HEMODIALYSIS : ADEQUACY AND

OUTCOMES

Dr. Dwi Edi Wahono, SpPD

SMF Ginjal Hipertensi

Dept. Penyakit Dalam
RSPAD Gatot Subroto
Jakarta
Overview
1. How to asses the adequacy of delivered HD ?
2. Factors Affecting of Hemodialysis Adequacy
3. Recommendations for Dialysis Dose Adequacy
4. Prescription of Dialysis Dose
5. Conclusion
 1. HOW TO ASSES THE
ADEQUACY OF DELIVERED HD ?
 The Concept of Dialysis Adequacy

The minimum dose of dialysis needed

to survive

Dialysis doses are needed so that

patients can live optimally

Lacson E, Wish J B.
In: Dialysis, 2nd. Ed: WilliamL.Henrich. Lippincott Williams & Wilkins, Philadelphia. P. 99-113
 What is ‘adequate’ hemodialysis ?

Adequate HD is treatment regimen that is acceptable

to the pts and dialysis provider in term of:
• Control of uremic symptoms and pts well-being
• BP control
• Biochemical markers of uremia and nutrition
• Achieved dialysis dose based on small solute
clearance
• Inconvenience and cost

• (Basic Clinical Dialysis, 2015)

Two central issues in the management of patients
undergoing maintenance hemodialysis :

Determining the optimal amount

of dialysis that should be
prescribed

Quantifying the amount of

dialysis that is actually
delivered to individual patients
 Clinical Dialysis Adequacy Criteria
• Subjective assessment
• How well are the symptoms of uremia controlled in the patients (e.g.
Appetite, nausea, tiredness, itch) ?
• Objective assessment
• Volume/BP control
• Is the patients still acidotic (as indicated by a low mid-week
predialysis bicarbonat level)?
• How well are blood phosphate level controlled?
• Is the serum albumin level normal (an indicator of nutrition strongly
associated with survival)?
• Dialysis dose assessment
• Is the desired level of urea removal being met?
 Assessment of dialysis adequacy
• Two methods are commonly used to assess the adequacy
of dialysis, is URR and Kt / V.
• Against dialysis blood samples at the beginning and at the
end of dialysis
• Urea levels in the two blood samples were then compared.
• The recommended frequency of assessment is:
• Every 3 months in patients who are stable
• Every month in patients who are unstable or after
changes in prescription dialysis
• If there are signs of decreased clearance (symptoms of
uremia)
(Basic Clinical Dialysis, 2015)
 URR :
Advantages:
• Practical / simple
Limitations:
• Does not take into account the
situation, nutrition, urea generation,
etc.
- URR ~ Kt / V
Lacson E, Wish J B.
In: Dialysis, 2nd. Ed: WilliamL.Henrich. Lippincott Williams & Wilkins, Philadelphia. P. 99-113
10

URR ?

• URR: urea reduction ratio, which means a reduction in

urea as a result of dialysis.
• URR: one measure of how effectively the dialysis
procedure removes waste products (urea) from the body
and is generally expressed as a percentage.
11

Reasons for using urea removal

• HD effectiveness as a renal replacement

therapy depends in part on the dose given to
the patient
• Urea: a material used to mark small size solute
buildup in kidney failure
• Urea is easily measured
• Urea: a product of protein catabolism & is 90%
of residual nitrogen that can be dialyzed
Reasons for using urea removal

• Residual renal functions can be measured in

various formulas (very important for new
dialysis patients)
• The use of formulas facilitates ongoing
monitoring of dialysis doses given to each
patient
• Measuring urea removal shows the results of
dialysis in patients
13

Limitations of urea removal as a measure

of adequate hemodialysis
• Measuring the adequacy of a given dialysis dose
should not only use urea discharge

• The removal of urea is not always related to the

disposal of other uremic poisons

• The accuracy of measurement depends on the

accuracy and timing of blood sampling after
dialysis
14

How to take post HD samples

1. At the end of HD:
a) Turn off the dialysate flow (Flow off)
b) Lower the speed of blood flow (Qb) to 50 ml
/ minute
c) Wait 15 seconds for the machine to alarm,
take blood from the arterial line
2. Continue with the procedure for ending
hemodialysis
3. Blood samples are labeled with the patient's
name and the label "post HD"
15

Metode Daugirdas
• Set UF rate to O
• Lower Qb 100 ml / minute for 10-20
seconds
• Turn off the blood pump
• Take a blood sample from the arterial
blood line port
16

Estimated urea clearance using a formula

Urea reduction ratio (URR)

predialisisUrea – post dialisis urea

URR = ------------------------------------------------- x 100
Pre-dialysis Urea

The minimum recommended

URR for HD is 65-70%.
17

CASE :
• Mrs. S, 50 years old
• BW pre-HD 52 kg
• Dry weight 50 kg
• HD 2x a week
• Time duration of HD 5 hours
• Qb 250 ml / minute
• F7 Dializer
• Ureum pre 200 mg / dl
• Ureum post 60 mg / dl

• What is the URR Ny. S?

18

Example calculation with URR

Known :
• Urea pre HD = 200 mg / dl
• Ure post HD = 60 mg / dl
How much is the URR?
Answer:
200 mg / dl - 60 mg / dl
URR = ---------------------------- x 100%
200 mg / dl

= 140 mg / dl
--------------- x 100% = 70%
200 mg / dl
Definition and calculation Kt/V

• Kt/V is defined as the dialyzer clearance of urea (K)

multiplied by the duration of the dialysis treatment (t, in

minutes) divided by the volume of distribution of urea in
the body (V, in mL), which is approximately equal to the total
body water, corrected for volume lost during ultrafiltration
Definition and calculation Kt/V

• The Daugirdas equation is validated for a Kt/V range of 0.8 -

2.0 and is widely used because of its simplicity and accuracy

R = the postdialysis-predialysis serum urea ratio,

t = treatment time (hours),
UF = ultrafiltration volume (liters), and
W = the patient’s postdialysis body weight (kilograms)
Sp = single pool
 Kt / V

• KT/V
• K: clearance in L / minute, dializer coefficient (KoA), blood flow
rate (Qb), and dialysate (Qd) flow rate
• t: dialysis time in minutes
• V: is the volume of urea distribution (in liters), male urea
distribution volume is around 58% of BW while female is 55%
of BW
• If a BW male patient is 70 kilograms (kg), dry weight is 65 kg
• Then the volume of urea distribution (V) = 70 kg multiplied by
58/100 = 40.6 liters
 Estimated urea clearance using a formula

Estimated single pool Kt/V (Dougirdas Formulation)

Post-dialysis urea
Kt/V = - log e [ ----------------------------- - 0,08 x t ]
Pre-dialysis urea

Post-dialysis urea
+ [ 4 – 3,5 x --------------------------- ]
Pre-dialysis urea

Pre-dialysis BW– Post-dialysis BW

x [-------------------------------------------------------------- ]
Pre-dialysis BW

t = dialysis time in hours

Kasus

• Tn. R, 35 tahun • Jawab :

Kt/V = 183 x 240
• BB Pre HD 60 Kg
34800
• HD 2x seminggu
= 43920
• Lama HD 4 jam 34800 ml
• QB 200 ml/menit = 43,9
• Dializer F6 (K. 183 ) 34.8 L
58%x60=34,8 L= 34800 = 1,26
Target Kt/V = 1,8
• Berapakah Kt/ V Tn R ? Bagaimana untuk
meningkatkan klirens?
Contoh perhitungan waktu dialisis (t):

• Jawab :
• Diketahui :
• Kt/V yang diinginkan t = 1,8 x V
(target) = 1,8 K
• V = 34800 ml (34,8 L) = 1,8 x 34800 ml
• K = 183 (F6) 183
= 62640 ml
• Berapa t dibutuhkan ? 183
= 342,30 menit
= 5 Jam 42 menit

Jadi pasien tsb membutuhkan 1 jam 42 menit lagi

untuk mendapatkan HD yang adekuat.
UREMIC TOXINS

• The retention in the body of compounds (are called uremic

retention solutes or uremic toxins) results in the uremic
syndrome.

• Uremic toxins include a small group of inorganic compounds,

such as water, potassium, phosphate, and trace elements, and a
much larger group of organic compounds that are further
subdivided into
• small water-soluble solutes (<500 d)
• middle molecules (>500 d)
• protein-bound solutes
Comprehensive Clinical Nephrology 5ed.
 Urea as a Surrogate Marker of Uremic Toxicity
Freely diffusible
Standard Solute through cell
Translocation membranes

allows rapid
✓ Small molecular weight equilibration of urea
✓ Can move freely from
extra cellular to intra
concentration within
cellular and dialysate whole body water
compartments after urea has been
removed from the
blood compartment

Urea removal does not closely parallel

that of other small water-soluble
compounds, protein-bound solutes, or
middle molecules
 INTRADIALYCTIC UREA KINETICS

konsentrasi urea
intradialisis dalam darah
selalu lebih rendah
daripada dalam jaringan
Equilibrasi penuh di antara
Dialiser sangat effisien antar kompartemen
mengurangi konsentrasi tercapai dalam 30-60
urea sampai 80-90%. menit setelah akhir dialisis

INTRADIALYCTIC
UREA
2. FACTORS AFFECTING OF
HEMODIALYSIS ADEQUACY
32

Factors Affecting of Hemodialysis Adequacy

• HD prescription
• Made by nephrologists before hemodialysis is done
• Individual
• The dializer selection
• Material:
• Cellulose: cuprophan
• Cellulose substituted: Cellulose acetate, Diacetate,
Triacetate
• Synthetic: Polysulfone, Polycarbonate, polyamide and
• polymethylmethacylate (PMMA)
• Others:
• Low Flux
• High flux dialyzer
• High efficiency dialyzer
33

Factors Affecting of Hemodialysis Adequacy

• Surface area :
o KoA (Coefficient Mass Transfer Urea)
o KUF (Coefficient Ultrafiltration)

• Dialysis frequency
• HD 2 times a week (mild BW, there is still
residual kidney function)
• HD 3 times a week
34

Factors Affecting of Hemodialysis Adequacy

• Kecepatan aliran darah (Qb)

• > 300 ml/menit

• Kecepatan aliran dialisat (Qd)

• 2x Qb

• Dialiser pakai Ulang (dialyzer reuse)

• TCV > 80%
35

Dosis Minimum Hemodialisis

Hemodialisis 3 x / minggu
• Kt/V minimal 1.2 (DOQI)
• URR minimal 65% (DOQI)
Diukur
Hemodialisis 2 x / minggu 1 x/bulan
• Kt/V minimal 1.8 – 2
( Tidak direkomendasikan oleh NKF-DOQI)

• URR : 80%
NKF-KDOQI 2015
36

Agar dapat mencapai hemodialisis

yang adekuat, maka target
adekuasi ditentukan lebih tinggi
Kt/V 1.3, URR 70%
37

Penyebab Hemodialisis Tidak Adekuat

v Underprescription
v Akses vaskular yang inadekuat
v Waktu dialisis yang diperpendek
v Darah membeku
v Penggunaan reuse dialyzer
v Variabel lain :
~ Pasien, staf medis, masalah mekanik

Lacson E, Wish J B.
In: Dialysis, 2nd. Ed: WilliamL.Henrich. Lippincott Williams & Wilkins, Philadelphia. P. 99-113
Approach to the patient with suspected inadequate dialysis
(Basic Clinical Dialysis,2015)
Are prescribed dialysis
times being met?

YES NO

Is blood flow rate >300 Increase to

Reasses in
mL/min and asses prescribed
1 month
resirculation <10%? time

YES NO

Is there another cause of poor health or • Temporary increase

poor dialysis ? delivered dose
• Cardiac failure • Evaluate for acces stenosis
• Malignancy
• Infection

NO YES

• Treat underlying disease if

Are desired target for
possible
small removal being
• Increase delivered dialysis
met?
dose

YES NO

• Increase delivered
Reasses in 1 month dialysis dose
39

Risiko Relatif Kematian Meningkat pada

Kt/V dan URR yang Lebih Rendah
1.5 1.5
RR = 0.93/0.1 Kt/V RR = 0.89/5 URR, %

1.0 (P < 0.01) 1.0 (P < 0.01)

RR

RR
0.5 0.5

0.0 0.0
0.8 1.0 1.2 1.4 1.6 50 60 70 80 90

Kt/V URR (%)

Ket. : Sampel diambil secara random dari pasien U.S. yang telah menjalani
dialisis selama lebih dari 1 tahun pada 31 Des’1990.
(N=2,311)
Modifikasi dari N.K. Man, J. Zingraff, P. Jungers.
In: Long –term Hemodialysis. Kluwer Academic Publisher, The Netherlands. pp. 49-60
Luaran Hemodialisis

• Luaran terbaik pasien dalam terapi HD

• Efek terhadap mortalitas
• Efek terhadap angka perawatan di RS
• Kualitas hidup pasien

• -Comprehensive clinical nephrology, fifth edition

3. RECOMMENDATIONS FOR
DIALYSIS DOSE ADEQUACY
Recommendation of KDOQI 2006

• For patients with minimal residual kidney function (<2 ml / minute

/ 1.73)
• Dialysis 3 times / week

• Minimum dose spKt / V = 1,2 or URR = 65%

• Target dose sp Kt / V = 1.4 or URR = 70%

• Dialysis 2 times / week is not recommended unless there is still

significant residual kidney function (GFR> = 5ml / minute)

Guideline 3: Measurement of Dialysis:
Urea Kinetics (KDOQI 2015)
• 3.1 We recommend a target single pool Kt/V (spKt/V) of
1.4 per hemodialysis session for patients treated thrice
weekly, with a minimum delivered spKt/V of 1.2. (1B)
• 3.2 In patients with significant residual native kidney
function (Kru), the dose of hemodialysis may be reduced
provided Kru is measured periodically to avoid inadequate
dialysis.(Not Graded)
• 3.3 For hemodialysis schedules other than thrice weekly,
we suggest a target standard Kt/V of 2.3 volumes per
week with a minimum delivered dose of 2.1 using a
method of calculation that includes the contributions of
ultrafiltration and residual kidney function. (Not Graded )
Konsensus Pernefri 2003

Inisiasi HD
1. LFG < 10 mL/m dengan gejala uremia/malnutrisi
2. LFG < 5 mL/m walaupun tanpa gejala
3. Indikasi khusus
Terdapat komplikasi akut (udem paru, hiperkalemia, asidosis
metabolik berulang)
Pada pasien nefropati diabetik dapat dilakukan lebih awal.
Adekuasi HD
-Setiap pasien HD harus diberikan resep /perencanaan/program HD
-Adekuasi HD (Kt/V) ditentukan dengan pengukuran dosis HD yang
terlaksana(delivery dose)
Konsensus Pernefri 2003

• Target Kt/V yang ideal adalah 1,2 (URR 65%)

untuk HD 3x perminggu selama 4 jam perkali HD
dan 1,8 untuk HD 2x perminggu selama 4-5 jam
perkali HD.

• Frekuensi pengukuran adekuasi HD sebaiknya

dilakukan secara berkala (idealnya 1 kali tiap
bulan) minimal tiap 6 bulan.
4. PRESCRIPTION OF DIALYSIS
DOSE
Hemodialysis Prescription

Determines Adequacy
• Hemodialysis Prescription Components:
• Duration of Treatment min 4 hours
• Dialyzer Urea Clearance (KOA)
• Blood Pump Speed min 250 ml/min
• Dialysate Flow Rate 500-800 ml/min
• Heparinization
• Access
FAKTOR FAKTOR YANG MEMPENGARUHI DELIVERED Kt/V

• Pembersihan urea dializer yang efektif (Kd) tergantung pada

kecepatan aliran dalam ruang penampungan darah dan dialisat,
dialyzer KoA, area permukaan membrane efektif, hematokrit,
antikoagulation, dan resirkulasi.
• Lama waktu HD , t sangat penting untuk mencapai target Kt/V .
• V tidak berubah banyak selama satu sesi, tetapi bisa berubah
seiring waktu.
• Dosis HD perlu disesuaikan bila ada kenaikan V. Sebaliknya,
jika ada kehilangan massa tubuh, yang biasanya terjadi karena
penurunan V, Kt/V tidak boleh dikurangi melainkan disesuaikan
ke angka yang lebih tinggi, V ideal pasien, atau seperti yang
diminta sebelumnya, ke BSA.
• Penyebab yang sering mengakibatkan dosis HD yang rendah
dan tidak layak adalah masalah akses vaskular yang
mengarahkan resirkulasi.
FAKTOR FAKTOR YANG MEMPENGARUHI DELIVERED Kt/V

• Pembersihan urea dializer yang efektif (Kd)

tergantung pada kecepatan aliran dalam ruang
penampungan darah dan dialisat, dialyzer KoA,
area permukaan membrane efektif, hematokrit,
antikoagulation, dan resirkulasi

• Lama waktu HD , t sangat penting untuk

mencapai target Kt/V

• V tidak berubah banyak selama satu sesi, tetapi

bisa berubah seiring waktu.
FAKTOR FAKTOR YANG MEMPENGARUHI DELIVERED Kt/V

• Pengambilan sampel darah yang tidak tepat harus juga

dipertimbangkan karena sampling post HD yang terlambat akan
mengurangi hasil Kt/V.
• Jika nilai Kt/V yang rendah tetap tak bisa dijelaskan, treatment
harus ditingkatkan dan harus dipertimbangkan penggunaan
dialiser yang lebih efisien, aliran darah dan dialisat yang lebih
cepat.
• Simulasi otot aktif atau pasif selama HD meningkatkan Kt/V
dengan cara meningkatkan suplai darah ke jaringan otot dan
juga memfasilitasi pembuangan urea dan phosphate.
• Nilai Kt/V pemberian harus di cek kapanpun resep HD diubah
secara substantial.
55

The method for raising the delivered

dialysis dose

• The most effective method

• Increase dialysis time (frequency and
time HD)
• Using a dialysis membrane that has a
larger size or permeability
• Another method
• Increases the blood flow
• Increase the dialysate flow
 Terapi Dialisis yang Optimal

Penilaian
Konseling Diet Status Nutrisi

Pelaksanaan Dialisis Penilaian Terapi

Perencanaan Dialisis yang Dilakukan

Dialisis vs
Dialisis yang Direncanakan

Modifikasi dari Renal Division, Baxter Healthcare Corporation

Kesimpulan

• Adekuasi HD adalah kecukupan dosis HD yang diberikan

kepada pasien dengan tujuan untuk meningkatkan kualitas
hidup pasien sehingga mempunyai harapan hidup yang sama
dengan orang sehat.
• Secara klinis adekuasi HD memperlihatkan ; pasien aktif
secara fisik,status nutrisi baik, tidak anemis,tidak hipertensi
dan euvolemik.
• Dua metode yang umumnya digunakan adalah Kt /V dan
URR.
• Peresapan HD meliputi , lama HD, UF Goal ,jenis dialiser,
antikoagulan,Qb,Qd, temperatur.