DIALYSIS ADEQUACY: HOW DO WE MEASURE IT?

DR RAVINDRA PRABHU A
PROFESSOR NEPHROLOGY
KASTURBA MEDICAL COLLEGE MANIPAL, MAHE
Adequacy
• Minimum amount of dialysis needed to sustain
life
• Keep patient clinically asymptomatic, active
• Correct altered metabolic and homeostatic
components of ESKD

• Optimal dialysis dose which reduces morbidity

and mortality associated with ESKD/ dialytic
procedure itself
• Dose above which an increase does not justify
the increased burden of treatment
ADEQUACY
• Small solute clearance
• Blood Pressure
• Volume
• Anemia
• Acidosis
• Mineral Bone Disease
• Inflammation
• Nutrition
CLEARANCE
• Blood flow
• Dialyser mass transfer area coefficient KoA
• Dialysate flow rate/composition
• Effect of RBC
• Blood water
• Molecular weight
• Flux
• Efficiency
UREA
• 60 da size
• Size
• abundance
• ease of measurement
• Dialysability
d(VC)/dt = G - KC
MIDDLE MOLECULE
• 500 to 5000 da
Kt/V
• K clearance of a solute ml/min = KoA
• T treatment duration minutes
• V volume of distribution = body water
Incorporate generation of solute and fluid
removal, residual kidney function
RECIRCULATION
• Vascular access
• Cardiopulmonary
• Compartmental
UREA REDUCTION RATIO
• PRE DIALYSIS UREA - POST DIALYSIS UREA
PRE DIALYSIS UREA
DAUGIRDAS 2
• KT/V = - ln (R – 0.008 t) + (4 – 3.5 R) X UF/W
• ln natural logarithm.
• R Post dialysis BUN/Predialysis BUN.
• t Duration of dialysis session in hours.
• UF Ultrafiltration volume in liters.
• W Patient's post dialysis weight in kilograms.
 EQUILIBRATED Kt/V

eKt/V = spKt/V X Td/(Td + 30.7)

eKt/V = spKt/V – 0.6 X spKt/V/hour + 0.03
STANDARD Kt/V
• stdKt /V = urea removal rate/ peak concentration
• = G /average predialysis BUN
• Can be used to compare with continuous therapies and PD
• Minimum 2.0 as per KDOQI guidelines
RESIDUAL RENAL FUNCTION
PERITONEAL DIALYSIS
ADEQUACY
Prescription
• MODALITY CAPD/APD
• Clearance
• Ultrafiltration
• Nutrition/Metabolic requirements
ADEQUACY
• Quantity of clearance
• Quality of prescription
CLEARANCE
• Kt/V Urea weekly > 1.7
• Creatinine clearance weekly/1.73 m2 45 L
• Most guidelines recommend inclusion of residual kidney function
Kt/V
• Total Kt = Peritoneal Kt + Residual renal Kt
• Peritoneal Kt = 24 hour dialysate urea/serum urea
• Renal Kt = 24 hour urine urea/serum urea
Kt/V
• Kt/Day = 24 hour drain volume x D/P Urea
• Weekly Kt/V = Daily Kt/V X 7
• CAPD Blood urea can be sampled at any time.
• APD Blood urea is sampled in middle of non cycling period(1 to 5 PM)
 CREATININE CLEARANCE CrCl
• Needs correction to 1.73 m2 Body surface area
• CrCl = Peritoneal CrCl + Renal CrCL
• Peritoneal CrCl = 24 hour peritoneal create/serum create
• Renal CrCl = 0.5(24 hour urine create/serum create + 24 hour urine urea/serum
urea)
• BSA (DuBois formula):
• BSA (m2) = 0.007184 × W0.425 × H0.725
• Where BSA = body surface area (m2), W = Ideal Body weight (kg), H = height (cm)
CrCl
• CrCl / day = 24 hour drain volume x DP Creat
• Corrected CrCl for BSA 1.73 m2 = CrCl/day x 1.73/BSA
• Weekly CrCl = CrCl/day x 7
• Measured after 1 month and then 4 monthly, 2 Monthly if
incremental and every time prescription changes
CLEARANCE DETERMINANTS
• Residual function
• Body size
• Transport character
• Dwell volume/frequency/tonicity
• APD Dwell volume/tonicity/frequency/cycles
NUTRITION
• n PNA Normalised Protein Nitrogen Appearance target 1.2 grams/kg/day
• Protein excretion ∝ Protein intake
• Bergström formulas
• PNA (g/d) = 20.1 + 7.5 UNA (g/d) or
• PNA (g/d) = 15.1 + 6.95 UNA (g/d) + dialysate protein losses (g/d)
• UNA (g/d) = urinary urea losses (g/d) + dialysate urea losses (g/d)
• Albumin
• Subjective Global Assessment
• Creatinine excretion
• Caloric intake