL/kg/hr) showed NO additional benefit
Net UF targetPrescribed by ICU physician (e.g. −100 to −200 mL/hr)
Fluid balanceHourly input vs output documentation
Replacement fluidPre/post-filter (pre-dilution reduces filter clotting)
WeighingICU scales — twice daily minimum
Filter Life Optimisation
  • Target filter life: >24 hours
  • Pre-dilution replacement fluid reduces clotting risk
  • Avoid high haematocrit (>35%) — increased clotting
  • High TMP (>250 mmHg) = imminent filter clotting
  • Falling effluent rate = filter clotting — prepare new circuit
  • Ensure adequate anticoagulation (see below)
  • Minimise circuit interruptions (downtime = clotting)
Anticoagulation in CRRT
Regional Citrate Anticoagulation (RCA) — Preferred
🧪
Citrate chelates ionised calcium (Ca²⁺) in the extracorporeal circuit → prevents clotting. Calcium infused back to patient post-filter.
  • Monitor post-filter ionised Ca²⁺ (target 0.25–0.35 mmol/L)
  • Monitor systemic ionised Ca²⁺ every 6 hours (target 1.0–1.2 mmol/L)
  • Citrate toxicity: metabolic alkalosis, rising total:ionised Ca²⁺ ratio >2.5
  • Contraindicated in severe liver failure (cannot metabolise citrate)
Systemic Heparin — Alternative
  • UFH infusion 5–15 IU/kg/hr
  • Target aPTT 45–60 seconds (1.5–2× normal)
  • Caution: HIT, active bleeding, coagulopathy
  • Monitor anti-Xa level if HIT risk
Electrolyte Monitoring
  • Potassium: q4–6h (CRRT removes K⁺ rapidly)
  • Phosphate: q6–8h — phosphate replacement often needed
  • Magnesium: daily
  • Sodium: q4–6h (avoid rapid osmolar shifts)
Drug Dosing in CRRT
💊
Augmented Renal Clearance (ARC): Some critically ill patients have supranormal creatinine clearance. Standard HD doses may be insufficient — always consult clinical pharmacist for CRRT drug dosing.
  • Vancomycin: dose by AUC/MIC, daily levels in CRRT
  • Meropenem: extended infusion often needed — increased clearance in CRRT
  • Fluconazole: loading dose full, maintenance reduced
  • Aminoglycosides: avoid if possible, check trough levels
  • Piperacillin/tazobactam: increased frequency needed
  • Cefepime: neurotoxicity risk — dose adjust
  • Antivirals (aciclovir): reduce dose significantly
  • Antifungals: monitor levels, CRRT increases clearance
🌙
Ramadan Consideration: Schedule HD during non-fasting hours (pre-dawn or post-Iftar). PD patients adjust bag exchange timings. Provide specific dietary counselling for Ramadan renal diet.
Fluid Management
Fluid restriction formula500 mL + previous day urine output
IDWG target<2–3 kg or <5% dry weight
IDWG >5%High risk: hypertension, pulmonary oedema
Daily weighingSame time, same scale, same clothing
UFR alarm threshold>13 mL/kg/hr = IDH risk
Fluid-Rich Foods to Limit
  • Soups, stews, gravies
  • Ice cream, gelatin, yoghurt
  • Watermelon, cucumber, tomatoes
  • Canned foods (high sodium → thirst)
Potassium Restriction
Target serum K⁺3.5–5.5 mmol/L (pre-dialysis)
Daily K⁺ limit1,500–2,000 mg/day
🌴
GCC Alert — Dates (Tamr)! Extremely high in potassium (~700 mg per 100g). Culturally significant food — patient education critical, especially during Ramadan Iftar.
High-K⁺ Foods to Avoid
  • Dates, dried fruits, raisins
  • Bananas, oranges, kiwi, avocado
  • Potatoes (boil, drain, discard water — leaching reduces K⁺)
  • Tomato paste, tomato juice
  • Nuts, seeds, legumes
  • Salt substitutes (potassium chloride!)
Phosphate Restriction
Target serum PO₄0.8–1.5 mmol/L
Daily limit800–1,000 mg/day
High-Phosphate Foods to Limit
  • Dairy: milk, cheese, yoghurt
  • Nuts and seeds
  • Cola drinks (phosphoric acid — highest bioavailability!)
  • Processed meats (phosphate preservatives)
  • Whole grains, bran
Phosphate Binders
  • Calcium carbonate: take WITH meals
  • Sevelamer (non-calcium): take WITH meals
  • Lanthanum carbonate: chew WITH meals
  • Sucroferric oxyhydroxide: chew WITH meals
Protein & Sodium
Protein (HD)1.2 g/kg/day
Protein (PD)1.2–1.5 g/kg/day (peritoneal losses)
Protein (pre-dialysis CKD)0.6–0.8 g/kg/day
Sodium restriction<2g/day (reduce thirst & IDWG)
Energy target30–35 kcal/kg/day
Nutritional Risk Screening
  • Monthly albumin (target >3.5 g/dL)
  • nPCR (normalised protein catabolic rate) >1.0 g/kg/day
  • Monthly weight trends
  • Subjective Global Assessment (SGA) tool
  • Refer to renal dietitian for all HD patients
GCC Regulatory Bodies — Renal Nursing
DubaiDHA (Dubai Health Authority) — DHA License Exam
Abu DhabiDOH (Dept of Health) — DOH Exam via Prometrics
Saudi ArabiaSCFHS (Saudi Commission) — Exam + Dataflow
QatarQCHP (Qatar Council Health Practitioners)
BahrainNHRA
KuwaitMOH Kuwait Licensing
Specialty certificationCNN — Certified Nephrology Nurse (ANCC/NNCC)
GCC Renal Burden — Key Facts
📊
GCC has the highest global prevalence of Type 2 diabetes → leading cause of CKD and ESRD in the region.
  • Saudi Arabia: >50,000 patients on dialysis (2024 estimates)
  • UAE: Diabetes prevalence ~19% — major CKD driver
  • Kuwait: ~30% adult obesity + diabetes → CKD cascade
  • Hypertension: 2nd leading cause of ESRD in GCC
  • Rapid dialysis infrastructure expansion — vision 2030
  • High proportion of expatriate nursing workforce
Cultural Considerations in Renal Nursing
  • Fistula arm — some patients prefer arm covered for prayer/wudu (religious washing): educate that wudu over fistula arm is acceptable in most Islamic jurisprudence
  • Ramadan fasting: coordinate HD schedule around Iftar/Suhoor
  • Gender concordance: female patients may prefer female nurses for access care
  • Family involvement: decisions often family-centred — involve designated family member
  • Dietary counselling must address GCC-specific foods: dates, Arabic bread, hummus, kabsa
  • Prayer times: schedule HD to allow prayers (5 daily) — provide prayer facilities access
  • Halal-compliant medications: verify IV albumin, heparin source (porcine heparin — some patients prefer bovine)
  • Arabic language materials: provide education in Arabic where possible
CNN Certification Tips
High-Yield Topics
  • Kt/V calculation & adequacy
  • Access assessment (thrill/bruit)
  • IDWG management
  • Anticoagulation protocols
  • PD peritonitis criteria
  • CRRT modes & effluent dose
Frequently Tested
  • IDH management steps
  • Haemolysis emergency response
  • Air embolism position (Durant)
  • Disequilibrium prevention
  • Potassium & phosphate targets
  • ESA & iron targets
Exam Strategy
  • Read question stem carefully — GCC context
  • Eliminate obviously wrong options first
  • Priority questions: Maslow & ABCs
  • CRRT questions focus on monitoring
  • PD peritonitis — cloudy effluent = act FIRST
  • Safety always before comfort
Practice MCQs — Nephrology & Dialysis
1. A haemodialysis patient develops sudden green discolouration of blood in the circuit with severe back pain. What is the FIRST nursing action?
A. Slow the blood pump to 100 mL/min
B. Administer IV normal saline bolus immediately
C. Stop the blood pump, clamp arterial and venous lines, DO NOT return circuit blood
D. Return blood to patient and stop session
Correct: C. Green blood = haemolysis (dialysate contamination, overheating, hypotonicity). The circuit blood has high potassium from lysed cells — returning it risks fatal hyperkalaemia. Stop and discard circuit blood.
2. A PD patient calls the dialysis unit reporting cloudy effluent with mild abdominal pain. What is the PRIORITY diagnosis to exclude?
A. Constipation causing slow drainage
B. PD peritonitis
C. Fibrin clot in the catheter
D. Wrong concentration dialysate used
Correct: B. Cloudy effluent = peritonitis until proved otherwise (ISPD guideline). Collect effluent for cell count and culture, start empirical IP antibiotics (vancomycin + gentamicin) immediately without waiting for culture results.
3. Target Kt/V per haemodialysis session is:
A. >0.8
B. >1.0
C. >1.2
D. >1.5
Correct: C. KDOQI guidelines recommend single-pool Kt/V >1.2 per session (equivalent weekly standard Kt/V >2.0) for thrice-weekly HD. Values below 1.2 are associated with increased morbidity and mortality.
4. During a CRRT session with citrate anticoagulation, the patient develops metabolic alkalosis and the total calcium to ionised calcium ratio rises to 3.1. What does this indicate?
A. Hypocalcaemia requiring calcium infusion increase
B. Filter clotting — replace filter
C. Citrate toxicity — citrate accumulation
D. Metabolic acidosis from AKI
Correct: C. Citrate toxicity: total Ca / ionised Ca ratio >2.5 indicates citrate accumulation (seen in liver failure — cannot metabolise citrate). Presents with metabolic alkalosis, hypocalcaemia symptoms. Action: reduce citrate, check liver function, consider switching anticoagulation method.
5. A dialysis patient in the GCC reports consuming 10 dates at Iftar last night. The morning pre-dialysis potassium is 6.8 mmol/L. Which immediate intervention is MOST appropriate?
A. Withhold dialysis and recheck in 2 hours
B. Give 15g kayexalate orally and discharge
C. Obtain 12-lead ECG and commence dialysis urgently with cardiac monitoring
D. Administer IV calcium gluconate and cancel dialysis
Correct: C. K⁺ 6.8 mmol/L is dangerously high. Dates are very high in potassium (~700 mg/100g). First: 12-lead ECG to detect hyperkalaemia changes (peaked T waves, wide QRS). Urgent HD is the definitive treatment. IV calcium gluconate stabilises the myocardium but is used if ECG changes are severe/imminent arrest risk — dialysis should still commence urgently with monitoring.
Dialysis Nursing Competency Checklist
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