Acute hemodialysis prescription
- Phillip Ramos, MD, MSCI
Phillip Ramos, MD, MSCI
- Nephrologist, Denver Nephrology, PC
- Denver, Colorado
- Mark R Marshall, MD
Mark R Marshall, MD
- Adjunct Associate Professor, School of Medicine
- University of Auckland, Faculty of Medicine and Health Sciences
- Middlemore Hospital, New Zealand
- Thomas A Golper, MD
Thomas A Golper, MD
- Section Editor — Dialysis
- Professor of Medicine
- Vanderbilt University Medical Center
- Section Editors
- Jeffrey S Berns, MD
Jeffrey S Berns, MD
- Section Editor — Dialysis
- Professor of Medicine
- Perelman School of Medicine at the University of Pennsylvania
- Paul M Palevsky, MD
Paul M Palevsky, MD
- Section Editor — Renal Failure
- Professor of Medicine
- University of Pittsburgh
- VA Pittsburgh Healthcare System
- Richard H Sterns, MD
Richard H Sterns, MD
- Editor-in-Chief — Nephrology
- Section Editor — Fluid and Electrolytes
- Professor of Medicine
- University of Rochester School of Medicine and Dentistry
Acute kidney injury (AKI), formerly called acute renal failure (ARF), is a major cause of morbidity and mortality, particularly in the hospital setting. Despite improvements in renal replacement therapy (RRT) during the last several decades, the mortality rate associated with AKI in critically ill patients remains high. (See "Renal and patient outcomes after acute tubular necrosis".)
Acute RRT is commonly indicated for patients with AKI. Available modalities for acute RRT include peritoneal dialysis, intermittent hemodialysis and variations of intermittent hemodialysis (such as hemofiltration), and continuous renal replacement therapy (CRRT).
This topic reviews the acute hemodialysis prescription for patients with AKI. The indications for acute dialysis and the choice of dialysis modality are discussed separately. (See "Renal replacement therapy (dialysis) in acute kidney injury (acute renal failure) in adults: Indications, timing, and dialysis dose", section on 'Indications for and timing of initiation of dialysis' and "Renal replacement therapy (dialysis) in acute kidney injury (acute renal failure) in adults: Indications, timing, and dialysis dose", section on 'Optimal modality' and "Continuous renal replacement therapy in acute kidney injury (acute renal failure)" and "Use of peritoneal dialysis for the treatment of acute kidney injury (acute renal failure)".)
The optimal vascular access for hemodialysis is discussed elsewhere. (See "Overview of central catheters for acute and chronic hemodialysis access".)
COMPONENTS OF THE ACUTE HEMODIALYSIS PRESCRIPTION
The components of the acute dialysis prescription include the choice of hemodialysis membrane, dialysate composition and temperature, blood flow rate, amount and rate of ultrafiltration (UF), choice of anticoagulation, and total dialysis dose.
- Marshall MR, Golper TA. Intermittent Hemodialysis in Intensive Care in Nephrology, Murray P, Brady H, Hall J (Eds), Taylor & Francis, Oxford 2005.
- Daugirdas JT, Blake PG, Ing TS. Handbook of dialysis, 4th ed, Lippincott Williams & Wilkins, Philadelphia 2007.
- Zehnder C, Gutzwiller JP, Huber A, et al. Low-potassium and glucose-free dialysis maintains urea but enhances potassium removal. Nephrol Dial Transplant 2001; 16:78.
- Hou S, McElroy PA, Nootens J, Beach M. Safety and efficacy of low-potassium dialysate. Am J Kidney Dis 1989; 13:137.
- Ward RA, Wathen RL, Williams TE, Harding GB. Hemodialysate composition and intradialytic metabolic, acid-base and potassium changes. Kidney Int 1987; 32:129.
- Ahmed J, Weisberg LS. Hyperkalemia in dialysis patients. Semin Dial 2001; 14:348.
- Morrison G, Michelson EL, Brown S, Morganroth J. Mechanism and prevention of cardiac arrhythmias in chronic hemodialysis patients. Kidney Int 1980; 17:811.
- Song JH, Lee SW, Suh CK, Kim MJ. Time-averaged concentration of dialysate sodium relates with sodium load and interdialytic weight gain during sodium-profiling hemodialysis. Am J Kidney Dis 2002; 40:291.
- Locatelli F, Ponti R, Pedrini L, et al. Sodium kinetics across dialysis membranes. Nephron 1984; 38:174.
- Gotch FA, Evans MC, Keen ML. Measurement of the effective dialyzer Na diffusion gradient in vitro and in vivo. Trans Am Soc Artif Intern Organs 1985; 31:354.
- Flanigan MJ, Khairullah QT, Lim VS. Dialysate sodium delivery can alter chronic blood pressure management. Am J Kidney Dis 1997; 29:383.
- Flanigan M. Dialysate composition and hemodialysis hypertension. Semin Dial 2004; 17:279.
- Kooman JP, van der Sande F, Leunissen K, Locatelli F. Sodium balance in hemodialysis therapy. Semin Dial 2003; 16:351.
- Oo TN, Smith CL, Swan SK. Does uremia protect against the demyelination associated with correction of hyponatremia during hemodialysis? A case report and literature review. Semin Dial 2003; 16:68.
- Huang WY, Weng WC, Peng TI, et al. Central pontine and extrapontine myelinolysis after rapid correction of hyponatremia by hemodialysis in a uremic patient. Ren Fail 2007; 29:635.
- Viktorsdottir O, Indridason OS, Palsson R. Successful treatment of extreme hyponatremia in an anuric patient using continuous venovenous hemodialysis. Blood Purif 2013; 36:274.
- Sirota JC, Berl T. Is osmotic demyelination a concern dialyzing hyponatremic patients? Semin Dial 2011; 24:407.
- Wendland EM, Kaplan AA. A proposed approach to the dialysis prescription in severely hyponatremic patients with end-stage renal disease. Semin Dial 2012; 25:82.
- Bender FH. Successful treatment of severe hyponatremia in a patient with renal failure using continuous venovenous hemodialysis. Am J Kidney Dis 1998; 32:829.
- Yessayan L, Yee J, Frinak S, Szamosfalvi B. Treatment of severe hyponatremia in patients with kidney failure: role of continuous venovenous hemofiltration with low-sodium replacement fluid. Am J Kidney Dis 2014; 64:305.
- Lenk MR, Kaspar M. Sodium-reduced continuous venovenous hemodiafiltration (CVVHDF) for the prevention of central pontine myelinolysis (CPM) in hyponatremic patients scheduled for orthotopic liver transplantation. J Clin Anesth 2012; 24:407.
- Yang YF, Wu VC, Huang CC. Successful management of extreme hypernatraemia by haemofiltration in a patient with severe metabolic acidosis and renal failure. Nephrol Dial Transplant 2005; 20:2013.
- Ostermann M, Dickie H, Tovey L, Treacher D. Management of sodium disorders during continuous haemofiltration. Crit Care 2010; 14:418.
- Braüse M, Deppe CE, Hollenbeck M, et al. Congestive heart failure as an indication for continuous renal replacement therapy. Kidney Int Suppl 1999; :S95.
- Henrich WL. Principles and practice of dialysis, 3rd ed, Lippincott Williams & Wilkins, Philadelphia 2004. p.696.
- Alappan R, Cruz D, Abu-Alfa AK, et al. Treatment of Severe Intradialytic Hypotension With the Addition of High Dialysate Calcium Concentration to Midodrine and/or Cool Dialysate. Am J Kidney Dis 2001; 37:294.
- Santoro A, Mancini E, Basile C, et al. Blood volume controlled hemodialysis in hypotension-prone patients: a randomized, multicenter controlled trial. Kidney Int 2002; 62:1034.
- Tonelli M, Astephen P, Andreou P, et al. Blood volume monitoring in intermittent hemodialysis for acute renal failure. Kidney Int 2002; 62:1075.
- Reilly RF. Attending rounds: A patient with intradialytic hypotension. Clin J Am Soc Nephrol 2014; 9:798.
- Paganini EP, Sandy D, Moreno L, et al. The effect of sodium and ultrafiltration modelling on plasma volume changes and haemodynamic stability in intensive care patients receiving haemodialysis for acute renal failure: a prospective, stratified, randomized, cross-over study. Nephrol Dial Transplant 1996; 11 Suppl 8:32.
- Schneditz D. Temperature and thermal balance in hemodialysis. Semin Dial 2001; 14:357.
- Maggiore Q, Pizzarelli F, Santoro A, et al. The effects of control of thermal balance on vascular stability in hemodialysis patients: results of the European randomized clinical trial. Am J Kidney Dis 2002; 40:280.
- Zager RA, Gmur DJ, Bredl CR, Eng MJ. Temperature effects on ischemic and hypoxic renal proximal tubular injury. Lab Invest 1991; 64:766.
- Uchino S, Bellomo R, Morimatsu H, et al. Discontinuation of continuous renal replacement therapy: a post hoc analysis of a prospective multicenter observational study. Crit Care Med 2009; 37:2576.
- Schneider AG, Bellomo R, Bagshaw SM, et al. Choice of renal replacement therapy modality and dialysis dependence after acute kidney injury: a systematic review and meta-analysis. Intensive Care Med 2013; 39:987.
- Solez K, Morel-Maroger L, Sraer JD. The morphology of "acute tubular necrosis" in man: analysis of 57 renal biopsies and a comparison with the glycerol model. Medicine (Baltimore) 1979; 58:362.
- Renal function changes during intermittent hemodialysis (IHD) vs continuous hemodialysis (CVVHD) in acute renal failure (ARF). ASAIO J (Abstract) 1996; 42:78.
- Effects of intermittent hemodialysis on residual renal function in critically ill patients with acute renal failure. J Am Soc Nephrol (Abstract) 1994; 5:477.
- Gibney RT, Bagshaw SM, Kutsogiannis DJ, Johnston C. When should renal replacement therapy for acute kidney injury be initiated and discontinued? Blood Purif 2008; 26:473.
- Kidney Disease: Improving Global Outcomes (KIDGO) Acute Kidney Injury Work Group. Section 5: Dialysis Interventions for Treatment of AKI. Kidney Int Suppl 2012; Suppl 2:89.
- Gibney N, Hoste E, Burdmann EA, et al. Timing of initiation and discontinuation of renal replacement therapy in AKI: unanswered key questions. Clin J Am Soc Nephrol 2008; 3:876.
- Schiffl H, Lang SM. Current practice of conventional intermittent hemodialysis for acute kidney injury. Indian J Nephrol 2013; 23:395.
- VA/NIH Acute Renal Failure Trial Network, Palevsky PM, Zhang JH, et al. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med 2008; 359:7.
- Shealy CB, Campbell RC, Hey JC, Tolwani AJ. 24 h creatinine clearance as a guide for CRRT withdrawal. A retrospective study. Blood Purif 2003; 21:192.
- Cruz DN, Ricci Z, Bagshaw SM, et al. Renal replacement therapy in adult critically ill patients: when to begin and when to stop. Contrib Nephrol 2010; 165:263.
- Wu VC, Ko WJ, Chang HW, et al. Risk factors of early redialysis after weaning from postoperative acute renal replacement therapy. Intensive Care Med 2008; 34:101.
- Medcalf JF, Harris KP, Walls J. Role of diuretics in the preservation of residual renal function in patients on continuous ambulatory peritoneal dialysis. Kidney Int 2001; 59:1128.
- van Olden RW, Guchelaar HJ, Struijk DG, et al. Acute effects of high-dose furosemide on residual renal function in CAPD patients. Perit Dial Int 2003; 23:339.
- Gerlag PG, van Meijel JJ. High-dose furosemide in the treatment of refractory congestive heart failure. Arch Intern Med 1988; 148:286.
- Kuchar DL, O'Rourke MF. High dose furosemide in refractory cardiac failure. Eur Heart J 1985; 6:954.
- Brown CB, Ogg CS, Cameron JS. High dose frusemide in acute renal failure: a controlled trial. Clin Nephrol 1981; 15:90.
- van der Voort PH, Boerma EC, Koopmans M, et al. Furosemide does not improve renal recovery after hemofiltration for acute renal failure in critically ill patients: a double blind randomized controlled trial. Crit Care Med 2009; 37:533.
- Chu JK, Folkert VW. Renal function recovery in chronic dialysis patients. Semin Dial 2010; 23:606.
- Siddiqui S, Norbury M, Robertson S, et al. Recovery of renal function after 90 d on dialysis: implications for transplantation in patients with potentially reversible causes of renal failure. Clin Transplant 2008; 22:136.
- Bhandari S, Turney JH. Survivors of acute renal failure who do not recover renal function. QJM 1996; 89:415.
- COMPONENTS OF THE ACUTE HEMODIALYSIS PRESCRIPTION
- HEMODIALYZER MEMBRANES
- DIALYSATE COMPOSITION
- - Patients with potassium <4.0 mEq/L
- - Patients with potassium between 4.0 and 5.5 mEq/L
- - Patients with potassium between 5.5 and 8.0 mEq/L
- - Patients with potassium >8.0 mEq/L
- - Efficiency of potassium removal
- - Arrhythmias associated with potassium removal
- - Patients with normal serum sodium
- - Patients with dysnatremias
- Acute dysnatremia
- Severe chronic hyponatremia
- Severe chronic hypernatremia
- Buffer solutions
- BLOOD FLOW RATE
- Determining goal
- Ultrafiltration-related hypotension
- PRE- AND POST-HEMODIALYSIS LABORATORY VALUE MONITORING
- DIALYSIS DOSE
- MANAGEMENT DURING RECOVERY OF RENAL FUNCTION
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS