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Measuring KtV

There are a number of different methods of measuring and assessing Kt/V, but
they all rely upon the fact that urea is equally distributed throughout the body in
the total body water. We will now consider the two most common methods of
assessing the Kt/V
1 : Single Pool Kt/V
2: eKt/V

Avitum uses the e K tN as it's preferred method of choice.

In order to understand how dialysis prescriptions can affect the patients Kt/V we
need to explore how the Kt/V calculations are made.
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Theory behind KtV

Urea kinetic modelling uses urea, a waste product of protein catabolism, as

a marker molecule for clinically important uraemic waste products. It is this -
D.
measurement that is used to assess dialysis efficiency, but it can also be
used to calculate individual dialysis prescriptions and measure protein
intake.
Urea has a number of advantages as a marker of dialyser clearance and
dialysis adequacy. It is
• present in high concentrations
• easy to measure
• it is a stable low molecular-weight compound
• soluble in water & easily removed in dialysis
• equally distributed throughout the body
These characteristics make it the best marker so far identified .
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Blood Sampling - Timing is all

The following post-dialysis

sampling technique has been
adopted throughout the Avitum
Dialysis centres .
At the end if dialysis slow down
the blood pump speed to
1OOmls/min then count to 15
seconds and take the blood
sample from the arterial needle or

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-
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eve arm.

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The following is a very simplified example to illustrate the influence of dialysis

time and changes in a dialyser can make to the Kt/V.
A 48yr old man, weighing 100 Kg dialyses for 3 hours using a Hips 15
dialyser
Using the. Watson formula his V = 34.6
•
3 hours dialysis: t = 180 mins .
'
K = 0.173

So if we put this into the Kt!V formula

Kt/V = 0.173 x 240 I 34.6 = 0.9

This is less than the minimum required of a KtV >1.2 , and indicates that he may
be underdialysed.
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KtV Example

Any change to each of the elements of

KtV will affect the result.
Changing dialysis time (t) or the
dialyser (K) will affect the
dialysis adequacy.
The only variable that you are unable
to influence will be 'V', as this is patient
dependent.
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So how can we improve this?

So what happens if we increase his dialysis time to 4 hours and recalculate?

Using the Watson formula his V = 34.6:
4 hours dialysis: t = 240 mins:
K = 0 .173

So if we put this into the Kt/V formula

Kt/V = 0.173 X 240 I 34.6 = 1.2

This results in a KtV of 1.2, so that he is now achieving the minimum standard
of dialysis adequacy.
This just illustrates the relationships between different aspects of dialysis that
you can influence to improve the quality of treatment your patient receives.
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Because of the difficulty in assessing complex patients to determine an

adequate dialysis dose interest turned away from purely clinical assessment
towards physical parameters that could describe the efficiency of solute
removal by an artificial dialyser. In the 1970's this included measurement of
permeability coefficients, mass transfer coefficients and clearance. Of these
parameters, clearance remains the principle parameter in any mathematical
method of assessing dialysis adequacy.
The publication of the National Co-operative Dialysis Study in the US in the
early 1980's set the scene for the use of urea as then main measurement
parameter for dialysis adequacy. It is now widely accepted that UKM is the
current measurement of choice. However, there is still some controversy over
it's use, and it is important to remember Kt/V should be used alongside
clinical
assessment.
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What is an Adequate Dialysis Dose or Kt/V?

The National Co-operative Dialysis Study (NCDS) identified that in patients

dialysed 3 times a week with a Kt/V of 0 .9, it was sufficient to maintain the
morbidity risks at an acceptable level. A Kt/V of less than 0.9 was associated
with an increased mortality and morbidity risk.

Subsequent studies and international standards and guidelines have since

shown that the minimum Kt!V target should be 1.2. But it is important to also
note that evidence is also showing that patients should also dialyse tor a
minimum of 12 hours a week.

Held et al (1991) reported a tendency to improve survival by 8% tor each

incremental increase in Kt/V of 0.1 up to a Kt/V of 1.4.

But what about patients who dialyse only twice a week? Studies have
indicated
that a Kt/V of between 1.8 - 2.0 should be targeted for twice a week
dialysis.
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Single Pool KtV

The generation of urea into this 'single pool' is determined by the rate of protein
catabolism. And removal of urea form the pool is equal to the sum of dialysis
clearance and residual renal function (if any). Different dialysers have different
clearance rates, and so will affect the amount of urea cleared during a dialysis
treatment. It is this clearance factor that gives us 'K' from the term Kt/V.
The amount of time that a patient spends on dialysis will also determine the
amount of urea (and other solutes) cleared during treatment. This gives us 't'.
Therefore
K = c learance (determined by the size and type of dialyser in mls/min)
t =time (actual dialysis treatment time in minutes)
V =volume (the calculated urea distribution volume in litres)
Dialysis Adequacy
- Theory of Kt/V

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Now you have completed the training take the test by closing down the
presentation and follow the instructions on the next screen.

End of the presentation.

To close the presentation please click
i5il -
at the right top corner of the
window .
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Determinants of Adequacy

There are many aspects to dialysis adequacy, and for the benefit of patient care
all of these separate components should be considered when assessing the
patient. However for the purpose of this presentation we will concentrate on the
issue of Kt/V only.

Fluid &
electrolyte Biocompatibility

I
Acidosis
homeostasis

_,!, _
correction Anaemia
Adequate solute /correction
removal HD schedule
/
DIALYSIS ADEQUACY ,.. - - - &
duration
Blood P r e s s u r e - - - - - - - - - ­
Control --------------- Good
nutrition
!..l• ;
Patient Outcome
Quality of life
Rehabilitation
Morbidity
Mortality
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Calculating V

Because urea is equally distributed throughout the total body water, single-pool
K t N regards water as being in one 'pool' called the urea distribution volume or
'V'. This volume can be estimated, taking total body water as 58% of lean body
mass. But because patients are all different sizes and shapes, V can be more
accurately calculated by taking into account the patient's height, weight and
gender (the Watson Formula). These are displayed below.

Don't worry, you are not expected to remember these equations, but just
understand how different body shapes and genders could affect the Kt!V.

• Male V = 2.477-(0.0952xAge(years))+(0.017xHeight(cm)))+0.336xWeight(kg))
·Female V = 2.097-(0.0952xAge(years))+(0.017xHeight(cm)))+0.247xWeight(kg))
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Introduction

Since the earliest days of haemodialysis there has been a continual search for
a method of identifying the correct dialysis dose for individual patients, and for
assessing the effectiveness of the delivered dialysis treatment.
Before the introduction of urea kinetic modelling (UKM) the methods used were
inconsistent and relied upon generalised standard procedures. These were in
turn influenced by the experience and expertise of the renal team .
The general use of predialysis blood values depended upon experienced
nephrology staff detecting when a patient is under-dialysed, which in turn was
dependent upon their ability to interpret clinical signs and symptoms which can
often be disguised by co-morbid conditions .
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Limitations of KtV

K t N results for specific patients should be carefully applied and it's limitations
appreciated. It should be remembered that Kt/V deals only with urea clearance
and cannot give a full picture regarding the clearance of all uraemic toxins,
though it does provide an estimation of dialysis efficiency as a whole.
There remains a poor understanding of the relationship between uraemia and
specific solute concentrations, so the extension of this mathematical model to
include other components of the dialysis prescription continue to be explored.
Therefore it remains important to undertake a full clinical assessment of the
patient as a whole, and not rely just on the Kt/V results for your patients.
The clinical considerations behind the Kt/V result will be explored further in
the next module "Dialysis Adequacy 2 - Influences on Effective Treatment ".
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Common errors in post dialysis blood sampling

The formula Avitum uses to calculate the patients KtV makes a number of
assumptions and is designed to estimate the KtV from the sampling technique
just described.

1:Taking the blood too soon

This results in an inaccurate high KtV because your are taking a sample of
mixed venous return blood and arterial blood.

2: Not reducing the blood pump speed

Again this will result in an inaccurate high KtV due to risk of venous return blood
mixing with the arterial blood in the fistula - recirculation

3: Waiting too long to take the sample

If you wait for too long after reducing the blood pump speed then there will be a
rebound of the urea from the interstitial compartments into the blood resulting
in a lower than expected KtV.
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Blood Sampling

Two blood samples are required for

calculation of the patients KtV. A predialysis
urea level and a post dialysis urea sample.
Timing of the sample collection is important
for both samples. The pre-dialysis sample
should be taken via the arterial needle of
central venous catheter (CVC) arm before
dialysis commences.
The timing of the post dialysis sample is
important to ensure consistent sampling
and therefore results. If different staff use a
different technique then it is impossible to
make comparison of treatments for each
individual patient over a period of time.
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eKtV

eKt/V considers urea to be distributed in two pools in the body

• the intracellular fluid (ICF)
• the extracellular fluid (ECF).
and the formula used to calculate the Kt/V is altered accordingly.

During dialysis, changes in the urea concentration of the ICF lag behind
changes in the ECF, and following the end of dialysis a 'rebound' in the serum
urea will occur. This lag is due to the diffusion of urea from the ICF into the
ECF, which continues until equilibrium is reached.

During the high efficiency solute exchange of today's haemodialysis the

dual-pool nature of urea is significant and the dual-pool formula used to
calculate Kt!V takes this into account. The target is to achieve a
minimum Kt!V of 1.2 for all patients on 3 times a week dialysis, unless
there is significant residual renal function .