AU2015202293A1 - Dialysis system including heparin injection - Google Patents

Abstract

A dialysis system (220) includes a diaysisinstrument (20) including a bloo pup atuatdr;a dialyzer (6); a heparin pump (152% and a dispOsable cassette (4Cflincluding a blood pnumping portion operable with the blood pump actuator of the dialysis instrument the blood pumping portion induding aninet and an outlet the inlet of the lood pumping portion of the disposable cassete poslioned and arranged to receive blood from an arterial line of an extraporeal circuit, the outlet of the blood pumping portion of the disposable cassette portioned and arranged to deliver the blood to the dialyzer and to receive heparnn from th heparin pump (1 52). Sheet 28 of 48 co :9 a.e CL n in a 41 U.e b ayz ese a a eoe LO u.C> C

Description

Regulation 3.2 Revised 2198 AUSTRALIA Patents Act, 1990 ORIGINAL COMPLETE SPECIFICATION APPLICANT/S: Baxter International Inc. (Organised and existing under the laws of the State of Delaware) Baxter Healthcare SA INVENTORS: CHILDERS, Robert W KELLY, Thomas D ROGER, Rodolfo ADDRESS FOR SERVICE: Peter Maxwell and Associates Level 6 60 Pitt Street SYDNEY NSW 2000 INVENTION TITLE: DIALYSIS SYSTEM INCLUDING HEPARIN INJECTION DETAILS OF ASSOCIATED APPL ICATION NO(S): Divisional of AU 2013 209 332 filed on 24 October 2008 which is a divisional of AU 2012 227 262 filed on 24 October 2008 The following statement is a full description of this invention including the best method of performing it known to us: 1 mAdocs\20081232\358012.doc BACKGROUND [0001] The present disclosure relates generally to medical treatments. 5 More specifically, the present disclosure relates to medical fluid treatments, such as the treatment of renal failure and fluid removal for congestive heart failure. [00021 Hemodialysis ("HD") in general uses diffusion to remove waste products from a patients blood. A diffusive gradient that occurs across the 10 semi-permeable dialyzer between the blood and an electrolyte solution called dialysate causes diffusion. Hemofiltration ("HF") is an alternative renal replacement therapy that relies on a convective transport of toxins from the patient's blood. This therapy is accomplished by adding substitution or replacement fluid to the extracorporeal circuit during treatment (typically ten to 15 ninety liters of such fluid). That substitution fluid and the fluid accumulated by the patient in between treatments is ultrafiltered over the course of the HF treatment, providing a convective transport mechanism that is particularly beneficial in removing middle and large molecules (in hemodialysis there is a small amount of waste removed along with the fluid gained between dialysis 20 sessions, however, the solute drag from the removal of that ultrafiltrate is not enough to provide convective clearance). [00031 Hemodiafiltration ("HDF") is a treatment modality that combines convective and diffusive clearances. HDF uses dialysate to flow through a dialyzer, similar to standard hemodialysis, providing diffusive clearance. In 25 addition, substitution solution is provided directly to the extracorporeal circuit, providing convective clearance. [0004] Home hemodialysis ("HHD") is performed in the patient's home. One drawback of home hemodialysis has been the need for a dedicated water treatment, which includes equipment, water connection and drainage. Installing 30 and using those components is a difficult and cumbersome task that can 1a require a patienta home to be modified. Nevertheless, there are benefits to daily hemodialysis treatments versus bi- or tri-weekly visits to a treatment center. In particular, a patient receiving more frequent treatments removes more toxins and waste products than a patient receiving less frequent but 5 perhaps longer treatments. Accordingly, there is a need for an improved HHD lb SUMMARY [0005] The present disclosure provides a home hemodialysis ("HHD") system. In one embodiment, the home system includes a mobile cart and integral bag manager. A latch is pulled out to unlock door of the system instrument. The door can be opened to expose a latch hook and peristaltic pump heads. [0006] The instrument accepts a disposable unit which in one embodiment is loaded from above and slid to the right. The disposable unit pivots towards the machine interface, which allows peristaltic tube loops of the disposable unit to fit over peristaltic pump heads of the instrument. Also, supply lines of the disposable unit are passed over individual pinch valve plungers. [0007] The pinch valve pluhgers pinch the supply tubes against a pinch valve strke plate. The valve assembly is in one embodiment a motor-driven cam. operated pinch valve subassembly. The motor in one embodiment is a stepper motor. [0008] The system in one embodiment includes a bellows or bladder that compresses a cassette against the instrument door using a pressure plate and gasket, These apparatuses are structured to accommodate an inline inductive heater provided with the disposable cassette, The bellows is air actuated in one embodiment. The instrument includes a primary coil that inductively heats conductive heating disks located within the cassette, which in turn heat fluid flowing through the cassette [0009] A multi-peristaltic pump race retracts and extends in one embodiment illustrates to facilitate loading of the peristaltic tubes of the cassette onto the peristaltic pump heads. The race is then moved towards the tubes for operation. [0010] The system in one embodiment includes a manual blood pump operator, which allows the patient or caregiver to move the blood pump head manually. [00111 The system includes a bag management system having shelves that fold up, out of the way, and down, sequentially for placement of supply bags. The system in one embodiment supports up to five, six liter solution bags. The bags can be dual chamber bags,. The shelves in an embodiment are provided with sensors that allow detection of whether the bags have been (i) loaded or not and (ii) opened or not for therapy. The sensors in one embodiment are capacitive sensors placed on opposite ends of the shelves. [0012] The disposable cassette in one embodiment connects fluidly to a heparin syringe for the injection of heparin into the blood circuit. The syringe fits into a luer connector assembly, which in tum is loaded into a syringe pump. The assembly is turned in 2> the syringe pump to lock the syringe in the syringe pump for treatment. The assembly accommodates large syringes, such as fifty to sixty milliliter syringes, which can lock directly into the syringe pump. In one embodiment, the heparin line passes through the side of the cassette. Here, heparin can enter at the blood pump outlet just prior to the dialyzer inlet. [00131 The system also includes a retractable saline bag support rod, The saline in one embodiment connects to the cassette near the heparin line. A saline valve is located on each side of the blood pump to control the flow of saline to same. [0014] A dialyzer inlet pressure sensor interface in one embodiment doubles as a flow control valve. The cassette can also form an integral venus air separation chamber. [0015] Priming is performed in one embodiment via gravity. Gravity primes the venous line, the arterial line and the air trap (drip chamber) 0016] In another embodiment, priming is preformed via a combination of pumping dialysate and a physiologically safe fluid, such as saline. In particular, a hemodialysis machine can include a blood circuit, a dialysate circuit, a dialyzer placed in communication with the blood circuit and the dialysate circuit; and a priming sequence in which dialysate is used to prime a first portion of the dialysate circuit and a physiologically compatible solution, other than dialysate, is used to prime a second portion of the dialysate circuit, the dialyzer and the blood circuit. The first portion of the dialysate circuit includes a recirculation loop primed by a dialysate supply pump in one embodiment. The second portion of the dialysate circuit can then be located at least substantially between the recirculation loop and the dialyzer, and which is primed by at least one of a blood pump and a downstream dialysate pump. in one embodiment, a volumetric balancing unit separates the first and second portions of the dialysate circuit. [0017] The cassette in one embodiment uses balance tubes to balance fresh and spend dialysate flow. The balance tubes have outlets at the top of the tubes when mounted for operation to allow air to leave the tubes. The cassette also employs diaphragm valves that operate with a compliance chamber that seals against backpressure. [0018] For instance, a hemodialysis machine can include a dialysis instrument having at least one peristaltic pump actuator and first and second pneumatic valve actuators. The instrument operates with a disposable cassette, the disposable cassette including a rigid portion, with at least one peristatic pump tube extending from the rigid portion for operation with the at least one pump actuator. The rigid portion defines first and second valve chambers in operable connection with the first and second valve actuators, respectively, the first and second valve chambers communicating fluidly with each other, at least the first 3 valve chamber communicating fluidly with a compliance chamberthe compliance chamber absorbing energy from a pneumatic closing pressure applied to close the first valve chamber, so as to tend to prevent the pneumatic closing pressure from opening an existing closure of the second valve chamber. [0019] The machine in one embodiment includes a vacuum applied to the compliance chamber to absorb the energy from the pneumatic closing pressure applied to close the first valve chamber. [0020] In the above example, a flexible membrane can be sealed to the rigid portion, the pneumatic closing pressure applied to the membrane to close the frst valve chamber. Here, the compliance chamber is formed in part via a portion of the flexible membrane, wherein the flexible membrane portion is configured to absorb the energy from the pneumatic closing pressure. The cassette can alternatively include a flexible diaphragm located on an opposing side of the rigid portion from the flexible membrane, the complance chamber formed in part via the flexible diaphragm, the flexible diaphragm configured to absorb the energy from the pneumatic closing pressure. [00211 The disposable cassette can have multiple compliance chambers operating with different sets of valve chambers. The compliance chamber aids both upstream and downstream valves. The compliance chamber overcomes a backpressure applied by the closing of the second valve chamber to the first valve chamber, to allow the first valve chamber to close properly. [0022] In another compliance chamber embodiment, the dialysis instrument has a pump actuator and first and second valve actuators. A disposable cassette is operable with the dialysis instrument, the disposable cassette including a pump portion operable with the pump actuator, the first and second valve chambers communicating fluidly with each other, at least the first valve chamber communicating fluidly with a compliance chamber, the compliance chamber negating a first backpressure due to a pneumatic closing pressure used to close the first valve chamber to help to ensure the pneumatic pressure applied to the first valve chamber will close the first valve chamber against a second backpressurc from an existing closure of the second valve chamber. Here, a pneumatic pressure applied to the second valve chamber can be the same as the pneumatic pressure applied to the first valve chamber. The first backpressure would exist around an outside of a port of the first valve chamber if not for the compliance chamber, the second backpressure existing inside the port. As before, the compliance chamber is further configured to tend to prevent the pneumatic pressure applied to the first valve chamber from opening the closed second valve chamber. 4 And, the machine in one embodiment includes a vacuum applied to the compliance chamber to ensure the pneumatic pressure applied to the first valve chamber will close the first valve chamber. [0023] In a further compliance chamber embodiment, the dialysis instrument has a pump actuator and first and second valve actuators. The disposable cassette is operable with the dialysis instrument, the disposable cassette including a pump portion operable with the pump actuator, and first and second valve chambers operable with the first and second valve actuators, respectively, the cassette further includes a compliance chamber in fluid communication with the first and second valve chambers, the compliance chamber defined at least in part by a rigid wall of the cassette and a diaphragm located on an opposing side of the rigid wall from the first and second valve chambers. The rigid wall in one embodiment defines first and second apertures that allow the first and second valve chambers to communicate fluidly, respectively, with the compliance chamber. The cassette can include a flexible membrane located on an opposing side of the cassette from the diaphragm, the membrane for closing the first and second valve chambers. Again, the compliance chamber can aid at least one of: (i) maintenance of an existing closure of the second valve chamber when the first valve chamber is closed; and (ii) a proper closure of the first valve chamber at a time when the second valve chamber is already closed. In one embodiment, the aiding is provided via a vacuum applied to the compliance chamber. [0024] In still a further compliance chamber embodiment, a dialysis instrument has a pump actuator and first and second valve actuator. A disposable cassette is operable with the dialysis instrument, the disposable cassette including a pump portion operable with the pump actuator, and first and second valve chambers operable with the first and second valve actuators, respectively. A compliance chamber is placed in fluid communication with the first and second valve chambers, the compliance chamber defined by in part by a flexible membrane used to close at least one of the first and second valve chambers, the valve chambers each defining an aperture for fluid cormnunication with the compliance chamber. The disposable cassette can include a rigid wall, the first and second valves chambers extending from the rigid wall towards the flexible membrane, wherein the apertures of the first and second valve chambers are formed in the rigid wall, and wherein the rigid wall also forms a third, larger aperture to allow fluid flowing through the valve chamber apertures to communicate fluidly with the flexible membrane of the compliance chamber. Again, the compliance chamber aiding at least one of: (i) maintenance of an existing closure of the second valve chamber when the first valve chamber is closed; and (ii) a proper closure of the 5 first valve chamber at a time when the second valve chamber is already closed, Again, the aiding can be provided via a vacuum applied to the compliance chamber. [0025] It is therefore an advantage of the present disclosure to properly seal valves in fluid communication with one another. [0026] It is another advantage of the present disclosure to provide an efficient priming technique that combines the use of dialysate and another physiologically safe fluid, such as saline. [0027] Additional features and advantages are described herein, and will be apparent from, the following Detaied Description and the figures. BRIEF DESCRIPTION OF THE FIGURES [0028] Fig. 1 is a perspective view of one embodiment of a personal home hemodialysis ("HHD") system having a mobile cart and integral bag manager, [0029] Fig. 2 illustrates the system of the present disclosure, in which a latch is pulled out to unlock a door. [0030] Fig. 3 illustrates the system of the present disclosure, in which a door is opened exposing a latch hook and peistal tic pump heads. [0031] Fig. 4 illustrates one embodiment of the system of the present disclosure, in which the door is hidden to more clearly show the door latch. [0032] Fig. 5 illustrates one embodiment of the system of the present disclosure, in which a disposable unit is loaded from above and slid to the right. [0033] Fig 6 illustrates one embodiment of the system of the present disclosure, in which the disposable unit is pivoted forward towards the interface. [0034] Fig. 7 illustrates one embodiment of the system of the present disclosure, in which the disposable unit pivots forward and the tube loops fit over the peristaltic pump heads. [0035] Fig. 8 illustrates one embodiment of the system of the present disclosure, in which the supply lins arc placed in operable communication with individual pinch valve plungers. [0036] Fig. 9 illustrates one embodiment of the system of the present disclosure, in which the supply lines are hidden to show pinch valve plungers. [0037] Fig. 10 is rear view of one embodiment of the system of the present disclosure showing a pinch valve strike plate. 6 [00381 FIG. 11 is a perspective view of one embodiment of a cam operated pinch valve subassembly operable with the system of the present disclosure, [0039] FIG. 12 is another perspective view of the pinch valve 5 subassembly of FIG. 11. [0040] FIG. 13 is a perspective view of the pinch valve subassembly of FIG. 11 with its housing and motor hidden, [0041] FIG. 14 illustrates a stepper motor operating with the pinch valve subassembly of FIG. 11. 10 [0042] FIG 15 illustrates blood lines operable with the system of FIG. 1 [0043] FIG. 16 illustrates blood line clamps closed on the blood lines of FIG. 15. [0044] FIG. 17 illustrates one embodiment of a blood line clamp 15 subassembly operable with the system of the present disclosure. [0045] FIG. 18 illustrates one embodiment of a blood line clamp manual override. [0046] FIG. 19 illustrates a user access to a manual override of the blood line clamps. 20 [0047] FIG. 20 is a perspective exploded view of one embodiment of a door showing a pressure plate, gasket and bellows operable with the system of the present disclosure. [0048] FIG. 21 illustrates the system with a door cover removed exposing tubes for bellows. 25 [0049] FIG. 22 illustrates the system with the door hidden to better show an inline heating system. [0050] FIG 23 illustrates the system with the door and cassette hidden to better show a heater coil and wave heater disks, [0051] FIG. 24 ilustrates a front view of a retracted peristaltic pump 30 race of the system of the present disclosure. 7 {0052] FIG. 25 iustrates a rear view of a retracted peristaltic pump race. [0053] FIG. 26 illustrates a rear view of the peristaltic pump race extended. 5 [0054] FIG. 27 illustrates that an instrument housing supports the front of the pump race actuator shafts. [00551 FIG. 28 illustrates one embodiment of a manual blood pump operation of the system of the present disclosure. [0056J FIG, 29 illustrates a manual blood pump operation with the 10 instrument door closed and latched. [0057] FIG. 30 illustrates one embodiment of a bag management system operable with the HHD system having shelves folded up and ready for placement of a first supply bag 15 [0058] Fig. 31 illustrates a supply bag placed on a bottom shelf of the bag management system. [0059] Fig. 32 illustrates one embodiment in which the bag management system can hold up to five solution bags. [0060] Fig. 33 ilustrates the bag management system with all solution bags connected and bag peel seals broken. [0061] Fig. 34 illustrates the bag management system with capacitive sensors pJaced on opposite ends of the shelves. [0062] Fig. 35 illustrates one embodiment of a connection of disposable set to a heparin syringe. [0063] Fig. 36 illustrates the syringe and luer connector assembly loaded into a syringe pump. [0064] Fig, 37 illiustrates the connector of Fig. 36 rotated 45* to lock the syringe into the syringe pump. [0065] Fig. 38 illustrates that a large, e.g., 50/60 ml, syringe can lock directly into the syringe pump. [0066] Pig. 39 illustrates one embodiment of a syringe pump mechanism operable with the HHD system of the present disclosure. [0067] Fig. 40 illustrates one embodiment of a viewing window for viewing heparin delivery. [0068] Fig. 41 illustrates the heparin line passing through the side of the cassette and attaching to the backside of the instrument. [0069] Fig. 42 illustrates that heparin enters at the blood pump oudet just before the dialyzer inlet. [0070} Fig. 43 lustrates one embodiment of a saline bag support rod operable with the HIHD system of the present disclosure. [0071] Fig. 44 illustrates the sale line connected to the cassette near the heparin line. [0072] Fig. 45 illustrates a saline valve located on each side of the blood pump. [0073] Fig. 46 lustrates that the saline valve ports feed into each side of the blood pumnp. [0074] Fig. 47 illustrates that a dialyzer inlet pressure sensor interface can serve additionally as a flow control valve. 8 [0075] Fig. 48 illustrates the venous and arterial lines are connected together to form a priming loop. [0076] Fig. 49 ilustrates one embodiment of a venous air separation chamber operable with the system of the present disclosure. [0077] Figs. 50 and 51 illustrate one embodiment of a venous air separation chamber valve operable with the system of the present disclosure. [0078] Fig. 52 is a fluid schematic illustrating one possible fluid flow regime for the H-D system of the present disclosure. [0079] Figs. 53A and 53B illustrate one embodiment of a disposable set operable with the system of the present disclosure. [0080] Fig. 54 is a fluid schematic illustrating one embodiment for gravity priming of the venous lne; the arterial line and the air trap (drip chamber) [0081] Fig. 55 is a fluid schematic illustrating one embodiment for pressurized priming of the dialyzer and purging of air from blood side circuit. [0082] Figs. 56 and 57 are fluid schematics illustrating one embodiment for priming the dialysate circuit. [0083] Fig. 58 is a section view of one embodiment for balance tubes having outlets at the tops of the tubes, the tubes operable with the HHD system of the present disclosure. [0084] Fig. 59 is a fluid schematic illustrating the HHD system of the present disclosure performing hemodialysis. [0085] Fig. 60 is a fluid schematic illustrating the HHifD system of the present disclosure performing pre-dilution hemofiltration. [0086] Fig. 61 is a fluid schematic illustrating the HHD system of the present disclosure performing post-dilution hemofiltration. [0087] Fig. 62 is a fluid schematic illustrating the HHD system of the present disclosure performing post-dilution hemodiaflltration. [0088] Fig. 63 is a fluid schematic illustrating one embodiment for closing an arterial line clamp, opening a saline valvc and infusing saline bolus during therapy. [0089] Fig. 64 is a fluid schematic illustrating one embodiment for recirculating fresh dialysate in heater circuit and balance tubes to remove ultrafitration ("UF"). [0090] Fig. 65 is a fluid schematic illustrating one embodiment for closing a venous line clamp, opening a saline valve and rinsing back blood from the arterial line. [00911 Fig. 66 is a fluid schematic illustrating one embodiment for closing an arterial line clamp, opening a saline valve and rinsing back blood from the venous line. 9 [0092] Fig. 67A is a perspective view of one embodiment of a disposable interface subassembly operable with the HHD system of the present disclosure. [0093] Fig. 67B is another view of the disposable interface subassembly of Fig. 67A. [0094] Fig. 67C is an exploded view of an internal module operable with the subassembly of Figs. 67A and 67B. [0095) Fig. 68 is a perspective view illustrating springs at the four corners of the subassembly of Figs. 67A and 67B that retract the internal module of Fig. 67C. [0096] Fig. 69 is a perspective view illustrating the backside of one embodiment of a cassette interface faceplate operable with the HHD system of the present disclosure. [0097] Fig. 70 is a perspective view illustrating the backside of one embodiment of a membrane gasket operable with the HHD system of the present disclosure, [0098] Fig. 71 is a perspective view of the internal instrument components from the backside of the hemodialysis system, showing that there is room for additional, e g. electrical, components. [0099] Fig. 72 is a perspective view of one embodiment of the HHD system operating in conjunction with an online dialysate generation system. [00 100] Fig. 73A illustrates one embodiment of a diaphragm valve assembly having a compliance chamber seal against backpressure, which is operable with the HHD system of the present disclosure. [00101] Fig. 73B lustrates one embodiment of a valve assembly having compliance chambers, 100102] Fig, 74 is a perspective view of a disposable cassette having the valve assembly of Figs, 73A and 73B, [00103] Fig, 75 illustrates one embodiment of a peristaltic pump head sized to operate with multiple supply lines for mixing different fluids of the HHD system of the present disclosure. DETAILED DESCRIPTION [00104] Referring now to the drawings, Fig. 1 illustrates onc embodiment of a system 10 sitting idle with its dust cover (not illustrated) removed. A handle 12 for a cart 14 is located in a lowered position to minimize the space that system 10 consumes. Shelves 16 for the supply bags (shown below) are also shown in a lowered or "down" position, which minimizes the height of system 10. [00105] System 10 is programmed in an introductory state to instruct the user to open a door 18 shown in Fig, 21 Fig. 2 illustrates a close-up view of system 10 with a latch 34 10 pulled out to unlock door 18. Once door 18 is unlocked as seen in Fig. 3, it swings open, e.g., about forty-five degrees, and is held in the open position by a stop (not seen), so that a disposable set (shown below) can be loaded or unloaded. [00106] Fig. 3 illustrates instrument 20 of system 10 with door 18 held in the open position, exposing multiple peristaltic pump heads 22, a latch hook 24, inductive heater coil 26 and a slotted area 28 for the blood lines (not illustrated) to run to and from the patient. Ultrasonic air bubble detectors and optical blood/saline/air detectors are integrated into the molded slotted area 28 just above a cutout in the slot for the venous and arterial line clamps. The cutout located in slotted area 28 accommodates the venous and the arterial line clamps. Figure 16 shows the venous and arterial line clamps 76 in the closed position, in which the clamps extend through a respective cutout. In an alternative embodiment, the inductive heater coil 26 is refracted into the system to facilitate loading. [00107] In Fig. 4, door 18 is not shown for clarity to illustrate latch 34 and latch hook 24, wherein latch 34 mechanically engages latch hook 24 to hold door 18 closed against the main portion of instrument 20. One suitable latch assembly is shown and described in Figs. II and 13 of U.S. Pat, No. 6,261,065, "System and Methods for Control of Pumps Employing Electrical Field Sensing", the pertinent portions of which are incorporated herein expressly by reference. [00108] As seen in Fig. 5, once door 18 has been opened, system 10 prompts the user to load the disposable set. A cassette 40 of the disposable set is lowered into the bag of instrument 20 and moved to the right (with respect to the orientation of instrument 20 in Fig. 4). Cassette 40 is loaded starting at the upper left side of open door 18, so that the patient's blood lines extending downwardly from cassette 40 do not interfere with the loading procedure, The patient's left hand can grasp a dialyzer 36 connected to cassette 40, while the patient's right hand can grasp a tubing bundle 38 formed by the supply and drain lines. Single handed loading is also possible, e.g., using right hand only grasp bundle 38 to move both cassette 40 and dialyzer 36. [01001 As seen in Figs. 6 and 7, door 18 pivots cassette 40 forward towards a cassette interface 50 of instrument 20 when an opening 42 in cassette 40 is located directly over the inductive heater transformer coil 26. In an alternative embodiment, transformer coil 26 is retracted to facilitate loading of cassette 40. In such case, coil 26 is then extended into operating position after cassette 40 is loaded against interface 50. A bezel (not shown) provides locating stops for stopping cassette 40 in the vertical and horizontal directions. 11 [0101] As cassette 40 mates with the cassette interface 50, the peristahic pump tubing loops 44 of cassette 40 slip over the vertically aligned pumping heads 22. A pump race 46 is retracted automatically upwardly when door 18 is opened to provide clearance between the pump heads 22 and pump race 26 to facilitate the loading of pump tubing 44 and cassette 40. [0102] Fig. 8 illustrates the supply lines 38a to 38e of bundle 38 (number of supply lines 38 can vary) passing over retracted pinch valves 48. System 10 also retracts pinch valves 48 automatically when door 18 is opened to facilitate the loading of bundle 38 and cassette 40 against interface 50 of instrument 20. System 10 opens and closes pinch valves 48 in a controlled manner, eliminating the need for manual clamps on supply lines 38a to 38e. Fig, 9 is shown with supply lines 38 removed to more clearly illustrate pinh valve plungers 48. [0103] Fig. 10 further illustrates pinch valve 48/supply line 38 interaction. Pinch valves 48 pinch supply lines 38 closed against a strike plate 52. In Fig. 10, four pinch valves 48 for supply lines 38b to 38e are pinching a respective supply line closed against strike plate 52, while a fifth pinch valve 48 is retracted, allowing supply line 38a to be open. [0104] Figs. II and 12 illustrate a pinch valve subassembly 60, in which three of the five plungers 48 are extended (closed state). Clamp heads 54 are connected to a pinch valve body 62 of subassembly 60. Fig. 13 is shown with body 62 removed to illustrate springs 56 that spring load pinch valve plungers 48, e.g., so as to be normally closed. Springs 56 preload pinch valve plungers 48, allowing for variations in the wall thickness of supply tubes 38. Fig. 13 also illustrates that clamp heads 54 are formed with cam followers 58, which ride on associated cam lobes 62 coupled to a camshaft 64 (Figs. 11 and 14). A motor 66, e.g., a stepper motor, is coupled to a drive camshaft 64. Fig. 14 illustrates that in one embodiment, the individual cam lobes 62 each define apertures configured fit onto a keyed portion 68 of shaft 64. Fig. 14 further illustrates the interaction of cam followers 58 and cam lobes 62. [0105] Fig. 15 illustrates that when cassette 4|0 is loaded into instrument 20 of system 10, blood lines 72 and 74 exit to the lower left of door assembly 90 with venous and arterial line clamps 76 (Fig 16) open initially. Fig. 16 illustrates that venous and arterial line clamps 76 pinch bloodlines 72 and 74 against housing portion 78 of instmment 20 to close bloodlines 72 and 74. During normal operation, system 10 operates clamps 76 independently as needed. Fig- 17 is shown wih housing portion 78 and door assembly 90 removed to more fully illustrate venous and arterial line clamp subassembly 70. A strike part of housing portion 78 seen in Fig. 16 is located between the venous and arterial lines 72 and 74 and pinches the lines together with the clamping levers 76 when closed, 12 [0106] Fig. 18 illustrates the venous and arterial line clamp subassembly 70 less a housing 77 shown in Fig. 17, in which clamps 76 are in the open position. Subassembly 70 includes bellows 80 that hold clamps 76 open during normal operation. Subassembly 70 also allows for an Allen wrench 82 with a T-handle 84 to be used to operate a worm gear 86 that is coupled operably to a cam 88, which cooperate to manually open both the venous and arterial line clamps 76 if need be. In an alternative embodiment, subassembly 70 includes dual worm gears and a split cam, so that the venous and arterial line clamps 76 can be manually operated independently. Fig. 19 illustrates the placement of the T-handle Allen wrench 82 with respect to instrument 20 when the venous and arterial line clamps 76 are operated manually. In one embodiment, system 10 causes an, e.g., red, flag (not illustrated) to protrude when the clamps 76 have been opened manually. The flag retracts when the manual override is not engaged. [0107] Fig. 20 lustrates an exploded view of the door assembly 90 taken from inside instrument 20. A pair of bellows or bladders 92a and 92b pushes a plate 94 having a gasket 96 to press the cassette 40 (not seen here) against the disposable interface 50 (not seen here). A space between bladders 92a and 92b is provided to accommodate the inductive heater coil 26 extending from disposable interface 50. Alteatively, instrument 20 provides a single bellows (bladder) to press cassette 40 against the disposable interface 50, which has an internal opening to accommodate heater coi 26 extending from disposable interface 50. [0108] In an ahemate failsafe embodiment (not iHustrated) the bellows 92a and 92b are replaced by a cavity with a diaphragm that is connected sealably to front pressure plate 18. Springs are located between front pressure plate 18 and the back wall of the cavity and press cassette 40 against disposable interface 50, except when a vacuum is present within the caviy. In the alternative embodiment, system 10 can also introduce positive pressure into the cavity to increase the sealing force. [0109] Fig. 21 illustrates system 10 with the door cover 98 (Fig. 20) removed. Pneumatic lines 102a and 102b to bellows 92a and 92b, respectively, are shown teed together bcforc the exiting door 18 through a hollow hinge 104. A vertical metal bar 106 completes a circuit for the inductive heater transformer primary coil 26 when the door 18 is closed against interface 50 of instrument 20. Fig. 22 is also shown with door 18 removed to illustrate the inductive heating system including transformer coil 26 and a wave-shaped disk or disks 108 located in disposable cassette 40, which form a secondary coil that heats dialysis fluid due to izR losses. Fig. 23 removes cassette 40 to show inductive heater 100 more clearly. Heater 100 transfers energy from the inductive coil of the transformer 26 into wave washers 108a 13 and 108b that are located within cassette 40. Washers 108a and I 08b in tum heat dialysate as it flows through cassette 40. [0110] Fig. 24 illustrates the front of the instrument 20 with door assembly 90 and device housing hidden to expose a mechanism 110 that extends and retracts triple peristaltic pump race 46. Mechanism 110 includes four idler gears 112 that tie geared triple cams 114 together to move race 46 to extend (towards tubing 44) and retract (from tubing 44) smoothly. Mechanism 110 is configured such that race 46 extends towards tubing 44 only after door 18 is closed and latched to preclude the operator from being exposed to any moving components. The centers of pump heads 22 are aligned to provide clearance between the pump heads and triple race 46 when the race is retracted. [0111] Fig. 25 illustrates the backside of the retractable triple peristaltic pump race 46 and mechanism 110 for moving race 46. Cams 114 are located at each end of race mechanism 110 and race 46. A middle cam 114 is also provided. Each idler gear 112 (Fig. 12) includes a shaft 113 that transmits rotational motion from the idler gears to all three cams 114 simultaneously. Cams 114 each include lobes 116 that rotate simultaneously and in concert within large rounded end slots 118 to simultaneously and evenly extend and retract race 46. Shafts 113 of idler gears 112 (Fig. 24) maintain the horizontal orientation of the peristaltic pump race 46 as the race moves up and down. [0112] Fig. 25 illustrates the cam lobes 116 rotated simultaneously and in concert upwardly, pushing the pump race 46 away from gear motors 120 that are coupled to pump heads 22. The open parts of the horizontally stabilizing idler guide slots are above the shafts 113 of idler gears. Fig. 26 illustrates the cam lobes 116 rotated simultaneously and in concert downwardly, pushing pump race 46 towards the pump gear motors 120 coupled to pump heads 22. The open parts of the horizontally stabilizing idler guide slots 122 are now below the shafts 113 of idler gears 112 [0113] Fig. 27 illustrates molded support bosses 124 secured to instrument 20 that support shafts 113 of the idler gears 112 and support the shafts 115 of cams 114 on one end. A bar (not shown here but shown in Fig. 71), which mounts to bosses 124, supports the shafts 113 of gears 112 and shafts 115 of cams 114 on their other ends. A motor (not illustrated) that drives cams 114, which operate the retractable pump race 46, is attached to any of the shafts 115 of any of cams 114. Attaching the motor to the shaft of center cam 114 may be preferred so that clearance in the gear train is symmetric with respect to outer cams 114. [0114] Figs. 28 and 29 illustrate that system 10 includes a crank 130 that is connected to the blood pump head 22 to operate the head manually. Manual return of the blood 14 contained within the extracorporeal circuit is necessary in the event of a failure of system 10 or after an extended power failure. It is typically necessary to manually operate the venous and arterial line clamps 76 (from a failed closed state) before being able to return the blood in extracorporeal circuit to the patient. Fig, 29 also lustrates that door 18 in one embodiment defines an opening or aperture 132 through which manual crank 130 for the blood pump 22 can be inserted with the door closed. Crank 130 includes a large gripping handle 134 and crankshan 136, which is sufficiently long to allow the user to easily turn blood pump head 22. In an altemate embodiment, manual crank 130 is built into the door assembly 90 and is accessible to engage pump head 22 when door 1 Fis opened and hinged away from machine interface 50. [0115] As seen in Fig. 30., in one bag management embodiment, system 10 prompts the user initially to fold up all of bag shelves 16 except for the bottom shelf 16. The user is then able to break a peel seal of a dual chamber bag (if used), place the first solution bag 140 on bottom shelf 16 and connect the bag to the bottom supply line 38e extending from disposable cassette 40, as shown in Fig. 31. When shelf sensors 138 detect that the bag has been placed onto first shelf 16 and that the peel seal 142 has been broken, system 10 prompts the user to place a second bag 140 on the second lowest shelf 16, and so on. System 10 continues to prompt the user to place solutions bags 140 onto shelves 16 and connect the bags to supply lines 38 until all of shelves 16 are filled, as shown in Fig. 32. [0116] As shown in Fig. 32, a pee seal 142 of dual chamber bag 140 present on the top shelf 16 is not broken, a condition which sensors 138 can sense, causing system 10 to instruct the user to break peel seal 142 before continuing with treatment. One such sensor arrangement and peel seal open check is described in U.S. Patent Application No. 1/73,742 entitled "Mobile Dialysis System Having Supply Container Detection", filed July 5, 2007, assigned to the assigned of the present disclosure, the pertinent portions of which are incorporated herein expressly by reference. Fig. 33 illustrates all solution bags 140 with peel seals 142 broken, such that treatment can continue. [0117] Fig. 34 illustrates one embodiment for the placement of the capacitive sensors 138 that detect the presence of the solution bags, whether peel seal is broken, and perhaps even whether the same solution is present in each bag 140. Other sensors or combinations of sensors can be used alternatively, including optical sensors, inductive sensors, bar code readers, radio frequency identification ("RFID") tags and cameras. [0118] Fig. 35 illustrates a luer connection assembly 144, which is located on an end of a heparin line 146, which in turn is connected to disposable cassette 40. A heparin syringe 15 148 ranging in size from ten milliliters to sixty milliliters, can be connected to luer connection assembly 144 of the disposable set and is inserted with the plunger 150 pointing down into a syringe pump 152 as shown in as shown in Fig. 36. The luer connection assembly 144 is then rotated to lock the syringe in place as shown in Fig. 37. Syringe 148, for sizes larger than 30 milliliters, is inserted with the plunger 150 pointing down into a syringe pump 152 as shown in as shown in Fig. 38. The integral grip 149 on the larger heparin syringes is rotated forty-five degrees to lock the syringe 148 into the syringe pump 152 as shown in Figs. 37 and 38 versus grip 149 shown in Fig. 36. [0119] Syringe pump 152 is shown in more detail in Fig. 39. Pump 152 includes a stepper motor 154, gears 156, guide rails 158 and a concave push plate 160 that self-centers on the end of the syringe plunger 150. Air exits syringe 148 above the heparin and is purged during the priming of the extracorporeal circuit because syringe 148 is inverted for use. Stepper motor 154 increments 0.9 degrees per step in one implementation. Pump 152 and assembly 144 are sized to accept nearly any size of syringe 148. The user inputs the syringe stroke length and syringe stroke volume into system 10. System 10 can thereafter determine the volume of heparin to be delvered. [0120] Smaller syringes 148 are visible through a window 162 in the side of the pump as shown in Fig. 40. Larger syringes housings are visible since they are not inserted into syringe pump 152 and remain outside of instrument 20 as illustrated in Fig. 38. Should a saline or dialysate bag leak, or be spilled, onto instrument 20, the liquid could flow into the heparin pump and out the opening in side window 162 but would not flow inside the instrument, where the fluid could damage instrument 20, [0121j Figs. 41 and 42 illustrate that hepaiin line 146 passes through an air bubble detector 164 to cassette 40. System 10 introduces heparin into the patient's blood stream at the outlet 166 of the blood pump just before the blood passes into the dialyzer. The internal volume of the heparin line is essentially that of a very small diameter tube of minimum length. A diaphragm actuated pinch valve 165 (plunger only shown in Fig. 41), which does not add to the internal volume of the hcpain line, can be provided to block the flow of beparin to cassette 40. [0122] Fig. 43 illustrates a support rod 168 that collapses into instrument 20 when not in use. Support rod 168 supports a saline bag 170 that is used for priming system 10 and rinsing blood back to the patient at the end of the therapy. Alternatively, rod 168 is detachable from instrument 20 when not in use. 16 [01 23] Figs. 43 and 44 illustrate that saline line 172 enters instrument 20 adjacent to the entry of heparin line 164 (see also Fig. 41). Fig. 45 illustrates that two saline flow control valves 174a and 174b are located on each side of blood pump tubing loop 44. The center port from each of the valves feeds directly into blood flow into, or coming from, the blood pump as shown in Fig. 46. The third saline valve 174c is located on the backside of cassette 40 as seen in Figs. 45 and 46 and is positioned to put saline directly into a venous air separation (drip) chamber 176. The saline valve 174a on the blood pump outlet, and the saline valve 174b leading to dialyzer 36, are opened sequentially to gravity prime the arterial blood line and the venous drip chamber 176 as illustrated later in Fig. 54. [0124] As seen in Fig. 47, a normally evacuated dialyzer inlet line pressure transducer interface 178 is pressurized so that it operates as a flow control valve, preventing saline from backflowing into the dialyzer or filter 36, The gravity head from the saline bag causes saline to flow into the blood circuit and into the reversed rotating pump inlet 180 (the outlet under normal operating flow) when saline valve 174a is opened. The reversed flow blood pump head 22 draws saline from the saline bag and pumps it through reversed flow outlet 182 (the inlet under normal operating conditions) and down the arterial line 186. [0125] As seen in Fig. 48, the venous line 184 and arterial line 186 are connected in series during priming so that air is purged from both lines via venous line drip chamber 176 shown in Fig. 49. Standard connections 188 (Fig. 48) can be used to connect the venous line 184 and arterial line 186 in a closed loop. Gravity prevents air from being drawn from the saline bag as Long as the bag contains saline. Saline flows slowly into the venous air separation chamber 176 in a "reverse" direction (from normal blood flow) during priming. [0126] In Fig. 49, the inverted-U shaped venous air separation chamber 176 has a vent port 190 located at its top, so that air can gather there and be vented to the drain. Fig. 50 shows a valve 196 located on the opposite side of the cassette 40 from vent port 190, which is opened whenever air needs to be vented from the chamber. A second vent valve 192 also shown in Fig, 50 can be placed optionally in series with first vent valve 196 and operated sequentially so that predetermined volumetric increments of air can be vented from system 10 to a controlled vent volume 194 shown in Fig. 51. As seen in Fig. 51, port 190 connected to the center of the cassette-based diaphragm valve 196 communicates with air separation chamber 176 so that the "dead" volume needed for these apparatuses is minimized. Valve 196 seals well against the pressure present in the venous air separation chamber. Saline bags can be replaced during a therapy since they can be primed directly into the drip chamber 176 using the third saline valve 174c (Fig. 49). 17 [0127] FIG. 52 is a schematic of one embodiment of a fluid management system associated with the disposable set, In general, the fluid management system includes a blood circuit 210 and a dialysate circuit 220. System 10 operates the disposable set to provide the hemodialysis therapy 5 Set 200 of FIGS. 53A and 53B illustrates an embodiment of a disposable set 200 operable with system 10. Disposable set 200 includes cassette 40, filter 36, pump tubes 44, supply tubes 38, balance tubes 202, arterial line 184 and venous line 186, etc,. discussed herein. [0128) Once disposable set 200 has been loaded into the hemodialysis 10 system 10, dialysate bags 140 have been connected, the saline bag 170 (FIG. 43) has been connected and the heparin syringe 148 has been loaded, system 10 primes itself automatically starting with the blood side circuit. The heparin pump plunger 150 is moved forward until heparin is detected by heparin line air detector AD-HL shown in FIG. 52. Heparin valve V-H is then closed. Next, 15 saline is flowed from the saline bag 170 into the blood side circuit 210 as illustrated in FIG. 54, first through valve V-SA and then through valve V-SDC. A level sensor L-ATB in the AIR TRAP drip chamber detects saline flow into the drip chamber 176 and determines when to close valves V-SA and V-SDC. [0129] As shown in FIG. 55, the post pump blood valve V-PPB is then 20 closed, V-SV is opened and PUMP-Blood pumps saline in a reverse flow direction. Pressure sensor P-VL and level sensor L-ATB are used to determine when to open air vent valves V-AVB-P and V-AVB-S. The blood pump pushes the saline backwards down the arterial line and into the venous line. When saline reaches the venous air separator (drip chamber 176), the air will be 25 separated from the fluid and will be discharged into a drain line 206 through vent valves V-AVB-P and V-AVB-S until the air separation chamber 176 is flooded with saline. [0130] Next, as seen in FIG. 55, saline is flowed up into the bottom of dialyzer 36 and up through its hollow fibers. Valve V-PPB is controllably 18 opened so that the air that exits the top of the dialyzer 36 flows into the priming loop, becomes separated in air trap 176 and discharged to drain 206. Saline is also flowed through pours of the fibers of dialyzer 36 to fill the housing of dialyzer 36. System 10 monitors the pressure in the venous line using pressure 5 sensor P-VL to maintain the blood side circuit 210 at a controled pressure during priming. [0031] As seen in FIG. 56, spent diafysate pump, PUMP-DS and valves V-DS, V-B1-SI, V-B-SO and V-DD vent air from the dialyzer housing to drain 206. Valves V-DI-VEN, CK-VEN, V-DI=FIL, V-DI-PRE and CK-PRE are 10 opened controllably to allow a predetermined volume of saline to be pushed into the dialysate circuit 220, purging air from 18a associated dialysate lines. A second saline bag 170 can be replaced during a therapy by selecting "replace saline bag", causing the saline line to be primed automatically into the air trap 176. [0132] As shown in Fig, 56, dialysate valve V-DBI that is associated with the dialysaite bag on the top shelf is opened so that dialysate can flow into the inlet of dialysate PUMP-DF. PUMP-DF pushes the dialysate through the inline fluid heater and into a dialysate side air trap 208. Dialysate flows out the bottom of the air trap 208, through valve V-Fl and into balance tube B2, through valve V-B2-FI, pushing fluid out the other side of balance tube B2. The fluid exiting the other side of balance tube B2 flows through valve V B2-SO and into the dialysate recirculating circuit 203 through valve V-DR. The recirculating circuit 223 tees into the supply line circuit 205 at the inlet to PUMP-DF Pump-DS is operating at the same time drawing air, dialysate and/or saline from the blood side of the dialyzer, though the dialysate side of the dialyzer, into the remainder of the dialysate circuit. PUMP-DS pushes the fluid through valve V-B1-SI and into balance tube B1, pushing fluid out the other side of balance tube B1. The fluid exiting the other side of balance tube B1 flows hroiugh valve V-Bi-FOQ and valve V-DI-FIL into the dialysate side of the dialyzer 36. [0133] Fig. 57 is similar to Fig. 56 except the roles of balance tubes 202 B1 and B2 are reversed. As fluid enters the dialysate circuit 220, the pressure in the circuit increases, forcing air to be discharged under pressure to drain line 206 through open vent valves V AVD-P and V-AVD-S. [0134] Fig. 58 illustrates balance tubes 202. Instrument 20 includes pairs of optical sensors (not shown) operable with balance tubes 202 to determine an end of travel of a separator 212 located within each balance tube 202. The optical sensors in one embodiment are reflective, so that an emitter and receiver of each sensor can be on the same (e.g., non door) side of balance tube 202. The sensors alternatively include emitters and receivers located on opposite sides of balance tubes 202. Outlets 214 on both ends of both balance tubes 202 are at the balance tube tops when mounted for operation as shown if Fig. 58, so that air wil pass through the balance tubes and not become trapped in the tubes as long as system 10 is level. Mechanical stops 216 limit the movement of separators 212 to that visible to the optical sensors. ro135] Fig. 59 illustrates HD system 10 performing hemodialysis. Here, fresh dialysate is pushed front balance tubes 202 to dialyzer 36 via valve V-DI-FIL, white spent dialysate is removed fror dialyzer 36 via valve V-DS to balance tubes 202. 19 [0136] FIG. 60 illustrates HHD system 10 performing pre-dilution hemofiltration. Here, fresh dialysate is pushed from balance tubes 202 to blood circuit 210 directly via valve V-DI-PRE, while spent dialysate is removed from dialyzer 36 via valve V-DS to balance tubes 202. 5 [0137] FIG. 61 illustrates HHD system 10 performing post-diution hemofiltration. Here, fresh dialysate is pushed from balance tubes 202 to blood circuit 210 directly via valve V-DI-VEN, while spent dialysate is removed from dialyzer 36 via valve V-DS to balance tubes 202. [0138] FIG. 62 illustrates HHD system 10 performing post-dilution 10 hemo-diafiltration. Here, fresh dialysate is pushed from balance tubes 202 to (I) dialyzer 36 via valve V-DI-FIL and (ii) blood circuit 210 directly via valve V-DI VEN, while spent dialysate is removed from dialyzer 36 via valve V-DS to balance tubes 202. [0139] FIG, 63 lustrates one embodiment for closing arterial line 15 clamp V-ALC, opening a saline valve V-SA and infusing a saline bolus into blood circuit 210 during therapy. [0140] FIG. 64 illustrates one embodiment for recirculating fresh dialysate through Fluid Heater and recirculating circuit 223 and balance tubes 1 and 132 to remove UF. in FIG. 64, pump-DF pumps fluid in a loop that 20 includes Fluid Heater since valve V-DBY is open. Valve V-Fl is closed so no fresh dialysate is delivered to balance chambers 202. Pump-DS pulls spent fluid from the dialyzer 36 through valve V-DS and pushes the spent fluid through valve V-SI-SI and into the right side of balance tube BI. Fresh fluid then flows from the left side of balance tube 11 through valves V-B2FI and 25 V-B2-FI and into the left side of balance tube B2. Spent fluid then flows out the right side of balance tube B2 through valves V-132-SO and V-DD and into the drain line In this manner, a volume of spent fluid is sent to drain 206 without a corresponding volume of fresh fluid delivered from supply bags 140 to either balance chamber B1 or B2. 30 20 [0141] FIG. 65 illustrates one embodiment for closing venous line clamp V-VLC, opening a saline valve V-SA and rinsing back the arterial line 184. [0142] FIG. 66 illustrates one embodiment for closing arterial line 5 clamp V-ALC, opening a saline valve V-SA and rinsing back the venous line 186. [0143] FIGS. 67A to 67C illustrate a cassette interface assembly 250, which houses, among other items, cassette interface 50, door latch 24, heater 26 a below bladder 252 and an internal module 260. Internal module 260 is 10 bounded by interface plate 50 and a back 20a plate 254. Internal module 260 houses a plurality of gaskets 256, a pneumatic valve assembly 258, a pinch valve assembly 262, and a plurality of manifold plates 264. [0144] All or most all of the valves, pressure sensors, level sensors, etc., can be removed without disassembly of subassembly 250. The inductive heater mechanism 26 and bellows bladder 252 (different from bladder 92 above) require removal of internal module 260. To this end, four screws 266, each with a spring 268, fix a housing 270 of subassembly 250 to internal module 260. Internal module 260 can be unbolted from screws 266, so that springs 268 push internal module 260 forward and out of the housing 270. Power and control connections (not shown) to subassembly 250 are also disconnected to remove internal module 260 completely. [0145] As seen additionally in Figs. 68 to 70, four springs 268 on the backside of subassembly 250 retract the internal interface module 260 when bellows bladder 252 is not pressurized by pushing screens away from housing 270 and pulling interface module 260 along with the screws. When the bellows bladder 252 is pressurized, internal module 260 is pushed forward and applies pressure to cassette 40, pushing the cassette against a door gasket, which seals fluid pathways on both the front side and the rear side of the cassette 40. The mnembrane gaskets 256 on the internal module 260 mate up against the faceplate 50 of the interface module 250. The faceplate 50 is configured so that it can support a vacuum between the cassette sheeting and pressure sensors, liquid level sensors, etc., bringing the sensors into inmate contact with the cassette sheeting and the fluid on the other side of the sheeting. System 10 is also configured to port a vacuum between the cassette sheeting and the thin sections of the membrane gasket 256 above the valves. This vacuum can be used to detect holes, tears or slits in the cassette sheeting before, and during a therapy. [0146] Fig. 71 is a view of the backside of system 10 with the cover removed. The open space houses interface assembly 250, hinged shelves 16, peristaltic pump motors 120 a pnieumatic pump, a power supply, battery and electronics that operate the system. [0147] Fig. 72 illustrates system 10 operating alternatively with an online dialysate generation system 300. System 300 generates dialysate online or on-demand, elminating bags 140, shelves 16 and multiple supply tubes 38. A single supply tube 38 feeds from generation system 300 to instrument 20. Water inlet line 302 and drain lines 304 lead to and from generation system 300, respectively. [0148] Figs. 73A, 73B and 74 lustrate a cassette 40 diaphragm valve chamber configuration 280, which solves an inherent problem with diaphragm valves have when attempting to seal against downstream pressure because the pressure that is hying to seal off 21 the valve is acting on an area that is just slightly larger than an area upon which the downstream pressure is acting. The difference between the two areas is the area defined by the top of the "volcano". Also, if the downstream fluid volume is completely fixed when the diaphragm valve closes, further movement of the diaphragm is prevented after the initiation of the seal because of the incompressibility of the trapped fluidi The result is that the downstream pressure equals the valve sealing pressure. Diaphragm valve configuration 280 provides a diaphragm valve that can seal against both upstream and downstream pressure via a connection of two diaphragm valve chambers 282 and 284 placed in series. Diaphragm valve chambers 282 and 284 are connected fluidly via a compliance chamber 286, which allows sheeting seals 288 of the cassette sheeting to close around respective volcano ports 290 of both valve chambers 282 and 284. [0149] Chamber configuration 280 in both Figs. 73A and 73B includes a rigid middle or base wall 281 from which valve ports 290 and the valve chamber walls extend upwardly. Wall 281 defines an aperture 283 for each valve chamber 282 and 284. Fluid communicates between valve chambers 282 and 284 and compliance chamber 286 via apertures 283. [0150] Fig. 73A shows a cross-section of two diaphragm valve chambers 282 and 284 with an integral compliance chamber 286, wherein the diaphragms can readily close seals 288 to ports 290. Here, a vacuum is applied to a lower diaphragm 289 at the compliance chamber 286. Diaphragm 289 is flexible and has a relatively large cross-sectional area to absorb the kinetic energy created by a pneumatic valve actuator applying a positive pressure Pa, such that the positive sealing pressure applied to one valve chamber 282 or 284 is much less likely to harm an existing seal of a fluidly connected upstream or downstream valve chambers. The negative pressure pulls sheeting 288 down around ports 290 and allows valve chamber 282 or 284 to be sealed against the backpressure applied by its own sealing pressure (around the outside of port 290) plus backpressure from a fluidly connected upstream or downstream valve chamber residing up through the center of port 290. [0151] Compliance chamber 286 as seen in Fig. 73B is configured a little bit differently and uses a portion of the membrane or shooting scals 288 of valve chambers 282 and 284 to provide a compliant material covering a relatively large cross-sectional area 292 of chamber 286. Here, a vacuum applied to sheeting 288 at chamber 286 negates the positive pressure Pc applied around the outside of ports 290 and expands the relatively large area 292 of the valve seal sheeting, pulling sheeting 288 down around the outside of port 290. The configuration of Fig. 73B is advantageous in one respect because positive and negative 22 pressures are applied to the same side of the cassette at chamber configuration 280, such that associated pneumatics can be located on a single side ofthe cassette.. [0152] By changing the pressure seen at compliance chamber 286 from a positive pressure when the valve chambers 282 and 284 are open to a negative value after the valve chambers results in that only the liquid side center of the volcano port 290 is exposed to high positive pressure. The liquid annular area of valve chambers 282 and 284 on the outside of volcano ports 290 sees the applied vacuum, which allows the air sealing pressure on the outside of the cassette to seal against backpressures that would have otherwise forced it open. This allows valve chambers 282 and 284 to seals well in both upstream and downstream configurations. [0153] In one example, suppose the total seal area of valve chambers 282 and 284 is one square inch and that the sealing area at the top of volcano port 290 is 0.1 square inch over the volcano. A positive ten psig air pressure would then apply an external force of 10 lbs to the entire valve chamber 282 or 284. A backpressure on the annular fluid side of the associated port 290 from the applied ten psig pressure plus a backpressure the backpressure up through the center of port 290 from a downstream sealed valve would exert almost the same opposite "unsealing" force of ten pound (only difference would be the small annular area of port 290 at the top, which is a function of the port wall thickness and the diameter of the tube), resulting in a potentially leaky valve chamber 282 or 284. A higher positive pressure, e.g., twenty psig, could be applied to valve chamber 282 or 284 forcing sheeting 288 to seal to port 290 against the 10 psig backpressure, however, the noise generated to create the twenty psig air pressure could objectionable to the user. There would also be no redundancy in the different valve pressures. [0154] Back to back valve chambers 282 and 284 of Figs. 73A and 73B, on the other hand, separated by an applied negative pressure, e.g., 5 psig vacuum, both seal independently well. The ten psig air pressure would still apply 10 lbs external force to seal both valves 282 and 284, however, the 10 psig pressure at the center of the volcano port 290 and the -5 psig pressure on the annular area around the volcano would apply a total pressure of ten psig * 0.1 sq in + (- 5 psig) * 0.9 sq in = ~3.5 lbs. The net force to close the valve would be 13.5 lbs so that valve would seal very well. [0155] It may be possibLe to not use a separate vacuum and instead rely on the expansion of the flexible part of the compliance chamber 286 to absorb energy from the backpressure from one valve chamber 282 or 284 applied to the other valve chamber 282 or 284. Here, apertures 283 allow the pressurized fluid inside chambers 282 and 284 and 23 around ports 290 to conunicate with fluid inside compliance chamber 286 and expand diaphragm 289 or sheeting area 292, allowing the backpressure around ports 290 to dissipate. [0156] Valves V-DI-PRE, CK-PRE, V-DI-VEN and CK-VEN in Fig. 52 (and other flow schematics) and valve chambers 282 and 284 of valve configuration 280 of cassette 40 shown in Fig. 74 are constructed as shown schematically in Figs 73A and 73B and can seal against higher pressure in either direction. That is, not only does compliance chamber 286 serve to not disrupt an existing upstream or downstream first valve chamber closure when a second valve chamber in fluid communication with the first valve chamber is opened, compliance chamber 286 also aids in the closure of a first valve chamber when a second valve chamber in communication with the first valve chamber (upstream or downstream) has been closed previously, which could otherwise create positive fluid pressure against which the closure of the first valve chamber would have to fight. [0157] Fig. 75 illustrates that system 10 in one embodiment includes a wide pump head 22 that drives two dialysate pump segments 44 to mix two solutions in a ratio that is approximately equal to the ratio of the tube inside diameters squared (mix ratio = (IDdD2)2), assuming the wall thicknesses of tubes 44 is the same. For a 1:1 mix ratio, consecutive segments of tubing from the same roll of tubing can be taken to provide segments of the same wall thickness and good mixing accuracy. Mixing accuracy is optimized because the inlet pressure on the supply lines is controlled within about four inches of water colunm by the bag manager, the tubing inner diameter is controlled during the manufacture of the disposable set, the pump race diameters are the same and the pump actuator rotational speed is the same for the parallel tubing segments. System 10 also ensures that an initial supply fluid temperature of each of the different dialysis fluids in tubes 44 is within a few degrees of each other. [0158] It should be understood that various changes and modifications to the presently preferred embodiments described herein will be apparent to those skied in the art. Such changes and modifications can be made without departing from the spirit and scope of the present subject matter and without diminishing its intended advantages. It is therefore intended that such changes and modifications be covered by the appended claims. 24

Claims (20)

1. A dialysis system comprising: a dialysis instrument including a blood pump actuator; a dialyzer; a heparin pump; and a disposable cassette including a blood pumping portion operable with the blood pump actuator of the dialysis instrument, the blood pumping portion including an inlet and an outlet, the inlet of the blood pumping portion of the disposable cassette positioned and arranged to receive blood from an arterial line of an extracorporeal circuit, the outlet of the blood pumping portion of the disposable cassette positioned and arranged to deliver the blood to the dialyzer and to receive heparin from the heparin pump.

2. The dialysis system of Claim 1, wherein the heparin purnp is positioned and arranged to introduce the heparin into the outlet of the blood pumping portion just prior to a disposable cassette inlet to the dialyzer.

3. The dialysis system of Claim 1, wherein the heparin pump includes a tube positioned to introduce the heparin into the outlet of the blood pumping portion of the disposable cassette.

4. The dialysis system of Claim 3, wherein the dialysis instrument includes a pinch valve operable with the tube to control the heparin introduced into the outlet of the blood pumping portion. 26

5. The dialysis system of Claim 3, wherein heparin in the tube passes through an air bubble detector before reaching the disposable cassette.

6. The dialysis system of Claim 1, wherein the heparin pump includes a syringe pointed downwardly so that air collects above the heparin within the syringe.

7. The dialysis system of Claim 1, wherein the heparin pump accepts a syringe ranging in size from ten millimeters to sixty millimeters.

8. The dialysis system of Claim 1, wherein the heparin pump includes a syringe located within a housing of the dialysis instrument.

9. The dialysis system of Claim 8, wherein the syringe is a smaller syringe, and wherein larger syringes are located at least partly outside of the dialysis instrument housing.

10. A dialysis system comprising: a dialysis instrument including a blood pump actuator; a dialyzer; a heparin source; and a disposable cassette including a blood pumping portion operable with the blood puMp actuator of the dialysis instrument, the disposable cassette placing the blood pumping portion in fluid communication with the dialyzer and an extracorporeal circuit, so that blood can be pumped from the extracorporeal circuit, through the blood pumping portion, to the dialyzer, 27 wherein the disposable cassette is configured to introduce heparin from the heparin source into the blood at a location of the disposable cassette between the blood pumping portion and the dialyze

11. The dialysis system of Clairn 10, wherein the disposable cassette is configured to introduce the heparin into the disposable cassette just prior to an inlet of the dialyzer.

12. The dialysis system of Claim 10, wherein the disposable cassette is configured to introduce heparin into the disposable cassette at an outlet of the blood pumping portion.

13. The dialysis system of Claim 10, wherein the disposable cassette accepts a tube extending from the heparin source.

14. The dialysis systern of Claim 13, wherein the tube is fitted into an air detector.

15. The dialysis system of Claim 10, wherein the heparin source includes a syringe pump.

16. A dialysis system comprising: a dialysis instrument including a blood pump actuator; a dialyzer; a disposable cassette including a blood pumping portion operable with the blood pump actuator of the dialysis instrument, the disposable cassette placing the blood pumping portion in fluid communication with the dialyzer and 28 an extracorporea circuit, so that blood can be pumped from the extracorporeal circuit, through the blood pumping portion, to the dialyzer; a heparin source in fluid communication with the disposable cassette via a tube; and an air detector operably connected to the tube.

17. The dialysis system of Claim 16, wherein the disposable cassette is configured to accept the tube just prior to an inlet to the dialyzer.

18. The dialysis system of Claim 16, wherein the disposable cassette is configured to accept the tube at an outlet of the blood pumping portion.

19. The dialysis system of Claim 16, wherein the heparin source includes a syringe pointed downwardly so that air collects above heparin within the syringe.

20. A dialysis system comprising: a dialysis instrument including a blood pump actuator; a dialyzer; a disposable cassette including a blood pumping portion operable with the blood pump actuator of the dialysis instrument, the disposable cassette placing the blood pumping portion in fluid communication with the dialyzer and an extracorporeal circuit, so that blood can be pumped from the extracorporeal circuit, through the blood pumping portion, to the dialyzer; and 29 a heparin source in fluid communication with the disposable cassette, the heparin source including a syringe pointed downwardly so that air collects above heparin within the syringe. Dated this 1 t day of May 2015 Baxter international nc. and Baxter Healthcare SA Patent Attorneys for the Applicant PETER MAXWELL AND ASSOCIATES