Hd Prescription

Hemodialysis Prescription
By
Mohammed Kamal Nassar, MD
Lecturer of Nephrology
Mansoura University

J Am Soc Nephrol 24: 465–473, 2013

The rate of movement will depend on:
- The concentration gradient
- Membrane permeability
- Membrane Surface area
- Blood proteins
- The size of the solute
DIFFUSION

N Engl J Med 2002;347:2010-9
EGE studyHEMO trial
J Am Soc Nephrol 2013

Am J Kidney Dis. 2015;66(5):884-930

Anticoagulation
• Anticoagulation-free treatment: frequent saline flushes
• Unfractionated heparin
• Low-molecular-weight heparins
• Direct thrombin inhibitors
• Regional anticoagulation with citrate or prostacyclin

Unfractionated Heparin
Routine heparin, repeated-bolus method Routine heparin, constant-infusion method
Initial bolus dose (4,000 units). Initial bolus dose (2,000 units)
1,000 - 2,000-unit bolus dose when needed. Infusion at a rate of 1,200 units per hour.
at start of each hour1,000 Stopping infusion 1 hour prior to the end of
dialysis
With venous catheters, continue to the end
of dialysis

Dialysis Prescription
• Dialysis Modality
• Dialysis frequency
• Dialysis duration
• Dialysis dose
• Dialysate:
 Sodium
 Potassium
 Calcium
 Bicarbonate
 Temperature
• Ideal body weight (IBW)
• Initial HD prescription
• Chronic HD prescription

John et al. Chest 2007:132;1379-1388

Am J Kidney Dis. 2014;63(1):153-163

Blankestijn. JASN 2013;24(3):332–334.

Bottom: 16 – 18.8 L
Middle: 20.2 – 22 L
Top: 24.4 – 27.4 L

Dialysis Frequency
Am J Kidney Dis. 2015;66(5):884-930

Hemodialysis six times per week (frequent hemodialysis, 125 patients) or
Three times per week (conventional hemodialysis, 120 patients)
For 12 months

Dialysis duration
Am J Kidney Dis. 2015;66(5):884-930

Cohort study
1206: thrice weekly extended-hours hemodialysis
or
111,707: receiving conventional hemodialysis treatments.
Kidney International (2016)

All-cause mortality
Patients treated with extended-hours hemodialysis had a 33% lower adjusted
risk of death compared to those who were treated with a conventional
regimen (95% confidence interval: 7% to 51%).
Kidney International (2016)

Kidney International (2016) 90, 1146–1163

•Dialysis dose
• Dialysate:
 Sodium
 Potassium
 Calcium
 Bicarbonate
 Temperature

Dialysis Dose
Am J Kidney Dis. 2015;66(5):884-930

N Engl J Med 2002;347:2010-9
HEMO trial

The three major determinants of urea clearance
during hemodialysis are:
1.Blood flow rate (Qb).
2.Dialysate flow rate (Qd).
3.Membrane (dialyzer) efficiency.

• Dialysis dose
• Dialysate:
Sodium
 Potassium
 Calcium
 Bicarbonate
 Temperature

Sodium
Clin J Am Soc Nephrol 7: 92–100, 2012.

Clin J Am Soc Nephrol 7: 92–100, 2012.

11,555 patients
Am J Kidney Dis. 2012;59(2):238-248

“We present the case of a patient who presented with renal failure requiring
dialysis and also with a serum Na of 112 mEq/l. Using a dialysate Na
concentration of 130 mEq/l and by limiting the blood flow to 50 ml/minute,
we were able to raise her serum Na by only 2 mEq/l/hour during her
hemodialysis treatment and thus control both the rate and total change in
the patient’s serum Na.”
Seminars in Dialysis, 2012;25:82-85

Effect of lowering dialysate Na on BP
Am J Kidney Dis. 2015;66(5):884-930

• Dialysis dose
• Dialysate:
 Sodium
Potassium
 Calcium
 Bicarbonate
 Temperature

Potassium
• The range of most commonly used dialysate concentrations is 2-4
mEq/L.
• Lower concentrations can be used in the setting of life-threatening
acute hyperkalemia, but only with extreme caution and frequent
intradialytic potassium measurements.
• There is no absolute recommended predialysis potassium level.
Better survival is associated with predialysis serum potassium
levels of 4.6-5.3 mEq/L.
Am J Kidney Dis. 2014;63(1):153-163

• Dialysis dose
• Dialysate:
 Sodium
 Potassium
Calcium
 Bicarbonate
 Temperature

Calcium
Kidney International (2009) 76 (Suppl 113)

• Dialysis dose
• Dialysate:
 Sodium
 Potassium
 Calcium
Bicarbonate
 Temperature

Am J Kidney Dis. 2013;62(4):738-746

Clin J Am Soc Nephrol 8: 254–264, 2013

Target pre-HD HCO3: >22 mmol/l, avoid severe
post-HD alkalosis

• Dialysis dose
• Dialysate:
 Sodium
 Potassium
 Calcium
 Bicarbonate
Temperature

Cool dialysate

Intradialytic hypotension

Change in mean arterial pressure

Symptoms of discomfort

Dialysis adequacy

• Dialysis dose
• Dialysate:
 Sodium
 Potassium
 Calcium
 Bicarbonate
 Temperature
•Ideal body weight (IBW)

IDWG
Clin J Am Soc Nephrol 2013.

Initial HD prescription
• Reduce 1st HD treatment time especially if serum urea level
is very high e.g. >240 mg/dL.
• A 2-hr session is recommended.
• Aim at URR of <40%.
• Subsequent session length can be gradually increased to a
standard of 4-5 hrs.

Various HD prescriptions
Am J Kidney Dis. 2015;66(5):884-930

Adequate Vs Optimal Dialysis
Conclusion

Basic criteria to be met
by adequate dialysis
• Fluid removal permitting return to correctly evaluated 'dry weight' at end of
dialysis.
• Predialysis blood pressure < 140/90 mmHg with or without antihypertensive drugs.
• Predialysis plasma concentrations :
 Potassium: < 5.5 mmol/l without adsorption of ion exchange resins.
 Bicarbonate: >22 mmol/l .
 Inorganic phosphate: < 5.5 mg/dl without oral binding agents.
 Urea: < 35 mmol/l with daily protein-intake 1.2 g/kg/BW .
 Albumin: > 4 g/dl .
 Hemoglobin: 10–11.5 g/dl with or without rHu-EPO.

Technical requirements for
delivery of adequate dialysis
• Vascular access: blood flow ≥ 300 ml/min .
• Dialysis fluid: bicarbonate buffered, sterile, pyrogen-free, QD: ≥500 ml/min.
• Volumetric ultrafiltration control.
• Dialyzer:
 Highly permeable, biocompatible membrane.
 Surface area: suitable.
• Dose of dialysis:
 Minimum Kt/V urea: 1.2–1.3 (single pool).
 Minimum urea reduction rate: 65–70%.
 Weekly dialysis time: ≥12 h (4–4.5 h × 3) .

Criteria for Optimal Dialysis
1.Normalized blood pressure with minimal antihypertensive
medications.
2.Normalized calcium-phosphate product with neither phosphate
binders nor phosphate supplements.
3.An absence of intradialytic symptoms such as hypotension, cramps,
and nausea.
4.An absence of interdialytic symptoms.
5.No interference with ability to hold a job.
6.Protein appetite under the patient's free will.
7.Neither alkalotic nor acidotic.
8.No evidence of left ventricular hypertrophy.

9. Hematocrit in the 35-to-38 range with the use of at least 50% or
less of today's average erythropoietin dose.
10. No dialysis-related or access-related hospitalizations.
11. Normal triglyceride level.
12. No evidence of amyloidosis.
13. The longest preservation of residual kidney function.
14. Life expectancy approximately that of living-related-donor
transplants.
15. Inflammation near normal.
Criteria for Optimal Dialysis

"Adequate" Kt/V Does Not Provide "Optimal" Dialysis
Kt/V Should be a Means, Not a Goal

Hd Prescription

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