RRB Dialysis Technician cheat sheet

Each kidney contains about 1 million nephrons; the nephron is the functional unit (glomerulus + tubule).

Glomerulus filters plasma into Bowman's capsule; filtration barrier = fenestrated endothelium, basement membrane, podocyte slit diaphragms.

Proximal tubule reabsorbs ~65% of filtered Na+ and water; it is the main site of glucose, amino acid, and bicarbonate reabsorption.

Loop of Henle creates the medullary osmotic gradient; the thick ascending limb is impermeable to water and drives the countercurrent multiplier.

Distal convoluted tubule reabsorbs Na+ via the thiazide-sensitive NCC transporter; collecting duct fine-tunes water via ADH and Na+ via aldosterone.

Juxtaglomerular apparatus = macula densa (distal tubule) + juxtaglomerular cells (afferent arteriole); it secretes renin for tubuloglomerular feedback.

Kidneys sit retroperitoneally at T12–L3; the right kidney is lower than the left because of the liver.

Renal artery → segmental → interlobar → arcuate → interlobular arteries; efferent arterioles form the peritubular and vasa recta capillaries.

Normal kidney size ~10–12 cm long; cortex is outer, medulla contains pyramids whose papillae drain into minor then major calyces.

Normal GFR ~90–120 mL/min/1.73 m²; CKD stages are defined by GFR: G1 ≥90, G2 60–89, G3a 45–59, G3b 30–44, G4 15–29, G5 <15.

GFR = Kf × net filtration pressure; it depends on renal plasma flow, afferent/efferent arteriolar tone, and oncotic pressure.

Kidney regulates acid-base by reabsorbing HCO3− and excreting H+ and NH4+; metabolic acidosis in CKD is typically normal-anion-gap hyperchloremic.

Kidney secretes erythropoietin (peritubular fibroblasts) and activates vitamin D (1-alpha-hydroxylation); loss causes anemia and renal osteodystrophy.

RAAS: low renal perfusion → renin → angiotensin II → vasoconstriction and aldosterone → Na+ and water retention.

Uremia signs: nausea, pruritus, asterixis, pericarditis, encephalopathy, platelet dysfunction; urea is not itself the sole toxin.

Hyperkalemia in CKD arises from reduced excretion plus acidosis and RAAS blockade; ECG changes: peaked T, wide QRS, sine wave.

Nephrotic syndrome: proteinuria >3.5 g/day, hypoalbuminemia, edema, hyperlipidemia; nephritic syndrome: hematuria, RBC casts, hypertension.

Acute kidney injury staged by KDIGO using serum creatinine rise and urine output; prerenal, intrinsic, and postrenal categories.

Diffusion moves solutes down a concentration gradient across the membrane; rate depends on gradient, membrane permeability, surface area, and blood/dialysate flow.

Convection (ultrafiltration) drags solvent and dissolved solutes across the membrane; it drives middle-molecule clearance in hemofiltration.

Osmosis is water movement across a semipermeable membrane; in dialysis, sodium and osmotic gradients determine refilling and thirst.

Clearance K = (Qb × (Ca − Cv))/Ca; delivered dose is measured by Kt/V (urea) - target spKt/V ≥1.2 per session for thrice-weekly HD.

URR (urea reduction ratio) = (pre-BUN − post-BUN)/pre-BUN × 100; target ≥65% for thrice-weekly HD.

Hemodialysis: blood and dialysate flow countercurrent through a dialyzer; typical Qb 300–400 mL/min and Qd 500–800 mL/min.

Peritoneal dialysis: dialysate instilled into peritoneum; clearance depends on dwell time and peritoneal membrane transport type (PET).

Ultrafiltration rate target usually ≤10–13 mL/kg/h; excessive rate increases intradialytic hypotension and stunning.

Prescription components: dialyzer, blood flow, dialysate flow, dialysate composition (Na, K, Ca, HCO3), temperature, duration, and UF goal.

Fistula rule: palpate thrill, auscultate bruit; a pulse without thrill suggests outflow stenosis; a high-pitched bruit suggests inflow stenosis.

Arm with access should be protected: no BP cuff, no venipuncture, no IV lines on that side.

Cannulation: arterial needle directed toward the anastomosis (or per unit protocol), venous needle directed toward the heart; use rope-ladder or buttonhole technique per protocol.

Needle gauge for AVF/AVG commonly 15G (or 16G); bevel up, 25–35° angle, flashback confirms lumen entry.

Post-cannulation hemostasis: apply pressure to needle sites only, sufficient to stop bleeding, typically 10–15 minutes; check for bleeding before discharge.

Signs of access infection: redness, warmth, induration, drainage, fever; avoid cannulating infected areas and notify the physician.

Central venous catheter care: use sterile technique, mask and gloves, scrub hub with antiseptic, aspirate lock solution, and assess for exit-site infection.

Access monitoring: intra-access flow (QA), static venous pressure trends, recirculation, and physical exam each treatment.

Steal syndrome: cold, painful hand distal to access; assess capillary refill, sensation, and motor function.

Water treatment train: prefilter → carbon tanks (remove chlorine/chloramine) → water softener (remove Ca/Mg) → reverse osmosis → UV or ultrafilter → distribution loop.

Chlorine/chloramine breakthrough is a serious hazard; test before each shift and after carbon change; limits per AAMI (chlorine <0.1 mg/L, chloramine <0.1 mg/L).

RO membrane removes ≥90–95% of dissolved ions; conductivity and TDS monitor performance; reject water must be drained properly.

Dialysate is prepared from treated water plus bicarbonate and acid concentrate; conductivity meters verify mix; never use dialysate with visible precipitate.

Dialysate temperature typically 36–37 °C; alarms for high/low temperature protect against hemolysis and hypothermia.

Air detector and venous pressure alarms must be functional; blood leak detector prevents blood loss into dialysate.

Reprocessing: dialyzers may be reused per unit protocol with validated clearance/volume testing; label with patient name, date, and reuse number.

Machine checks before treatment: alarm test, conductivity, temperature, pressure holding test, and residual disinfectant test (e.g., <1 ppm).

Disinfection: chemical (peracetic acid, citric acid, bleach) or heat; document concentration, contact time, and rinse verification.

Monitor pre-, intra-, and post-dialysis: weight, BP, HR, temperature, access status, and symptoms; check vitals at least every 30–60 minutes per protocol.

Intradialytic hypotension: SBP drop ≥20 mmHg or <90 mmHg with symptoms; respond by reducing UF, Trendelenburg, saline bolus per order.

Muscle cramps: often related to rapid UF, low sodium, or hypovolemia; slow UF and give saline or hypertonic saline per order.

Air embolism: stop pump, clamp lines, place patient in Trendelenburg and left lateral decubitus, give 100% O2, call for help.

Hemolysis: suspect with dark blood in lines, chest pain, back pain, dyspnea; stop dialysis, do not return blood, check dialysate for hypotonicity or contamination.

Dialyzer reaction (Type A anaphylaxis): occurs within minutes; stop dialysis, do not return blood, give oxygen and epinephrine per protocol.

First-use syndrome (Type B): chest/back pain within minutes; usually milder; treat symptomatically and consider reuse or different membrane.

Arrhythmia and cardiac arrest: assess rhythm, start CPR, use AED, follow ACLS; hyperkalemia may cause peaked T waves and wide QRS.

Bleeding at access site: hold pressure, assess for hematoma, and check post-treatment bleeding before discharge.

Hand hygiene is the single most important measure; use alcohol-based rub or soap and water before and after patient contact and glove use.

Standard precautions apply to all patients: gloves, gown, mask, eye protection based on anticipated exposure.

Dialysis-specific: wear gloves for cannulation, catheter care, and blood contact; change gloves between patients.

Hepatitis B: vaccinate patients and staff; isolate HBsAg-positive patients in a separate room/machine per CDC; do not share supplies.

Hepatitis C: no separate room required, but strict aseptic technique and dedicated equipment; screen and treat per protocol.

Catheter care bundle: hand hygiene, maximal barrier precautions, chlorhexidine antisepsis, and daily review of need.

Surface disinfection: use EPA-registered disinfectant; blood spills cleaned with gloves and appropriate disinfectant.

Sharps: never recap by hand; dispose immediately in puncture-resistant container; report needlestick per protocol.

Staff surveillance: annual TB screening, HBV vaccination, and reporting of exposures; follow post-exposure prophylaxis guidelines.

Dry weight = estimated weight without edema or excess fluid; reassess using BP, edema, and bioimpedance or clinical judgment.

Nutrition targets: protein ~1.0–1.2 g/kg/day for HD, ~1.0–1.3 g/kg/day for PD; energy ~25–35 kcal/kg/day.

Fluid restriction: usually 500–1000 mL/day plus urine output; interdialytic weight gain target ≤2–3 kg or ≤4–5% of dry weight.

Sodium restriction ~2 g/day; potassium restriction individualized based on labs; phosphorus binders taken with meals.

Phosphate binders: calcium carbonate, calcium acetate, sevelamer, lanthanum; take with meals to bind dietary phosphate.

Vitamin D analogs and calcimimetics manage secondary hyperparathyroidism; monitor calcium, phosphorus, and PTH.

ESA (erythropoiesis-stimulating agent) for anemia; monitor hemoglobin, iron studies, and BP.

Medication timing: some drugs are dialyzable and need post-dialysis dosing; check pharmacy guidance for each drug.

Assess for malnutrition: albumin, prealbumin, weight trend, appetite, and functional status; refer to dietitian.

Document pre-, intra-, and post-dialysis vitals, weights, machine settings, alarms, interventions, and patient response.

Record access assessment, cannulation sites, needle gauge, and hemostasis time each treatment.

Water quality records: chlorine/chloramine tests, conductivity, RO performance, and disinfection logs with dates and initials.

Quality indicators: Kt/V or URR, hemoglobin, albumin, phosphorus, access infection rates, catheter use, and hospitalization rates.

CMS Conditions for Coverage and ESRD regulations set minimum standards for dialysis facilities in the US.

AAMI standards cover water quality, dialysate, and reprocessing; follow manufacturer instructions for use.

Incident reporting: document adverse events, needlesticks, machine failures, and near misses per policy.

Audit and QAPI: review data monthly/quarterly, identify trends, implement improvement plans, and document outcomes.

Confidentiality: protect PHI per HIPAA; share only on a need-to-know basis.

Informed consent: explain procedure, risks, benefits, and alternatives; document patient understanding and voluntary agreement.

Patient autonomy: respect refusal of treatment and advance directives; involve family per patient wishes.

Confidentiality: do not discuss patient information in public areas or on social media; follow HIPAA and unit policy.

Professional boundaries: avoid dual relationships and gifts that could compromise care; maintain respectful communication.

Error disclosure: report mistakes honestly to the patient and team; participate in root-cause analysis.

Patient identification: use two identifiers (name and date of birth) before any procedure or medication.

Speak-up culture: any staff member can stop a procedure if patient safety is at risk.

Cultural competence: use interpreters, respect language and belief differences, and confirm understanding with teach-back.

Documentation ethics: record facts accurately, never alter records, and correct errors per policy.