Hd Prescription

Hemodialysis PrescriptionBy

Mohammed Kamal Nassar, MDLecturer of Nephrology

Mansoura University

Hemodialysis Circuit

Vascular Access

J Am Soc Nephrol 24: 465–473, 2013

DIFFUSION

The rate of movement will depend on:

-The concentration gradient-Membrane permeability-Membrane Surface area -Blood proteins-The size of the solute

DIFFUSION

HYDROSTATICULTRAFILTRATION

Dialyzers specification

High flux vs low flux

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 hour 1,000 Stopping infusion 1 hour prior to the end of dialysisWith venous catheters, continue to the end of dialysis

Low molecular weight heparin

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

Dialysis Prescription•Dialysis Modality• Dialysis frequency• Dialysis duration• Dialysis dose• Dialysate:



Dialysis modality

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 LMiddle: 20.2 – 22 LTop: 24.4 – 27.4 L

Dialysis Prescription• Dialysis Modality

•Dialysis frequency• Dialysis duration• Dialysis dose• Dialysate:



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

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

Dialysis Prescription• Dialysis Modality• Dialysis frequency

•Dialysis duration• Dialysis dose• Dialysate:



Dialysis duration

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

Cohort study1206: thrice weekly extended-hours hemodialysis or111,707: 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 Prescription• Dialysis Modality• Dialysis frequency• Dialysis duration

•Dialysis dose• Dialysate:



Dialysis Dose

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

N Engl J Med 2002;347:2010-9

HEMO trial

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

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 Prescription• Dialysis Modality• Dialysis frequency• Dialysis duration• Dialysis dose

•Dialysate: Sodium Potassium Calcium Bicarbonate Temperature


Dialysate


•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


•Dialysate: SodiumPotassium 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


•Dialysate: Sodium PotassiumCalcium Bicarbonate Temperature


Calcium

Kidney International (2009) 76 (Suppl 113)


•Dialysate: Sodium Potassium CalciumBicarbonate 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


•Dialysate: Sodium Potassium Calcium BicarbonateTemperature


Cool dialysate


Intradialytic hypotension


Change in mean arterial pressure


Symptoms of discomfort


Dialysis adequacy


IDWG

Clin J Am Soc Nephrol 2013.



• Ideal body weight (IBW)

• Initial HD prescription• Chronic HD prescription

InitialHD

Prescription

DialysisDisequilibrium

Osmoticdemyelination

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.



• Ideal body weight (IBW)• Initial HD prescription

•Chronic HD prescription

Various HD prescriptions

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

The three major determinants of urea clearance during hemodialysis are:

1.Blood flow rate (Qb).

2.Dialysate flow rate (Qd).

3.Membrane (dialyzer) efficiency.

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

HDPrescription

AdequateHD

OptimalHD

Dose

Doseplus

"Adequate" Kt/V Does Not Provide "Optimal" Dialysis

Kt/V Should be a Means, Not a Goal

Thank You

Hd Prescription

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