HAEMODIALYSIS: TECHNICAL ASPECTS

AND TREATMENT PRESCRIPTION

Jeroen Kooman
Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Centre, Maastricht, The Netherlands

Corresponding author: Jeroen Kooman; email: jp.kooman@maastrichtuniversity.nl

Content Summary

Haemodialysis (HD) is the most widely used dialysis therapy. The removal of uraemic toxins and correction
of the electrolyte and acid–base balance is mainly based on diffusion between the blood and dialysis
fluid, separated by a semipermeable membrane. Modifications in the flow of blood and dialysis fluid, as
well as membrane characteristics, have a large impact on the clearance of low molecular weight toxins.
Better removal of larger molecular weight uraemic toxins is achieved by innovations in dialysis membrane
technology or the use of online haemodiafiltration (HDF). This subchapter will focus on technical aspects
of HD and HDF. Dialysis adequacy will also be covered, explaining that adequate dialysis depends
on a multidimensional strategy of which small molecular weight removal is one part of the spectrum.
Individualization of dialysis frequency prescription is discussed in an ‘In the spotlight’ section.

HAEMODIALYSIS: TECHNICAL ASPECTS AND TREATMENT PRESCRIPTION 1

 Haemodialysis: technical aspects
and treatment prescription
Content Topics
Diffusive and convective Membranes:
Basic principles transport Flux
Ultrafiltration Biocompatibility
Blood flow (Qb), dialysate flow (Qd)
Urea kinetics and Urea kinetics:
dialysis adequacy URR, Kt/V
FLOW

Time and frequency Alternative schedules

When to start dialysis Incremental dialysis
Dialysis prescription
Dialysate prescription/ Home HD
individualization

Removal of middle- Hemodiafiltration Adequate dialysis

and larger molecular Backfiltration Multidimensional approach including volume control,
weight toxins Medium cut-off membranes mineral metabolism, nutrition and physical and
psychosocial support
Dialysate concentrates
Dialysis fluid and Water treatment On-line hemodiafiltration
water Environmental aspects of dialysis CONVINCE TRIAL: HR 0.77 for all-cause mortality

This subchapter will focus on technical aspects of HD and HDF. Dialysis adequacy will also be covered, explaining Kooman, J.
that adequate dialysis depends on a multidimensional strategy of which small molecular weight removal is one ERA Neph-Manual
part of the spectrum. Individualization of dialysis frequency prescription is also discussed. 2024

HAEMODIALYSIS: TECHNICAL ASPECTS AND TREATMENT PRESCRIPTION 2

Case Presentation

A 5-year-old male patient on chronic haemodialysis (HD) treatment presented at the emergency department
with severe hyperkalaemia (8.0 mmol/l) and changes on the electrocardiogram. After emergency treatment with
calcium gluconate and insulin/glucose, HD was started. At the last monthly blood check his potassium level was
higher than usual (6.5 mmol/l). He denied any dietary changes. Awaiting fistula placement, he was dialyzed
using a central venous catheter (CVC) three times weekly for 4 hours with a high-flux polysulphone dialyzer.
Because the prescribed blood flow (Qb) of 300 ml/min was not reached, attachment of the blood lines with
the arterial and venous lines was reversed. Single-pool Kt/Vurea (spKt/V) based on pre- and post-dialytic serum
samples taken from the central venous catheter was >1.2.

However, it was noted that spKt/V based on ionic dialysance was only 0.41, with an estimated urea clearance of
83 ml/min. Repeated spKt/V measurement using peripheral blood samples was only 0.44, whereas it was 1.55
based on samples taken for the central venous catheter. Computed tomography scanning showed a stenosis in
the superior vena cava from the brachiocephalic vein into the atrial atrium (Figure 1). A caval stent was inserted
and a new CVC implanted, together with creation of an arteriovenous fistula. The spKt/V after this intervention
was 1.21 (urea clearance 233 ml/min). No repeated episodes of hyperkalaemia were observed.

Figure 1. The tip of the dialysis catheter is positioned in the occluded superior vena cava (A: arterial lumen; V: venous lumen). Iodinated
radiocontrast is observed cranial to the occlusion in the azygos vein and caudal to the occlusion in the right atrium. An anteroposterior
view of the chest is shown in panel A and a lateral view is seen in panel B. (Patient gave consent for use of this figure).

Teaching point: Severe access recirculation because of reversal of arterial and venous poles [1] and proximal
stenosis in the superior caval vein (Figure 2) leads to severe hyperkalaemia. The reduction in dialysis efficiency
was not detected because blood samples were taken from the ports of the CVC. Assessing Kt/V by ionic dialy-
sance demonstrated very low levels that were confirmed by urea sampling from peripheral veins.

HAEMODIALYSIS: TECHNICAL ASPECTS AND TREATMENT PRESCRIPTION 3

 A B C
Inflow Inflow Outflow

Outflow Outflow Inflow

Recirculation

Vein Vein Vein

Normal circulation in dialysis catheter Small distance between inflow and Reversal of inflow and outflow
outflow tips causes recirculation lumens causes recirculation

Figure 2. Access recirculation with a CVC. Figure adapted from [1].

Basic principles of HD
The aim of HD is to remove uraemic toxins, restore the electrolyte and acid–base balance and remove excess
water and sodium from the body. During HD, the main principle for the transport of lower weight uraemic toxins,
electrolytes and buffer bases is diffusion, which is the random (‘Brownian’) movement of molecules based on their
thermal energy.

1. Low molecular weight (<500 Da), water-soluble

2. Low molecular weight, protein-bound
3. Middle molecular weight (500–12 000 Da)
4. High molecular weight (>12 000 Da)

Table 1. One of the classification schemes for uraemic toxins. Source: Kashani et al. [2].

During HD, blood and dialysis fluid, separated by a semipermeable membrane, stream in a countercurrent
direction in order to maximize the concentration gradient between the blood and dialysis fluid. Along with these
concentration differences, diffusion is dependent on the resistance and on the size of the membrane [3], which
are expressed as the dialyzer mass transfer area coefficient (KoA) (Table 2).

KoA is the maximum clearance for a given substances that can be achieved under ideal circumstances and is
a parameter used to classify the efficiency of a dialyzer. By convention, a KoA value <450 ml/min is regarded
as a low-efficiency dialyzer and a KoA value >700 ml/min is high efficiency [4] (Figure 3). Dialyzers used for
conventional HD usually have KoA values >500 ml/min and therefore membrane characteristics are rarely the
limiting factor in low molecular weight solute removal [5].

HAEMODIALYSIS: TECHNICAL ASPECTS AND TREATMENT PRESCRIPTION 4

 300 KoA 1000

250

Clearance (ml/min)
200 KoA 500

150

100

50

0
100 200 300 400 500
Qb (ml/min)

Figure 3. Relation between KoA, Qb, and urea clearance. Adapted from [5].

The Qb rate and dialysate flow rate (Qd) are the other factors determining removal of low molecular weight
solutes. Qb is typically 250–350 ml/min and Qd is 500–700 m, although, especially in the USA and Canada,
sometimes higher Qbs (up to 400 ml/min) are prescribed [6].

If you want to know more...

See ‘Relation between Qb, Qd and KoA in low molecular weight solutes’ in Supplementary Material.

With an increase in molecular weight, both lower solute velocity as well as a restriction of passage by the pore
size of the membrane are limiting factors for diffusion. Increasing Qb and Qd will have a lesser effect on their
clearance [8], which is more limited by time and membrane characteristics. The so-called high-flux membranes
have a larger mean pore size than low-flux membranes. Classification of high and low-flux membranes has gen-
erally been defined by the ultrafiltration coefficient (KUF), which is the ratio of the rate of water removal to trans-
membranous pressure (TMP) [5], or the sieving coefficient (SC) for individual solutes (discussed below).

Although there are different values in the literature, membranes with a KUF >20–30 ml/mmHg/h are generally
classified as high flux [5]. Whereas benefits of high-flux HD have mainly been observed in subanalyses of rand-
omized controlled trials, European Renal Best Practice (ERBP) guidelines [9] provide a strong recommendation to
use high-flux membranes in high-risk patients (defined as serum albumin levels <40 g/l) and a weak recommen-
dation for their use in all other patients [10]. In the 2015 Kidney Disease Outcomes Quality Initiative (KDOQI)
guidelines, the recommendation for high-flux membranes is expressed less strongly [11].

It is important to realize that the flux of a membrane, when defined by KUF, is a parameter of its hydraulic per-
meability, which is dependent upon pore size as well as pore density. Thus KUF is related to, but not synonymous
with, diffusive permeability for middle and larger molecular weight solutes. Other parameters that have been
used to classify membranes as high flux are the clearance of molecular weight solutes such as β2 microglobulin
(11.8 kDa and the SC for individual molecules (see Figure 4).

If you want to know more...

See ‘Median cut-off (MCO) membranes’ in Supplementary Material.

HAEMODIALYSIS: TECHNICAL ASPECTS AND TREATMENT PRESCRIPTION 5

 1.0

Pore density
0.8

Sieving coefficient 0.6

LF HF MCO
0.4 Urea B12 β2-M Myoglobin Albumin
Pore size (Å)
0.2

0
1000 10 000 100 000
Urea β2 microglobulin Albumin

Molecular weight (Da)

Figure 4. The SC with low-flux, high-flux and medium cut-off membranes. MWCO: molecular weight cut-off; MWRO: molecular weight
retention onset; β-2 M: β2 microglobulin; LF: low-flux membrane; HF: high-flux membrane; MCO: medium cut-off membrane. Adapted
from [15].

Convection, evoked by hydrostatic pressure differences between the blood and dialysate compartment, resulting
in bulk movement of fluid and solutes, is the other main mode of transport during HD. UF, which is the removal of
plasma water through the membrane based on the pressure gradient over the dialyzer, is also based on con-
vective transport. With haemodiafiltration (HDF), convection is the main mode of transport for removal of larger
molecules (Figures 5 and 6), combined with diffusion for removal of smaller molecular weight toxins. With online
HDF, the substitution volume, which is used to replace the filtrated plasma water, is produced by additional filtra-
tion of ultrapure dialysis fluid. Convective clearance with online HDF in its optimal prescription is >100 ml/min.
Online HDF
with 90 ml/min
convective removal

300 510

Blood Ultrapure
dialysis fluid

420 500

80
290 Substitution
fluid
Figure 5. Basic principle of online HDF. From [13].

Inulin Vitamin B12 Urea

Clearance (ml/min)

200
Convection
Diffusion

100 Blood flow rate

= 300 ml/min

0
0 30 60 90 0 30 60 90 0 30 60 90
Ultrafiltration rate (ml/min)

Figure 6. Removal of small and larger molecular weight toxins. Figure adapted from [14].

HAEMODIALYSIS: TECHNICAL ASPECTS AND TREATMENT PRESCRIPTION 6

Convective clearance with HDF is dependent on the filtrated volume and the SC of the membrane, which is the
ratio of the concentration of a solute in the filtrate divided by the concentration in plasma, and has a value be-
tween 0 and 1 (Table 2) [5, 13] .

Metric Unit Meaning Dependent on*

The maximum clearance for a given substances that Membrane surface area, pore density, wall
KoA ml/min
can be achieved under ideal circumstances thickness
Pore size distribution, pore density, mem-
KUF ml/h/mmHg Hydraulic permeability for water (‘flux’)
brane surface area
Concentration of a solute in the filtrate divided by
SC Unitless Pore size
the concentration in plasma

Table 2. Commonly used indices for membrane characteristics. *Not exhaustive.

If you want to know more...

See ‘Convective clearance during dialysis, the role of backfiltration’ in Supplementary Material.

Regarding the effect of convective therapies on mortality, of three large randomized controlled trials, only one
study showed a significant improvement in outcomes. However, in a meta-analysis, HDF was associated with
a 14% reduction in all-cause mortality and a 23% reduction in cardiovascular mortality [15]. Consistent in sub-
group analysis of all studies is the relation between achievement of higher filtration volumes, for which an ade-
quate vascular access is needed, and reduced mortality. In a systematic review, online HDF was not associated
with an improved quality of life as compared with HD [17] and the potential benefits of online HDF remain under
debate. However, recently the CONVINCE was published, which showed a significant decrease in mortality with
the use of on-line HDF, potentially setting a new standard of care (note added in proof).

Biocompatibility of dialysis membranes

A dialyzer is composed of several thousand hollow fibres (Figure 7). The materials of these fibres are traditionally
subdivided into unmodified cellulose membranes, modified cellulosic membranes and synthetic membranes (the
latter group consisting of a range of different materials). Contact between the blood and a foreign material, such
as a dialysis membrane, can produce a (bioincompatibility) response starting with protein adhesion, followed
by stimulation of the contact activation system and subsequently resulting in activation of the complement system,
leucocytes and thrombocytes [18]. The initiation of this response is therefore different from the response to tissue
injury, in which the trigger is a release of tissue factor [19].

Figure 7. Ultrastructure of a polysulphone membrane. From [20].

HAEMODIALYSIS: TECHNICAL ASPECTS AND TREATMENT PRESCRIPTION 7

The problem of bioincompatibility was most pronounced in the early days of dialysis with the use of unmodified
cellulosic membranes, primarily due to the presence of hydroxyl (OH−) groups. The responses can largely be
prevented by substitution of OH− by acetate. Cellulosic triacetate membranes are frequently used in contempo-
rary HD treatment. Synthetic membranes such as poly(ether)sulphone or polyamide form a different class of mem-
branes with a completely different structure, resulting in less membrane resistance and a different biocompatibility
profile [15, 20].

It is important to realize that despite large improvements in membrane technology, no dialyzer is fully biocom-
patible and complement activation and thrombocytopenia can still occur [21]. For more information on recent
developments in membrane technology, the reader is referred to an excellent recent review on this topic [5].

Urea kinetics and dialysis adequacy

One of the markers for dialysis adequacy is based on the removal of low molecular weight solutes. In its simplest
form, urea removal is estimated by the urea reduction ratio (URR), which is based on the ratio of the urea concen-
tration at the start (Co) and end (Ce) of HD [4]. In clinical practice, spKt/V and double-pool or equilibrated Kt/V
(eKt/V) are distinguished. While in the calculation of both spKt/V and eKt/V pre- and post-dialytic urea samples
are used (Table 3), the calculations of both metrics differ according to the way in which urea rebound after HD is
considered (see ‘If you want to know more’). Another method, ionic dialysance, enables the assessment of Kt/V
during every dialysis session. The difference between spKt/V and eKt/V is ≈0.15–0.2. ERBP and Renal Associa-
tion Clinical Practice guidelines recommend a minimum target eKt/V of 1.2 [9, 22], whereas the KDOQI recom-
mends a target spKt/V of 1.4 and delivered spKt/V of 1.2 [10]. Importantly, Kt/V does not provide information
on the removal of middle and larger molecular weight toxins [23].

Metric Blood sampling Principle Urea rebound

URR Yes Ratio urea pre/post No
spKt/Vurea Yes UKM No
eKt/Vurea Yes UKM Yes
Kt/VID No Conductivity pulses No

Table 3. Comparison of different metrics used in urea kinetic modelling.

If you want to know more...

See ‘Urea kinetics’ in Supplementary Material.

It is important to realize that URR, spKt/V and eKt/V only provide information for a single dialysis and their in-
terpretation is based on thrice weekly HD regimens [30]. Moreover, these metrics do not consider residual renal
function. In order to account for alternative HD regimens and residual renal function, different concepts were de-
veloped, of which the standardized Kt/Vurea (stKt/V), which provides information on (equivalent) urea clearance
on a weekly interval, is the most frequently used. An stKt/V of 2.1 is usually regarded as a target for adequacy
for small molecular weight clearance [9].

Moreover, indices expressed by urea kinetics only give an indication of the removal of small molecules by HD,
for which guidelines have set minimal standards, as lower values have been associated with adverse outcomes.
In this respect they are one of the various indicators of adequate treatment of a dialysis patient, which encompass
a multidimensional spectrum of factors such as toxin removal, electrolytes and acid–base balance, hydration
state, nutrition [31] and indices of patient well-being (Table 4). More information is available on these parameters
in the hyperlinks and in other chapters of this e-manual.

HAEMODIALYSIS: TECHNICAL ASPECTS AND TREATMENT PRESCRIPTION 8

 Factors
Hypertension, fluid overload
Bone mineral disorder
Vascular calcification
Metabolic acidosis
Anaemia
Reduced physical activity
Others: sexual dysfunction,
itching, depression
Intervention Guidelines or KDIGO conference summary
Blood pressure and volume management in dialysis: conclusions
Dietary counselling, dry weight from a Kidney Disease: Improving Global Outcomes (KDIGO)
adjustment Controversies Conference
Adjustment of ultrafiltration rate
Extended or additional treatment Project Mandate Template (ukkidney.org)
sessions
https://www.ajkd.org/article/S0272-6386(15)01019-7/fulltext
Diet, phosphate binders CKD-Mineral and Bone Disorder (CKD-MBD) – KDIGO
Adjusting dialysate bicarbonate
Project Mandate Template (ukkidney.org)
(careful!), oral bicarbonate, diet
Anemia in CKD – KDIGO
Correction iron and vitamin
deficiencies
Updated-130220-Anaemia-of-Chronic-Kidney-Disease-1-1.pdf
Erythropoietin
(ukkidney.org)
Intradialytic exercise,
Project Mandate Template (ukkidney.org)
rehabilitation programs
Targeted

Table 4. Factors addressed by adequate dialysis treatment.

When to start HD?

Starting dialysis is a major life event for the patient, with physical and psychosocial consequences, and the
decision when to start preparations for and the actual HD treatment itself should be thoroughly discussed with
patients. Whenever possible, an unplanned start should be avoided. KDOQI guidelines and a Kidney Disease:
Improving global Outcomes (KDIGO) controversies conference provide directions for planning and initiating
HD treatment [10, 32]. It is important to consider that apart from the classical indications for starting HD, such
as refractory fluid overload, refractory electrolyte and acid–base disturbances and uraemic encephalopathy or
pericarditis, there is not a single eGFR value at which HD has to be initiated. The starting point for HD thus de-
pends on the clinical status of the patient and should be part of a shared decision process. Decisions regarding
the choice between starting renal replacement therapies or conservative care in patients with kidney failure are
covered in the chapter on renal failure in the elderly.

Home HD
Providing the possibility for home treatment may greatly increase the patient’s autonomy, but home HD is an un-
derrepresented treatment modality in current dialysis practice. Table 5 presents the advantages, challenges and
solutions of home HD.

Benefits Challenges Solutions

• Patient autonomy • Patient/caregiver burnout • Team/buddy support
• Flexibility • Medicalization of home environment • Counselling
• Improved quality of life? • Patient anxiety • Training
• Benefits from extended HD schedules (if • Fear of self-cannulation • Telemonitoring
prescribed): volume and blood pressure • More rapid loss of residual renal function (with
control, mineral metabolism nocturnal HD)
• Vascular access complications (with more frequent
sessions)

Table 5. Advantages, challenges and solutions of home HD. Partly adapted from Bieber and Young [7] and Tattersall et al. [10].

HAEMODIALYSIS: TECHNICAL ASPECTS AND TREATMENT PRESCRIPTION 9

Dialysis fluid and water
Dialysis fluid is composed of three components. Along with purified water there is the A (acid) component, con-
taining electrolytes, glucose and a small amount of acid for pH stabilization (usually acetic acid, although citric
acid is also used), and the B component, containing sodium bicarbonate. In the HD machine, these three com-
ponents are mixed by a proportioning system. The A and B components are kept separate until mixing in order to
prevent deposition of calcium carbonate. Prescription of the dialysis fluid can have profound effects on the elec-
trolyte and acid–base status of the patient, and a balance has to be sought between the prevention of short-term
complications and potential drawbacks of loading or insufficient removal of electrolytes.

Regarding sodium, the most frequently prescribed concentration is 138–140 mmol/l [38]. Whereas lower di-
alysate sodium levels may reduce interdialytic weight gain (IDWG) and thirst, they may also contribute to cramps
and intradialytic hypotension [39, 40]. Higher dialysate sodium levels may prevent intradialytic hypotension in
the short term, but lead to thirst, higher IDWG and hypertension in the long term [41]. Whereas individualization
of dialysate sodium has shown promising results in short-term studies [42], observational studies towards hard
outcomes with different dialysate sodium levels have yielded somewhat contradictory results.

Component Higher Lower

Sodium Increased IDWG, thirst, hypertension Cramps, intradialytic hypertension
Potassium Insufficient correction of hyperkalaemia Arrythmias
Calcium Vascular calcifications, vascular stiffness Increased QTc, intradialytic hypotension
Headache, respiratory depression, hypokalaemia,
Bicarbonate Insufficient correction of acidosis
risk of infection
Table 6. Possible side effects of the dialysate prescription. IDWG: inter-dialytic weight gain.

With respect to dialysate potassium, levels <2 mmol/l were associated with higher mortality, especially in pa-
tients with lower serum potassium levels, in which dialysate potassium ≥3 mmol/l may be indicated [43]. Regard-
ing dialysate calcium levels, low levels (<1.25 mmol/l) may increase the QT interval and increase the possibility
of sudden cardiac death [43], whereas higher levels (>1.25 mmol/l) may increase vascular calcification and
arterial stiffness [44]. Bicarbonate in the dialysate is used to correct acid–base balance. However, high con-
centrations have been associated with increased mortality. Whereas the mechanisms behind this observation is
unknown, an increased risk of arrhythmias due to more rapid potassium shifts has been suggested.

Relatively few recommendations on dialysis fluid prescription are available in the guidelines, with the exception
of dialysate calcium. The KDOQI guidelines recommend a standard concentration of 1.25 mmol/l, whereas the
KDIGO recommends 1.25–1.5 mmol/l [44]. Renal association clinical practice guidelines recommend a di-
alysate potassium prescription of 1–3 mmol/l and a dialysate buffer level <37 mmol/l [22].

Water treatment for dialysis

Before water is suitable for fabrication of dialysis fluid, it has to undergo several purification steps. Charcoal filters
are used to remove chlorine and organic contaminants. Softeners exchange calcium and magnesium for sodium
[45]. Reverse osmosis (RO) membranes remove the remaining ions and bacterial contaminants are removed. The
water that enters RO is called the feed water, the water that has passed through RO is called the permeate and
the water that is discarded is the reject water [46] (Figure 8). Water treatment systems can include several other
components, such as a second RO unit and an (electrical) deionisation unit, as well as ultrafilters. There are strict
criteria for the microbiological (Figure 9) and chemical purity of water used for HD.

HAEMODIALYSIS: TECHNICAL ASPECTS AND TREATMENT PRESCRIPTION 10

 RO reject water

RO reject water
recirculation

Feed water Sediment filter Carbon filter Pump Permeate

RO membrane

Return of unused permeate

Figure 8. Schematic of an RO unit. Figure adapted from [46].

Pretreatment Mix with

Tap + RO Water for concentrates Standard Ultrafiltration Ultrapure Ultrafiltration Sterile,
water dialysis* dialysis fluid* dialysis fluid* non-pyrogenic*
substitution fluid

Microbiological CFU/ml <102 <102 <10–1 SAL ≥6

quality: EU/ml <0.25 <0.50 <0.03 <0.03

Dialysis fluid
Basis for Dialysis fluid Infusion
in low-flux HD
Application in dialysis all fluid in all forms of solution in
with synthetic
preparation HD and HDF HDF and HF
membranes

Figure 9. Different standards for water quality. From [13].

RO: reverse osmosis; CFU: colony-forming units; EU: endotoxin units; SAL: salinity assurance level.
*To achieve the respective quality levels the entire process must be operated with validated components and appropriate hygiene.

If you want to know more...

See ‘Environmental aspects of HD’ in Supplementary Material.

Test Yourself
Case 1
A 75-year-old man with diabetic nephropathy is treated thrice weekly with HD for 4 h using a CVC. He is treated
with a high-flux dialyzer with a KoA of 1050 ml/min, a surface area of 1.5 m2 and a KUF of 50 ml/h/mmHg.
His prescribed blood flow rate (Qb) is 300 ml/min, but this often not achieved due to negative arterial pressure
alarms. His effective Qb is ≈190 ml/min with lines in the normal position, but this can be increased to 275 ml/
min with lines in the reversed position. His dialysate flow rate is 600 ml/min. His spKt/V values are ≈0.8 and his
pre-dialytic potassium and phosphate levels increased. Due to central venous stenosis in the left and right jugular
and superior vena cava, replacement of the CVC together with central venous stenting is planned. While await-
ing the procedure, what is the best approach to improve his dialysis efficiency?

A. Increase the dialysate flow rate

B. Increase the dialysis time
C. Prescribe a dialyzer with a greater surface area
D. Reverse the attachment of the blood lines with the CVC poles

HAEMODIALYSIS: TECHNICAL ASPECTS AND TREATMENT PRESCRIPTION 11

Answers

Case 1
Answer: B
Explanation: Increasing the dialysate flow rate (answer A) will have only a very limited effect in case of a low
Qb. The same holds true for answer C, as the low blood flow rate is the limiting factor for low molecular weight
solute removal. Reversing the attachment of the blood lines with CVC poles will increase recirculation. Therefore
the only effective method to increase removal of small molecular weight toxins and electrolytes is by increasing
the dialysis time.

HAEMODIALYSIS: TECHNICAL ASPECTS AND TREATMENT PRESCRIPTION 12

Meet the Author

Jeroen P. Kooman (1966) received his MD degree in 1990 and his PhD in 1992, has
been a consultant nephrologist since 1998 and, since 2012, a full professor in the Depart-
ment of Internal Medicine, Division of Nephrology, Maastricht University Medical Centre,
Maastricht, The Netherlands. Although an all-round clinician, his clinical expertise focuses
on general nephrology, acute and chronic kidney injury and renal replacement therapy.
His research interests are broad but concentrate mainly on diagnosis and prevention of
cardiovascular and nutritional complications from renal failure and on the pathogenesis
and prevention of (acute) complications during haemodialysis treatment. As of August
2022, Jeroen has published 330 papers in international journals (Hirsch index 62) and
has contributed to various book chapters. He has supervised many PhD students. Jeroen
also has a keen interest in medical education and received a Master’s degree in health professions education.
He has served as a coordinator of the Bachelor in Medicine at Maastricht University and was head of medical
training for nephrology residents from 2017 until 2020. From 2020–September 2022 he was the director of ED-
LAB, Maastricht University of Education Innovation. In the coming years he will focus on his clinical, research and
educational duties and serve as editor of the E-manual for Nephrology for the European Renal Association.

HAEMODIALYSIS: TECHNICAL ASPECTS AND TREATMENT PRESCRIPTION 13