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HEMODIALYSIS PRESCRIPTION and TREATMENT Sonny L. Antonio,M.D.

HEMODIALYSIS PRESCRIPTION  Session Length ( Duration )  Blood Flow Rate ( BFR, QB )  Dialyzer  Dialysis Solution Composition  Dialysate Flow Rate ( DFR, QD )  Dialysis Solution Temperature  Fluid Removal Orders  Anticoagulation Orders

 SESSION LENGTH / DURATION SESSION LENGTH and BLOOD FLOW RATE - most important determinants of the amount of dialysis to be given. (Dialyzer efficiency is also a factor) 1. Reduce the amount of dialysis for the initial one or two sessions ( Acute hemodialysis ) Initial treatment: when the preHD BUN is very high (>130 mg/dL) - URR of about 40% - BFR = 3X Kg BW - Duration: 2 hours Longer initial dialysis session + use of excessively high blood flow rates = may result in dysequilibrium syndrome If longer initial dialysis session is needed ( for purposes of fluid removal ): DO isolated ultrafiltration

Increased urea sequestration in muscle: patients on pressors: decreased blood flow to muscle and skin 5. If given 3x/week: associated with high mortality . 6-12 hour daily sessions  BLOOD FLOW RATE At the start of the dialysis session: BFR is initially set at 50 mL/min.1. 3-4 hour duration if every other day: 4-6 hours.option: daily basis (6x/week). Recirculation occurs in venous catheters: greatest femoral position 3. Concomittant IV infusions: dilute BUN levels . Treatment interruptions due to hypotension 4.difficult to deliver a large amount of dialysis in the acute setting: 1.typical 3-4 hour acute HD session: Kt/V 0.Length of 2nd Hemodialysis session : can be increased to 3 hours ( provided that preHD BUN <100 mg/dL ) Subsequent sessions : up to 6 hours 2.Sustained low-efficiency dialysis (SLED): becoming popular. True delivered BFR through a venous catheter rarely exceeds 350 mL/min: often substantially lower 2. . Dialysis frequency and dose for subsequent treatments and Dialysis adequacy .standard therapy: 3-4 hour session given every other day .3 .2 .9 only. Kt/V 1. then 100 mL/min until the entire blood circuit fills with blood à BFR should be increased promptly to the desired level.

materials: polyacrylonitrile (PAN) polysulfone polycarbonate .Cellulose diacetate . Cellulosynthetic a tertiary amino compound (synthetic material) is added to liquefied cellulose during membrane formation Cellosyn or Hemophan d. Cellulose obtained from processed cotton various names: regenerated cellulose Cuprammonium cellulose (Cuprophane) Cuprammonium rayon Saponified cellulose ester b.not cellulose-based . DIALYZER Dialyzer Membranes a.Cellulose triacetate c.Cellulose acetate .cellulose polymer whose large numbers of free hydroxyl groups at its surface are chemically bonded to acetate . Substituted cellulose . Synthetic .

free hydroxyl groups: activate the complement system . provided dialyzers have not been exposed to bleach 2.complement activation is reduced when reused. . Substituted cellulose 3.altered by adjusting the thickness of the membrane and the pore size Dialyzer membrane efficiency and Dialyzer membrane flux Membrane surface area – determines the ability of a dialyzer to remove small molecular weight solutes (urea) High efficiency dialyzer . can have small or large pores.number of milliliters of fluid per hour that will be transferred across the membrane per mmHg pressure gradient across the membrane Desired Kuf (Coefficient of ultrafiltration) to be chosen depends on whether an ultrafiltration controller is available Ultrafiltration controller – accurately controls the ultrafiltration rate by means of special pumps and circuits .have large pores capable of passing larger molecules (1.000-15. have high water permeability: Kuf (Coefficient of ultrafiltration) >10 mL/hr/mmHg Kuf (Coefficient of ultrafiltration) .a dialyzer with high surface area: high ability to remove urea. Synthetic membranes lesser complement activation Membrane permeability to solutes and to water .permeability of dialyzer membrane to water: function of membrane thickness and pore size.000 MW).polyamide polymethylmethacrylate (PMMA) Biocompatibility: Complement activation with different membrane materials 1. Cellulosynthetic 4.Unsubstituted cellulose . can have either high or absent clearance for larger molecular weight solutes (B2 microglobulin) High flux dialyzer.

water along with small solutes moves from the blood to dialysate in the dialyzer : Hydrostatic pressure gradient between the blood and dialysate compartments. < 500 mL/hour < 3. The rate of ultrafiltration – will depend on the total pressure difference across the membrane  DIALYSIS SOLUTION COMPOSITION standard composition: designed for acidotic.0 (moderate permeability) To remove 1000 mL/hour : required TMP 250 mmHg If the Kuf is 8. hyperkalemic chronic dialysis patients. hyperphosphatemic. may lose accuracy if a high fluid removal rate is attempted using a dialyzer that is relatively impermeable to Desired Fluid Removal Rate Ideal dialyzer Kuf water. example: Kuf 2.0 500-1000 mL/hour >1000 mL/hour 3-4 4-5 IF dialysis machine with UF controller is not available: choose dialyzer with low Kuf If the Kuf is low.0 To remove 1000 mL/hour : TMP 125 mmHg Transmembrane pressure (TMP) During hemodialysis.0 To remove 1000 mL/hour : 500 mmHg TMP will be needed If the Kuf is 4. inappropriate in an acute setting Components of Standard Bicarbonate-containing Solution: .Most machines with volumetric ultrafiltration controllers: designed to use dialyzers with high water permeability.

set dialysis sodium concentration to 140 + (140 – preHD serum Na+ value) Example: preHD serum Na+ 130 meq/L 140 + (140 – 130) 140 + (10) = 150 meq/L Dialysate sodium Hyponatremia : preHD serum sodium <130 meq/L . lethargy.75 meq/L 98-124 meq/L 2-4 meq/L 30 – 40 meq/L 100 – 200 mg/L Dialysate Bicarbonate concentration 30 – 40 meq/L Higher Bicarbonate levels – required in treating acidotic patients.To achieve a post HD serum sodium of 140 meq/L. 20-28 meq/L Dangers of metabolic alkalosis: soft-tissue calcificatioin cardiac arrhythmia adverse symptoms such as nausea.Sodium Potassium Calcium Magnesium Chloride Acetate Bicarbonate Dextrose 135-145 meq/L 0 – 4 meq/L 2. If preHD plasma bicarbonate level is 28 meq/L or higher or if patient has respiratory alkalosis: standard dialysis solution containing 35 or 38 meq/L bicarbonate should not be used. headache Dialysate Sodium Concentration 135-145 meq/L 145 meq/L : acceptable for patients with normal or slightly reduced preHD serum sodium Adjusted if there is marked preHD hypernatremia or hyponatremia Hyponatremia : preHD serum sodium >130 meq/L .5 meq/L 0.g.5 – 3.5 – 0. Use lower bicarbonate level: e.

dialysate calcium levels < 3.5 – 3.for severe chronic hyponatremia: Set dialysate sodium concentration no higher than 15-20 meq/L above the preHD serum Na+ level . Acute hypercalcemia – minimize overly rapid decrease in serum calcium: tentany or seizure.5 meq/L Magnesium – vasodilator .5 meq/L .5 – 3. requires frequent measurement and physical examination during HD Dialysate Magnesium concentration 0.If the dialysate sodium level is > 3 – 5 meq/L lower than the preHD serum Na+: 3 complications: 1. Hypotension 2.correction of hyponatremia during multiple dialysis treatments performed over several days Hypernatremia .. should be raised to 2. .5 meq/L .0 meq/L : predisposes to hypotension preHD hypocalcemia – further lowering with correction of acidosis during HD: routine use of 2.0 meq/L.75 meq/L Dialysate Dextrose concentration 100 – 200 mg/L .0 meq/L is appropriate.0 meq/L for patients at risk for arrhythmia or in those on digitalis. monitor serum K+ hourly Dialysate Calcium concentration 2. preHD serum K+ >7. preHD serum K+ >5.dialysate potassium level should be 4 meq/L or higher.dialysate potassium level below 2.0 meq/L . Blood pressure is better maintained with dialysate Mg of 0.75 meq/L / usual 0.75 – 1.dangerous to correct by hemodialyzing against a low sodium dialysate .correct hypernatremia by slow administration of slightly hyponatric fluids Dialysate Potassium concentration 0 – 4 meq/L preHD serum K+ < 4 meq/L .dialysate potassium level of 2.dialyze patient with a dialysate sodium level close (within 2 meq/L) to that of the serum Na+ . if chronic: dangerous to achieve normonatremia quickly .5 meq/L calcium is inappropriate.Note duration of hyponatremia. cerebral edema – exacerbates dialysis dysequilibrium syndrome.5 – 0. muscle cramps 3.

lower range should be used in hypotension-prone patients  FLUID REMOVAL ORDERS Guidelines: .normally absent from the dialysate . Phosphorus cannot be added to citrate containing dialysis solutions: Ca-Mg-PO4 solubility problems  DIALYSATE FLOW RATE For acute dialysis: usually 500 mL/min For maintenance dialysis: .3 mmol/L (4 mg/dl).increase the amount of phosphate removal during dialysis .alterations in hemoglobin oxygen affinity .usually 35-37oC .standard: 500 mL/min .g.respiratory muscle weakness . lower incidence of dialysis-related side effects Dialysate phosphate concentration (none) .Hypophosphatemia ..respiratory arrest .aggravated by dialysis against a zero phosphate bath .large surface area dialyzer + longer dialysis session .reduces risk of hypoglycemia.patients have elevated serum phosphate levels . >400 mL/min) increasing DFR to 800 mL/min will increase dialyzer clearance by about 10%  DIALYSIS SOLUTION TEMPERATURE .when BFR is high (e.adding phosphorus to bicarbonate-containing dialysis solution: final dialysate should be 1.

e.thorough rinsing: reduces incidence or severity of anaphylactic dialyzer reactions . Patient often experience malaise. During the initial dialysis – length should be limited to 2 hours. remove the fluid at 1 L/hour.changes periodically and should be reevaluated at least every 2 weeks  ANTICOAGULATION ORDERS (Separate Topic) Heparin: Routine heparinization Regional heparinization Tight heparinization Low molecular weight heparin Heparin-free dialysis HEMODIALYSIS TREATMENT A.1. a washed-out feeling. Chronic dialysis (Maintenance Dialysis) Concept of dry weight: Dry weight – the postdialysis weight at which all or most excess body fluid has been removed. (Note: BFR <200 ml/min: risk of dialyzer clotting) 3. cramps and dizziness after dialysis.determined on a trial-and-error basis .2L that the patient will receive at the end of the treatment and other fluid ingested or administered during the hemodialysis session 2. If a large amount of fluid (i. Rinsing and priming the dialyzer . . If dry weight is set too low: patient may suffer from frequent hypotension during the latter part of the dialysis session. Best to remove fluid at a constant rate throughout the dialysis treatment. If dry weight is set too high: patient will remain in a fluid-overload state at the end of the dialysis session. 4L) must be removed: impractical and dangerous à DO isolated ultrafiltration OR dialyze patient for 4-5 hours at a reduced BFR. Fluid removal plan during dialysis should take into account the 0.

.pressure levels of the arterial and venous pressure monitors are noted. Arteriovenous (AV) graft . pressure limits are set .inserted bevel up at 45-degree angle pointing toward the anastomosis Venous needle .apply tourniquet. Tips regarding needle placement: In a patient with poorly distended venous limb .insertion point at least 3 – 5 cm proximal to the arterial needle 3. Obtaining vascular access 1.BFR is initially set at 50 mL/min.check patency of catheter lumen 2. iii.clot or residual heparin is first aspirated .initiate dialysis solution flow . removed during dialysis. then 100 mL/min until the entire blood circuit fills with blood .at least 3 cm away from the site of AV anastomosis . In unstable patients: priming fluid is usually administered to the patient to help maintain the blood volume.use of tourniquet is never necessary C.inserted bevel up at 45-degree angle pointing toward the heart . Initiating dialysis . Arteriovenous (AV) fistula i.Priming fluid is the dialyzer and tubing can either be given to the patient or disposed of to drain.after the circuit is filled with blood and proper blood levels in the venous drip chamber are ensured à BFR should be increased promptly to the desired level. Percutaneous venous cannula .guidelines for placing needles same as for AVF . . Use 16-gauge or 15-gauge needle Prepare needle insertion site with povidone-iodine for a full 10 minutes Needle placement: Arterial needle . ii.B.inserted first . presence of tourniquet during dialysis will encourage recirculation.

arterial blood line is clamped close to the patient .blood in the extracorporeal circuit can be returned using either SALINE or AIR SALINE: .patient usually receives 100-200 mL of saline during the rinse-back procedure AIR: .not uncommon for the weight loss to be greater or lesser than that anticipated. Weight loss . Postdialysis evaluation 1. opening it to air . Patient monitoring and complications . Use of TMP that failed to account that the in vivo Kuf may be markedly less than the published in vitro value .weigh patient after dialysis .compare postHD weight with the preHD weight .arterial blood line is the disconnected just distal to the clamping.increases risk of air embolism F.watch out for complications: separate topic E.D.air is allowed to displace the blood in the dialyzer .blood pump is shut off and the return procedure is terminitaed .blood pump is restarted at a reduced rate (20-50 ml/min) .when air reaches the venous air trap or when air bubbles are first seen in the venous blood line – venous line is clamped . but at least every 15 minutes (acute dialysis) .patient’s blood pressure should be monitored as often as necessary. Sources of errors: a.blood pump is first shut off . Termination of dialysis .

. Errors a-d minimized by use of a dialysis machine with ultrafiltration controller END OF TOPIC. Difficulty in maintaining the desired TMP during dialysis due to changes in venous resistance d.b. Use of a dialyzer that is highly permeable to water e. Reduction in the dialyzer water permeability because of coating of the membrane with protein or clot c. Failure to take into account fluid administered to the patient during hemodialysis.