Hemodialysis Adequacy Lutfi Alkorbi MD King Faisal Specialist Hospital Riyadh Saudi Arabia.
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Transcript of Hemodialysis Adequacy Lutfi Alkorbi MD King Faisal Specialist Hospital Riyadh Saudi Arabia.
![Page 1: Hemodialysis Adequacy Lutfi Alkorbi MD King Faisal Specialist Hospital Riyadh Saudi Arabia.](https://reader033.fdocuments.in/reader033/viewer/2022061507/551be89f550346c3588b618f/html5/thumbnails/1.jpg)
Hemodialysis Adequacy
Lutfi Alkorbi MDKing Faisal Specialist Hospital
Riyadh Saudi Arabia
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Global dialysis population
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Cardiovascular mortality in general population VS ESRD patients
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Mortality in Hemodialysis Patients in Europe, Japan, and the United States
DOPPS 2006
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Dialysis adequacy and death
The effect of dialysis dose on survival
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First Randomised Controlled Trial In Dialysis
• The National Cooperative Dialysis Study (NCDS) was the first multicentric, randomized and controlled trial to investigate the impact of dialysis dose on patients' outcome. 160 patients were randomized to two different urea time‐averaged concentrations (TAC; 100 vs 50 mg/dl) and to two different treatment times (2.5–3.5 vs 4.5–5.5 h) and followed‐up for 6 months.
NCDS 1980
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First Randomised Controlled Trial In Dialysis
NCDS 1980
Predialysis urea 38 vs 26 mmol. Dialysis 2.5-35h vs 4.5-5 h
high kt/v and long dialysis
high kt/v and short
dialysis
low kt/v and long dialysis
low kt/v and short dialysis
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Secondary analysis of NCDS
• A quantification of dialysis dose using spKt/V was first proposed by Gotch in a secondary analysis of NCDS data. In his analysis, probability of dialysis failure was higher for Kt/V ≤0.8 and abruptly decreased for Kt/V >0.9.
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Higher Kt/V has better outcome
Gotch FA,Sargent Kidney Int 1985;28:526
Kt/v=1.2
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NCDS Conclusion
• Thus, according to NCDS patient morbidity and treatment failure are related to the dialysis dose
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Why Should We Measure Dialysis Dose?
There is a correlation between delivered dose of hemodialysis and patient morbidity and mortality
Clinical symptoms are not reliable
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Increasing dialysis dose improved survival
dialysis dose
Kidney Int 1996; 50:550
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Measures of dialysis adequacy
• SpKt/V
• eKt/V
• StdKt/V
• URR
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Hemodialysis Dose Measurement
Kt/V K= dialyzer urea clearance L/h
t = dialysis session length hr
v = distribution volume of urea L
URR
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Urea reduction Ratio(URR)
URR = 100 x (1-Ct/Co)
Ct = postdialysis BUN
Co = predialysis BUN
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Urea Reduction Volume (URR)
Simple Prediction of mortality
Limitation:
Does not account for the contribution of UF to dialysis dose
Kt/V=1.1 (UF=0)
Kt/v = 1.35 (UF=10%BW)URR=65
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URR & Kt/V
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Hemodialysis Dose Measurement
• The preferred method is by formal kinetic urea modeling
K/DOQI 2006
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Kt/V
Computerized softwareMathematical logarithm Kt/v = -Ln (R-0.008t)+(4-3.5xR) x UF
WLn = natural logarithmR = postdialysis BUN
predialysis BUN UF = Ultrafiltration volume in litersW = Postdialysis weight in kg
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BUN Sampling
Predialysis Postdialysis Immediate predialysis Slow flow/stop pump
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Urea Rebound
Organs with low blood flow (skin, bone, muscles) may serve as reservoir for urea 70% of TBW is contained in organs that receive only 20% of CO
So: during HD, there is loss of urea from well perfused areas, this result in in BUN over 60 minutes post dialysis.
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Post Dialysis BUN Sampling
Avoid 2 rebound:
Early (<3min post dialysis) Access recirculation,begin immediately post
hemodialysis and rebound in 20 seconds Cardiopulmonary recirculation, begin 20 seconds post
hemodialysis and is completed in 2-3 minutes after slowing or stopping the blood pump.
Late (>3 min) Completed within 30-60 minutes due to flow-volume
disequilibrium.
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Urea Rebound
65% rebound ( >50% is AR,15%CP,31% D)
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Single-Compartment Fixed VolumeSolute Kinetic Mode
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Single-Pool vs Double-Pool
Single-pool
Does not account for urea transfer between fluid compartments
With dialyzer clearance, urea removed from extracellular compartment can exceed transfer from intracellular compartment
Urea rebound (30-60 min)
So: Dialysis dose will be overestimated if this urea pool is large (underestimated of true V)
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Two-Compartment Variable VolumeSolute Kinetic Model
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Equilibrated Kt/V
eKt/v is 0.2 units less than single-pool kt/v, but it can be as great 0.6 unit less.
For most patient, urea rebound is nearly complete in 15 minutes after hemodialysis but for minority, it may require up to 50-60 minutes
The degree of rebound is high in small patient• eKt/V= spKt/V - 0.6 x (spKt/V) / t + 0.03 (for arterial
access) • eKt/V= spKt/V - 0.47 x (spKt/V) / t + 0.02 (for venous
access)
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Minimum dialysis dose
• SpKt/V > 1.2 US
• eKt/V > 1.2 Europe
• StdKt/V 2.14
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Daugirdas Formula
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Daugirdas Formula
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Prescribed vs. delivered Kt/V
Prescribed Kt/V is a computerized estimation of what the patients Kt/V would be, based on the prescription
• Delivered Kt/V is actual results based onhow the patient really dialyzed the day thekinetic labs were drawn
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Discrepancies Between Delivered and Prescribed Dialysis Dose
Delivered less than the prescribed: Low blood flow Inadequate dialyzer performance Low dialysate flow Dialysis machine programmed incorrectly Hemodialysis ended prematurely The predialysis BUN was drained after
initiation of hemodialysis Access recirculation
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Discrepancies Between Delivered and Prescribed Dialysis Dose
Delivered Dose More than the Prescribed:
Postdialysis BUN was drained from venous bloodline
The post dialysis BUN was diluted with saline
Small (V)
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Low kt/v
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How to improve clearance
• Blood flow
• Dialysate flow
• Dialyzer
• Duration
• frequency
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Blood flow and Clearance
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Blood flow and Clearance
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Dialysate flow and clearance
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The HEMO Study (2002)
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The HEMO Study (2002)
Standard dose group
• SpKt/V 1.3
• eKt/V 1.16
• URR 66.3
• Dialysis T 190 min
High dose group
• SpKt/V 1.7
• eKt/V 1.53
• URR 75.2
• Dialysis T 219 min
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The HEMO Study (2002)
EKNOYAN et al N Engl j Med .2002;347:2010
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Optimal Dialysis
Anemia management
Good nutritionBP control
Adequate solute
removal
Fluid and electrolytes hemostasis
BMDmanagement
Dialysisadequacy
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Optimal Dialysis
Anemia management
Good nutritionBP control
Adequate solute
removal
Fluid and electrolytes hemostasis
BMDmanagement
Dialysisadequacy
Kt/v
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Filters
Efficiency and Flux• Efficiency: ability to achieve large small solute clearance withhigh blood flows (all filters are high efficiency these days)• Flux: ability to achieve high middle molecule clearance andultrafiltration rate (determined by the average pore size)
Diffusion and Convection• Diffusion: solutes move by diffusion between blocks of fluidseparated by the membrane• Convection: solutes move en mass with a block of fluid acrossthe membrane (more effective for moving large molecules)
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The HEMO Study (2002)
EKNOYAN et al N Engl j Med.2002 ;347:2010
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The MPO Study (2009)
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Standard Kt/V
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Standard Kt/Vwhy Hemo study is negative ?
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FHN
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Better survival with long dialysis
UpToDate
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Residual renal function
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Residual renal function
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Time is important
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What about hemodiafiltration ?