Haemodialysis Adequacy-2

HAEMODIALYSIS ADEQUACY
Dr. Ahmed Akl , MD, PhD

ISN EDUCATION AMBASSADOR
CONSULTANT OF
NEPHROLOGY&TRANSPLANTATION,
UROLOGY&NEPHROLOGY CENTER,
MANSOURA
, EGYPT
The urology & Nephrology center, Mansoura, e-mail : aiakl2001@yahoo.com

Egypt
OPTIMAL DIALYSIS
Anemia
management
BP control Good nutrition
Dialysis
adequacy
Fluid and
electrolyte
s
hemostasis
Kt/v
BMD
management
In 1913 three medical scientists working in the Department of
Pharmacology at Johns Hopkins Medical School devised equipment
and methods for vividiffusion in animals; haemodialysis was invented.
However, thirty years elapsed before a clinically effective system was designed, by
Willem Kolff working in the Municipal Hospital at Kampen.

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THE FIRST ARTIFICIAL KIDNEY
Four artificial kidneys built in 1943 and sent to the UK, the USA, Canada and
Poland

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Gord on Murray (from Gord on Murray, Quest in Medicine, Mill'ray 's first d i a ly se.t , a coil d esign w o u n d o n a s t e el
The Ryerson Press, Toronto, 1963). fr a me ( l eft) . N o t e th e narro w calibre o f th e blo o d tubing ,
which was o nly 6 1nm wid e, b u t u p to 50 n1 long. Also s ho wn is
M u n a y ' s a traun1.atic
bl o o d p u m p (ceu t re) , ·which a llo..,.red venoveno u s dialysis.
(C o urt esy
of D r VV. G . Big el ow, T o r o n t o . ) . ·
The Murray-Roschlau ‘second-generation’ Flat-Plate
Dialyser.
•This was an advanced flat-plate parallel-
flow dialyser with:
•30 layers of dialysis units.
•Each unit with two membranes and two

dialysis compartments.
• Forming a dialyser of 0.6 m2 surface area

and with a priming volume of only 225 ml. (National archive of Canada, MG 30
B110
D.W.G. Murray Papers, Volume 41,
File
16, Negative No. C143613; Supplied
by
Dr. W. Roschlau).

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Urea (or BUN) levels
Urea is the substance most often monitored in clinical practice

because:
•It is a small, readily dialyzed solute that is the bulk catabolite of dietary protein.
• Constitutes 90% of waste nitrogen accumulated in body water.
• Is easily measured in blood.
• Fractional clearance of urea in body water correlates with patient outcomes.
•BUN stands for Blood Urea Nitrogen. With normal kidney function,
a person has a BUN in the range of 8 - 25 mg/dl.

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Shooting for BUN Targets
• In the 1970s and early 1980s, a common practice was to

prescribe hemodialysis therapy in order to attain a target BUN.
• The pre-treatment BUN never to exceed 80 mg/dl. To achieve that

goal,
they adjusted:
• The amount of time on dialysis.
• The blood flow rates.
• Changed dialyzers.
• Issued restrictions on dietary protein.
Sad, but true - 1970's Renal Dietary Counseling: Stop eating so much protein
OR WE'LL HAVE TO INCREASE YOUR DIALYSIS TIME !!
Using target BUNs Seemed like a logical approach to
prescribing hemodialysis.
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Questions No One Could Answer
However, many patients who hitting these BUN targets were still not
doing well, and some displayed symptoms of being underdialyzed.
Why was this?
Why did patients who weighed the same and ate the same amount of
protein require different amounts of dialysis therapy to stay healthy?
Why were some patients who had pre-treatment BUNs of 100

perfectly healthy, yet others who had pre-treatment BUNs of 60 unhealthy
and in need of more dialysis?

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Using Urea Clearances
•They found the data didn't make much sense until they invented a new
way of measuring dialysis therapy.
•Their new method still utilized urea, but it didn't use a target BUN.
Instead, it measured the volume of blood that was cleared of urea
during a treatment and compared it to the amount of water in the
patient's body.
•The end result was that Gotch and Sargent arrived at a simple, elegant
formula for measuring dialysis therapy:
K t

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National Cooperative Dialysis Study (NCDS)
•In the 1970's, the NCDS was funded to try to

determine which dialysis therapies provided
the best patient outcomes.
•A huge database of information about

dialysis patients for the first time.
•Analyzed the study's database trying to find new

common factors for those patients that were doing
well (and for those patients that were doing poorly).
Dr. John Sargent
Prof. Frank Gotch

Urea Kinetic Modeling
•Why were some patients who had urea levels of 100 perfectly healthy,
yet others who had levels of 60 unhealthy and in need of more dialysis?
•Why did two patients who weighed the same amount need
different lengths of dialysis treatments to stay healthy?
•The formula Kt/V effectively answered these questions for

the first time.
•When Gotch and Sargent applied the Kt/V formula to the data they had
for these patients, the healthy and unhealthy patients fell into two
distinct numerical groupings.

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•If the patient had a Kt/V value that was 1.0 or higher, they were doing
well in terms of being adequately dialyzed.
• If they had a Kt/V value less than 0.8, they were underdialyzed and were
doing poorly.
•This new approach became known as UREA KINETIC MODELING.
•It uses the results of two blood tests, pre and post treatment BUNs, in its
calculations.
• Urea kinetic modeling includes protein metabolism analyses and

It
calculates the protein catabolic rate (PCR).

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Another benefit of Gotch and Sargent's analyses was that it

provided strong scientific evidence that dialysis patients were better off
eating more protein, not less.
As more data accumulated, it became apparent that reducing protein

in the diet to keep the urea levels low was actually resulting in patients
not getting enough protein to stay healthy (low albumin levels).
Over the years, it also became apparent that there were additional
long- term benefits for the patients in increasing their Kt/V values to
1.2 and higher.
At the 1970's patients who ate more than their allowed amount of
protein were "punished" with more dialysis time. That were actually in
sync with today's best clinical practices.

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Around 1990, researchers were able to show a high degree of
correlation between Kt/V values and urea reduction ratios (URR).
A URR can be calculated with simple algebra and only uses the
same two blood tests as the Kt/V equations.
While a URR is not as accurate as a Kt/V value, nor does it provide

any information about the patient's protein intake, a URR value does
provide an easy-to-calculate marker for dialysis adequacy.
As an example, a Kt/V of 1.2 is roughly equivalent to a URR of about

63 percent. Like Kt/V, the higher the URR value, the better.

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INCREASING DIALYSIS
DOSE IMPROVED
SURVIVAL
Kidney Int 1996; 50:550

Measures of dialysis
adequacy
• SpKt/V
• eKt/V
• StdKt/V
• URR
Urea reduction Ratio
(URR)
URR = 100 x (1-Ct/Co)
Ct = postdialysis
BUN Co = predialysis
BUN
Urea Reduction Volume
(URR)
 Simple
 Prediction of mortality
Limitation:
Does not account for the contribution
of UF to dialysis dose
Kt/V=1.1 (UF=0)
URR=65
Kt/v = 1.35 (UF=10%BW)
URR & Kt/V
Hemodialysis Dose
Measurement
• The preferred method is by formal kinetic

urea modeling
K/DOQI 2006
Kt/V
Computerized software
Mathematical logarithm
Kt/v = -Ln (R-0.008t)+(4-3.5xR) x UF
W
Ln = natural logarithm
R = postdialysis BUN
predialysis BUN
UF = Ultrafiltration volume in liters
W = Postdialysis weight in kg
BUN Sampling
 Predialysis
 Postdialysis
 Immediate predialysis
 Slow flow/stop pump
Urea Rebound
 Organs with low blood flow (skin, bone,

muscles) may serve as reservoir for urea
70% of TBW is contained in organs that
receive only 20% of CO
So: during HD, there is loss of urea from
well perfused areas, this result in  in
BUN over 60 minutes post dialysis.
Post Dialysis BUN Sampling
• Avoid 2 rebound:
• Early (<3min post dialysis)

• Access recirculation,begin immediately post
hemodialysis and rebound in 20 seconds
• Cardiopulmonary recirculation, begin 20 seconds
post hemodialysis and is completed in 2-3 minutes
after slowing or stopping the blood pump.
• Late (>3 min)

• Completed within 30-60 minutes due to flow-
volume disequilibrium.
Urea Rebound
65% rebound ( >50% is AR,15%CP,31%

D)
Single-Compartment Fixed
Volume Solute Kinetic
Mode
Single-Pool vs Double-Pool
Single-pool
Does not account for urea transfer between fluid
compartments
With  dialyzer clearance, urea removed from
extracellular compartment can exceed transfer
from intracellular compartment
Urea rebound (30-60 min)
So: Dialysis dose will be overestimated if this
urea pool is large(underestimated of true V)
Two-Compartment Variable
Volume Solute Kinetic
Model
Equilibrated Kt/V
 eKt/v is 0.2 units less than single-pool kt/v, but
it can be as great 0.6 unit less.
 For most patient, urea rebound is nearly
complete in 15 minutes after hemodialysis but
for minority, it may require up to 50-60 minutes
 The degree of rebound is high in small patient
• eKt/V= spKt/V - 0.6 x (spKt/V) / t + 0.03 (for
arterial access)
• eKt/V= spKt/V - 0.47 x (spKt/V) / t + 0.02 (for
venous access)
Minimum dialysis dose
• SpKt/V > 1.2 US
• eKt/V > 1.2 Europe
• StdKt/V 2.14
Daugirdas Formula
Prescribed vs. delivered Kt/V
Prescribed Kt/V is a computerized estimation of

what the patients Kt/V would be, based on the
prescription
•Delivered Kt/V is actual results based on

how the patient really dialyzed the day the
kinetic labs were drawn
What Should You Do if Your Patient Kt/V Is Below 1.2 or if Your URR Is
Below 65 Percent ?

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The NKF-K/DOQI Hemodialysis Adequacy Work
Group identified several topics pertinent to
implementing and maintaining adequate
hemodialysis.

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PATIENTS TO WHOM APPLIED ?
These guidelines apply to all adult & pediatric HD patients with ESRD
& negligible kidney function (GFR <5 mL/min) who receive outpatient
HD three times per week.

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EVIDENCE-BASED Versus OPINION-BASED
These guidelines are based on evidence in published

literature & when not available, on consensus opinion
of Work Group.

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GUIDELINE 1: REGULAR MEASUREMENT OF THE
DELIVERED DOSE OF HD (EVIDENCE)
The dialysis care team should routinely measure &

monitor the delivered dose of HD.

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GUIDELINE 2: METHOD OF MEASUREMENT OF
DELIVERED DOSE OF HD (EVIDENCE)
The delivered dose of HD in adult & pediatric patients

should be measured using formal urea kinetic modeling
(UKM), employing the single-pool, variable volume model.

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UREA KINETIC MODELING (UKM)
UKM is a method for verifying that the amount of dialysis

prescribed (prescribed Kt/V) equals the amount of dialysis delivered
(effective Kt/V).
UKM also quantifies the amount of urea generated, which is a marker of the
protein catabolic rate & therefore of protein intake.

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CALCULATION OF Kt/V
Kt/V may be determined by formal UKM or by

extrapolation from the fractional change in blood
urea concentration during a dialysis session. The delivered
dose of HD may also be assessed using the URR.

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Formal UKM
Advantages:
When rigorously performed, it is a reproducible & quantitative

method.
It provides guidance about which specific parameters of prescription

to modify, to achieve target HD dose (dialysis time, dialyzers, blood
or dialysate flow rates).
Impact of residual kidney function on urea clearance can also

be
considered.

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Formal UKM
Disadvantages:
Complexity of calculations requires use of computational devices

& software.
Physical parameters, such as K & V, are difficult to measure & monitor

& actual t can be difficult to determine.
Time required for dialysis staff to collect & process all patient
information to support these calculations can be significant.
Although cost of computers & software is low, it is a factor for some

dialysis centers.

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Statistical models
•If a computer modeling program is not available, only one

alternative method for calculating Kt/V (Kt/V natural logarithm formula)
& one other measurement of the delivered dose of HD (URR) should be
considered for routine use in adults.
• A calculator capable of performing natural logarithms is

required.
Kt/V natural logarithm formula (Kt/V Ln):
Kt/V = -Ln (R - 0.008 x t) + (4 - 3.5 x R) x

UF/W.

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Kt/V natural logarithm formula
Advantages:
It provides the closest approximation to the single-pool,

volume Kt/V derived from formal It is
variable
accurate over its full range
UKM. (range, 0.7 to 2.1).
It accounts for intradialytic volume changes secondary to UF &

the
resultant convective solute transport.

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Kt/V natural logarithm formula
Limitations:
•Alone it does not support calculation of nPCR (can be

derived from a nomogram, or by an equation).
• It does not permit rigorous, quantitative analysis of the

HD
prescriptions.
(e.g. if delivered Kt/V is observed to be too low, Kt/V Ln does

not provide insight into how therapy should be altered).
Therefore, the HD Adequacy Work Group does not recommend this

method for primary use.

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Urea reduction ratio (URR)
 One of the three methods that HD Adequacy Work Group

considered appropriate for measuring delivered dose of HD.
 Calculation of URR:
URR = (1 - [postdialysis BUN / predialysis BUN])
 Because of its ease of calculation, URR is frequently

utilized.

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Urea Reduction Ratio (URR)
Limitations:
Does not account for contribution of UF to final delivered dose
of dialysis (less accurate).
Errors in delivered dose of HD may be particularly difficult to detect
in target range of URR of > or =65% where a curvilinear relationship
exists between URR & Kt/V.
Correcting observed deficiencies in URR requires

empirical modification of components of treatment
prescription.
Does not support calculation of nPCR & ignores contribution of

residual kidney function to urea clearance.

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Percent Reduction In Urea (PRU)
Involves the same calculation as URR except that the result

is
multiplied by 100 to be expressed as a percentage.

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Kt/V Derived From Percent Reduction Of Urea (PRU)
Several equations are proposed to estimate Kt/V from

PRU :
Kt/V = (0.026 PRU) -
x 0.460
Kt/V = (0.024 PRU) -
x 0.276
These equations correlate reasonably well with the more rigorous
UKM when the Kt/V & PCR are in the normal or expected range.
These equations, although reasonably accurate, are not a substitute

for Kt/V Ln formula.

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ARE THERE ALTERNATIVES TO Kt/V FOR
ASSESSING
ADEQUACY ?
Not all investigators accept Kt/V as optimal method for

assessing
HD adequacy.
Other modalities evaluated, include:
1-Timed average urea
concentration. 2-Solute removal
index.
3-Kt that is not normalized by body

volume.
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Timed average urea concentration (TAC
urea)
 Preferable to Kt/V because it also measures interdialytic

urea generation, thereby allowing estimation of PCR.
 It has a major limitation in that poor nutrition (often due to

inadequate dialysis) can lead to a low predialysis BUN & TACurea
that misleadingly suggests that patient is being adequately
dialyzed.
 Thus, TAC urea must be evaluated in concert with PCR to

estimate protein intake.

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Solute Removal Index
Is defined as percentage of total body urea nitrogen content that is

removed by a dialysis treatment.
It is directly measured by multiplying urea concentration in dialysate

by volume of spent dialysate.
Advantages:
1 It is unaffected by factors that significantly alter Kt.

2 Minimizing exposure of patients & staff to blood-borne
pathogens.

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Solute Removal Index
Limitations:
1 Lack of studies correlating it to patient outcome.

2 Impracticality of collecting the total spent dialysate.
3 Relative inaccuracy of calculated HD dose obtained.
DOQI clinical work group focused their recommendations exclusively

upon blood-based measures of adequacy, suggesting that further
research on solute removal needs to be performed.

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Haemodialysis dose & nutrition
Protein catabolic rate (PCR) in maintenance dialysis
PCR, also called protein equivalent of nitrogen appearance (PNA), is the

parameter used in most HD units to assess dietary protein intake in
patients who are in a steady state.
It is a function of protein catabolism.
Determined by measuring interdialytic appearance of urea in body fluids

plus any urea lost in urine in patients with residual renal function.

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CALCULATION OF PCR
• It is usually expressed as g/kg/day, a parameter that is also

called the normalized PCR (nPCR). Less commonly, the PCR
is not normalized to weight & is expressed as g/day.
• It is routinely calculated by various urea kinetic modeling

software programs.

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CALCULATION OF PCR
•If a computer program is not available, the following simple formulas

will give a good estimate of the nPCR.
nPCR (anuric) = 0.22 + [0.036 X ID rise in BUN X 24] / ID

intervals
• Another formula calculates nPCR from the Kt/V & the

average
BUN:
nPCR = (0.0136 X F) + 0.251

F = Kt/V X [(predialysis BUN + postdialysis BUN) /
2]
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CALCULATION OF PCR
Residual renal function

Urinary nitrogen loss must be accounted for in patients with
residual renal function. Thus, for patients with urine output:
nPCR (total) =
nPCR (anuric) + [Urinary UN X150] / ID interval
X weight
These formulas cannot be used in patients treated with

continuous peritoneal dialysis, since the BUN is relatively
constant.
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OPTIMAL PCR & THE DIALYSIS PRESCRIPTION
• NCDS recommended a minimal nPCR of 0.8 g/kg/day, but a

target
of 1.0-1.2 g/kg/day or higher is currently recommended.
•A small percentage of patients have a "high" PCR (>1.2 g/kg/day).

The appropriate response should be to increase Kt/V rather than
to restrict dietary protein. Unfortunately, this generally
constitutes a negative economic incentive to the dialysis facility.

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COMPUTER MODELS
Computer software packages can be purchased separately or as

an
integral component of dialysis machine.
When supplied with simple clinical information these programs will

perform the necessary computations & print Kt/V, PCR & other
data.
Used for two goals:
1 Calculation of the delivered kt/v
2 Prediction of the delivered kt/v

Egypt
ula n 1- Calculation of the delivered kt/v
standard complete
[p r e - schedule patient data
r. 3X/we ek
.-.,....n
H Ddate time weight urea creat
creatinine r 2X/we ek height J
i t / • 0/•/1. ,.. Jv o j 32 j 1000 r;7 kinetic s r alt day 180
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immidiate
sex ( male
3
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post-HD
sample 3 r anuric
j o4:oo
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p ost-HD r entered I l PC R
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unne
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start dat e time volume urea creat
==:1 I 11 19 0 J r.
r
interdialytic KrU
2000 24 1 .6 SRI Kt/V creat Cl
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Exit
Artificial Intelligence: A New Approach for Prescription and
Monitoring of Hemodialysis Therapy
Ahmed I. Akl, MD Mohamed A. Sobh, MD, Yehya M. Enab PhD, and James Tattersall, MD
•The effect of dialysis on patients is conventionally predicted using a formal mathematical model. This approach
requires many assumptions of the processes involved, and validation of these may be difficult. The validity
of dialysis urea modeling using a formal mathematical model has been challenged. Artificial intelligence using
neural networks (NNs) has been used to solve complex problems without needing a mathematical model or an
understand ing of the mechanisms involved. In this study, we applied an NN model to study and predict
concentrations of urea during a hemodialysis session. We measured blood concentrations of urea, patient weight,
and total urea removal by direct dialysate quantification (DDQ) at 30-minute intervals during the session (in
15 chronic hemodialysis patients). The NN model was trained to recognize the evolution of measured urea
concentrations and was subsequently able to predict hemodialysis session time needed to reach a target
solute removal index (SRI) in patients not previously studied by the NN model (in another 15 chronic
hemodialysis patients). Comparing results of the NN model with the DDQ model, the prediction error was
10.9%, with a not significant difference between predicted total urea nitrogen (UN) removal and measured UN
removal by DDO. NN model predictions of time showed a not significant difference with actual intervals needed to
reach the same SRI level at the same patient conditions , except for the prediction of SRI at the first 30-minute
interval, which showed a significant difference (P = 0.001). This indicates the sensitivity of the NN model to what
is called patient clearance time; the prediction error was 8.3%. From our results, we conclude that artificial
intelligence applications in urea kinetics can give an idea of intradialysis profiling according to individual
clinical needs. In theory , this approach can be extended easily to other solutes, making the NN model a step
forward to achieving artificial-intelligent dialysis control.
© 2001 by the National Kidney Foundation,
Inc.
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KDOOI HD Adequacy Guideline: 2015
Update
Box 2. St.mmary of Recommendation Statements
Guideline 1: T im i n g of Hemodialysis Initiation

1. Patients who reach CKD stage 4 (GFR < 30 mllmi!V1.73 m2 , including those who have imminent need for
maintenance )
dialysis at the time of i n lial assessment, shoukJ receive education about kidney failure and options for its
treatment , including
kidney transplanlation , PO, HD in the home or in-center, and conservative treatment. Patients' family members and
care
givers also should be educated about treatment choices for kidney failure . ( Not Graded )
2. The decision to initiate maintenance dialysis In patients who choose to do so should be based primarily upon an
assessment of signs and/or symptoms associated with uremia, evidence of protein-energy wasting, and the ability to
safely manage metabolic abnormalities and/or volt.me overload wth medical therapy rather than on a specifc level of
kidney function in the absence of such signs and symptoms. (Not Graded)
Guideline 2: Frequent a nd Long D urat i on Hemodialysis

I n-center F requent HD
3. We suggest that patients with end-stage kidney disease be offered in-center short f requent hemodialysis as an alternative to
conventional in-center thrice weekly hemodialys is after considering Individual pat ent preferences , the potential quality of life
and physiological benefits , and the risks of these therapies . (2C)
4. We recommend that patients considering in-center short frequent hemodialysis be informed about the risks of this therapy,
including a possible increasein vascular access procedures (18 ) and the potential for hypotension during dialysis. ( C)
Home Lon g HD
3. Consider horne long hemodialysis (6-8 hours, 3 to 6 nights per week) for patients with end-stage kidney disease who prefer
this therapy for lifestyle considerations . (Nof Graded)
4. We recommend that patients considering home long frequent hemodialysis be informed about the risks of lAs therapy
,
including possible increase in vascular access complications, potential for increased caregiver burden, and
accelerated
declne In residual kidney fl.nction. ( 1C)
Pregnanc y
5. Durng pregnancy , women with end-stage kidney disease should receive long frequent hemodialysis either in-center or
at horne, depending on convenience . (Not Graded)
Guideline 3: Measu rement o f Dial ysis: Urea Kinetics
6. We recommend a target single pool K W (spKW) of 1.4 per hemodialysis session for patients treated thrice weekly , with
a
minmt.m delivered spKW of 1.2. (18)
2. In patients with signifuant residual native kidney function (Kru), the dose of hemodialysis may be reduced provided Kru is
measured periodically to avoidinadequate dialysis. ( Not Graded)
3. For hemodialysis schedules other than thrice weekly, we suggest a target standard K W of 2 .3 volt.mes per week with
a minmt.m delivered dose of 2.1 using a method of calculation that Includes the contributions of ultrafiltration and
residual kidney function. ( Not Graded)
Guideline 4: Volume and B lood Pressure Con trol: Treatment Time and Ultraf il tr ation Rate
4. We recommend that patients with low residual kdney function( < 2 rnUmin) undergoing thrice weekly hemodialysis
be prescribed a bare minimum of 3 hours per session. (ICY)
1. Consider additional hemodialysis sessions or longer hemodialysis treatment times for patients with large weight gains,
high ultrafiltration rates, poorly controlled b lood pressure , difficulty achieving dry weight , or poor metabolic control
(such as hyperphosphatemia, metabolic acidosis, and/or hyperkalemia). (Not Graded)
5. We recommend both reducing dietary sodium intake as well as adequate sodium/water removal with hemodialysis to
manage hypertension, hypervolemia, and left ventricular hypertrophy . ( 18)
1. Prescribe an ultrafiltration rate for each hemodialysis session that allows for an optimal balance among achieving
euvolemia, adequate blood pressure control and solute dearance, while minimizing hemodynamic instability
and intradialytic symptoms . ( Not Graded)
A variety of factors may result in the actual delivered dose
of HD falling below the prescribed dose
Common factors include:
1-Compromised urea
clearance. 2-Reductions in
treatment time.
3-Laboratory or blood sampling

errors.

Egypt
Predialysis blood sampling procedures
 When utilizing an AV fistula or graft:

* Obtain blood specimen from arterial needle.
* Do not draw a sample if HD has been initiated.
 When utilizing a venous catheter:

*Withdraw any heparin & saline from arterial port of catheter.
*Withdraw another 3-10 mL of blood from arterial port of
catheter.
*Connect a new syringe or collection device & draw sample.

Egypt
Postdialysis blood sampling procedure
 At the completion of HD, turn off Qd & decrease UFR to 50 mL/h or

off.
 Decrease the Qb to 50-100 mL/min for 15 seconds.
 Proceed with either slow flow or stop pump technique.

Egypt
Postdialysis blood sampling procedure
 Slow flow sampling technique

*With blood pump still running at 50 - 100 mL/min, draw blood
sample from arterial sampling port.
*Stop blood pump & complete disconnection.
 Stop pump sampling technique

*Immediately stop blood pump.
*Clamp arterial, venous lines &
arterial needle tubing.
*Blood is sampled from arterial
sampling port or from arterial
needle
tubing.
*Patient disconnection
procedure
The proceeds.
urology & Nephrology
Egypt
center, Mansoura, e-mail : aiakl2001@yahoo.com
SUMMARY
1 Preferential use of a single pool, variable volume model
for calculating urea removal during HD at least once per
month.
2Quantification of urea removal during a single dialysis

session using formal urea kinetic modeling for adults & children.
3 Prescription of a Kt/V of > or =1.4, so that the minimum

delivered
Kt/V would be > or =1.2.
4-Vigorous effort to ensure patient during HD by using
comfort
strategies to minimize cramps &
hypotension.

Egypt
It is the duty of the dialysis team to consider implementing
these recommendations
on an individual basis & when not or cannot be applied,
to strive to optimize patient care by offering reasonable
& safe alternative processes of care.

Egypt
Thank
You

Haemodialysis Adequacy-2

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Haemodialysis Adequacy-2

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HAEMODIALYSIS ADEQUACY

Dr. Ahmed Akl , MD, PhD

The urology & Nephrology center, Mansoura, e-mail : aiakl2001@yahoo.com

BP control Good nutrition

The urology & Nephrology center, Mansoura, e-mail : aiakl2001@yahoo.com

The urology & Nephrology center, Mansoura, e-mail : aiakl2001@yahoo.com

•30 layers of dialysis units.

•Each unit with two membranes and two

• Forming a dialyser of 0.6 m2 surface area

The urology & Nephrology center, Mansoura, e-mail : aiakl2001@yahoo.com

Urea is the substance most often monitored in clinical practice

• Constitutes 90% of waste nitrogen accumulated in body water.

• Is easily measured in blood.

• Fractional clearance of urea in body water correlates with patient outcomes.

The urology & Nephrology center, Mansoura, e-mail : aiakl2001@yahoo.com

• In the 1970s and early 1980s, a common practice was to

• The pre-treatment BUN never to exceed 80 mg/dl. To achieve that

Why were some patients who had pre-treatment BUNs of 100

The urology & Nephrology center, Mansoura, e-mail : aiakl2001@yahoo.com

The urology & Nephrology center, Mansoura, e-mail : aiakl2001@yahoo.com

•In the 1970's, the NCDS was funded to try to

•A huge database of information about

•Analyzed the study's database trying to find new

Dr. John Sargent

Prof. Frank Gotch

•The formula Kt/V effectively answered these questions for

The urology & Nephrology center, Mansoura, e-mail : aiakl2001@yahoo.com

•This new approach became known as UREA KINETIC MODELING.

• Urea kinetic modeling includes protein metabolism analyses and

The urology & Nephrology center, Mansoura, e-mail : aiakl2001@yahoo.com

Another benefit of Gotch and Sargent's analyses was that it

As more data accumulated, it became apparent that reducing protein

The urology & Nephrology center, Mansoura, e-mail : aiakl2001@yahoo.com

While a URR is not as accurate as a Kt/V value, nor does it provide

As an example, a Kt/V of 1.2 is roughly equivalent to a URR of about

The urology & Nephrology center, Mansoura, e-mail : aiakl2001@yahoo.com

Kidney Int 1996; 50:550

URR = 100 x (1-Ct/Co)

• The preferred method is by formal kinetic

 Organs with low blood flow (skin, bone,

• Early (<3min post dialysis)

• Late (>3 min)

65% rebound ( >50% is AR,15%CP,31%

• SpKt/V > 1.2 US

• eKt/V > 1.2 Europe

Prescribed Kt/V is a computerized estimation of

•Delivered Kt/V is actual results based on

The urology & Nephrology center, Mansoura, e-mail : aiakl2001@yahoo.com

The urology & Nephrology center, Mansoura, e-mail : aiakl2001@yahoo.com

The urology & Nephrology center, Mansoura, e-mail : aiakl2001@yahoo.com

These guidelines are based on evidence in published

The urology & Nephrology center, Mansoura, e-mail : aiakl2001@yahoo.com

The dialysis care team should routinely measure &

The urology & Nephrology center, Mansoura, e-mail : aiakl2001@yahoo.com

The delivered dose of HD in adult & pediatric patients

The urology & Nephrology center, Mansoura, e-mail : aiakl2001@yahoo.com

UKM is a method for verifying that the amount of dialysis

The urology & Nephrology center, Mansoura, e-mail : aiakl2001@yahoo.com

Kt/V may be determined by formal UKM or by

The urology & Nephrology center, Mansoura, e-mail : aiakl2001@yahoo.com

When rigorously performed, it is a reproducible & quantitative

It provides guidance about which specific parameters of prescription

Impact of residual kidney function on urea clearance can also