Prescribing and assessing adequate hemodialysis
- Wajeh Y Qunibi, MD
Wajeh Y Qunibi, MD
- Professor of Medicine
- University of Texas Health Sciences Center
- William L Henrich, MD, MACP
William L Henrich, MD, MACP
- University of Texas Health Science Center at San Antonio
The amount of dialysis that a patient receives can impact morbidity and mortality [1,2]. Thus, two central issues in the management of patients undergoing maintenance hemodialysis include determining the optimal amount of dialysis that should be prescribed and quantifying the amount of dialysis that is actually delivered to individual patients.
Improvement in patients' symptoms and the blood urea nitrogen (BUN) concentration are not accurate measures of dialysis adequacy for two reasons:
●The dialysis dose that reduces uremic symptoms is lower than the dose shown to increase survival. This is especially true when erythropoietin is started concurrently with dialysis for anemia since many symptoms attributed to uremia are actually related to anemia. (See "Erythropoietin for the anemia of chronic kidney disease among predialysis and peritoneal dialysis patients" and "Erythropoietin for treatment of the anemia of chronic kidney disease in hemodialysis patients".)
●The BUN depends on factors that are independent of the dialysis dose, such as protein intake, protein catabolic rate, and residual renal function. A low BUN may reflect inadequate nutrition rather than sufficient dialytic urea removal.
All methods used to measure dialysis dose are based upon urea clearance. Although the best method is not known, the Kt/V is used by most nephrologists. This topic reviews the Kt/V and other methods that are used to measure the amount of dialysis delivered to individual patients. We also discuss dialysis dose recommendations for hemodialysis patients. Assessing the adequacy of peritoneal dialysis is discussed elsewhere (see "Prescribing and assessing adequate peritoneal dialysis" and "Measurement of solute clearance in continuous peritoneal dialysis: Kt/V and creatinine clearance" and "Problems with solute clearance and ultrafiltration in continuous peritoneal dialysis"). Patient outcomes related to dialysis are discussed elsewhere. (See "Patient survival and maintenance dialysis" and "Dialysis modality and patient outcome".)
- Lowrie EG, Laird NM, Parker TF, Sargent JA. Effect of the hemodialysis prescription of patient morbidity: report from the National Cooperative Dialysis Study. N Engl J Med 1981; 305:1176.
- Harter HR. Review of significant findings from the National Cooperative Dialysis Study and recommendations. Kidney Int Suppl 1983; :S107.
- Hemodialysis Adequacy 2006 Work Group. Clinical practice guidelines for hemodialysis adequacy, update 2006. Am J Kidney Dis 2006; 48 Suppl 1:S2.
- Daugirdas JT. Second generation logarithmic estimates of single-pool variable volume Kt/V: an analysis of error. J Am Soc Nephrol 1993; 4:1205.
- Daugirdas JT, Depner TA. A nomogram approach to hemodialysis urea modeling. Am J Kidney Dis 1994; 23:33.
- Besarab A, Sherman R. The relationship of recirculation to access blood flow. Am J Kidney Dis 1997; 29:223.
- Tattersall JE, DeTakats D, Chamney P, et al. The post-hemodialysis rebound: predicting and quantifying its effect on Kt/V. Kidney Int 1996; 50:2094.
- Eloot S, Van Biesen W, Vanholder R. A sad but forgotten truth: the story of slow-moving solutes in fast hemodialysis. Semin Dial 2012; 25:505.
- Chertow GM, Owen WF, Lazarus JM, et al. Exploring the reverse J-shaped curve between urea reduction ratio and mortality. Kidney Int 1999; 56:1872.
- Lowrie EG, Li Z, Ofsthun N, Lazarus JM. Body size, dialysis dose and death risk relationships among hemodialysis patients. Kidney Int 2002; 62:1891.
- European Best Practice Guidelines Expert Group on Hemodialysis, European Renal Association. Section II. Haemodialysis adequacy. Nephrol Dial Transplant 2002; 17 Suppl 7:16.
- Jindal K, Chan CT, Deziel C, et al. Hemodialysis clinical practice guidelines for the Canadian Society of Nephrology. J Am Soc Nephrol 2006; 17:S1.
- Eknoyan G, Levey AS, Beck GJ, et al. The hemodialysis (HEMO) study: rationale for selection of interventions. Semin Dial 1996; 9:24.
- McClellan WM, Soucie JM, Flanders WD. Mortality in end-stage renal disease is associated with facility-to-facility differences in adequacy of hemodialysis. J Am Soc Nephrol 1998; 9:1940.
- Wolfe RA, Ashby VB, Daugirdas JT, et al. Body size, dose of hemodialysis, and mortality. Am J Kidney Dis 2000; 35:80.
- Lowrie EG, Chertow GM, Lew NL, et al. The urea [clearance x dialysis time] product (Kt) as an outcome-based measure of hemodialysis dose. Kidney Int 1999; 56:729.
- Eloot S, Torremans A, De Smet R, et al. Kinetic behavior of urea is different from that of other water-soluble compounds: the case of the guanidino compounds. Kidney Int 2005; 67:1566.
- Gotch FA. The current place of urea kinetic modelling with respect to different dialysis modalities. Nephrol Dial Transplant 1998; 13 Suppl 6:10.
- Owen WF Jr, Chertow GM, Lazarus JM, Lowrie EG. Dose of hemodialysis and survival: differences by race and sex. JAMA 1998; 280:1764.
- Lowrie EG, Lew NL. The urea reduction ratio (URR): A simple method for evaluating hemodialysis treatment. Contemp Dial Nephrol 1991; (Feb):11.
- Li Z, Lew NL, Lazarus JM, Lowrie EG. Comparing the urea reduction ratio and the urea product as outcome-based measures of hemodialysis dose. Am J Kidney Dis 2000; 35:598.
- Lowrie EG, Li Z, Ofsthun N, Lazarus JM. Measurement of dialyzer clearance, dialysis time, and body size: death risk relationships among patients. Kidney Int 2004; 66:2077.
- Vanholder R, Glorieux G, Eloot S. Once upon a time in dialysis: the last days of Kt/V? Kidney Int 2015; 88:460.
- Daugirdas JT. Rapid methods of estimating Kt/V: three formulas compared. ASAIO Trans 1990; 36:M362.
- Lowrie EG, Lew NL. The urea reduction ratio (URR). A simple method for evaluating hemodialysis treatment. Contemp Dial Nephrol 1992; 12:11.
- Daugirdas JT. Linear estimates of variable-volume, single-pool Kt/V: an analysis of error. Am J Kidney Dis 1993; 22:267.
- Sherman RA, Cody RP, Rogers ME, Solanchick JC. Accuracy of the urea reduction ratio in predicting dialysis delivery. Kidney Int 1995; 47:319.
- Covic A, Goldsmith DJ, Hill K, et al. Urea kinetic modelling--are any of the 'bedside' Kt/V formulae reliable enough? Nephrol Dial Transplant 1998; 13:3138.
- Cheng YL, Choi KS, Chau KF, et al. Urea reduction ratio that considers effects of ultrafiltration and intradialytic urea generation. Am J Kidney Dis 2001; 37:544.
- Keshaviah P. The solute removal index--a unified basis for comparing disparate therapies. Perit Dial Int 1995; 15:101.
- Cheng YL, Shek CC, Wong FK, et al. Determination of the solute removal index for urea by using a partial spent dialysate collection method. Am J Kidney Dis 1998; 31:986.
- Depner TA, Greene T, Gotch FA, et al. Imprecision of the hemodialysis dose when measured directly from urea removal. Hemodialysis Study Group. Kidney Int 1999; 55:635.
- Tattersall J, Martin-Malo A, Pedrini L, et al. European best practice guidelines on haemodialysis. Nephrol Dial Transplant 2007; 22 (Suppl 2):ii1.
- Owen WF Jr, Lew NL, Liu Y, et al. The urea reduction ratio and serum albumin concentration as predictors of mortality in patients undergoing hemodialysis. N Engl J Med 1993; 329:1001.
- Gotch FA, Levin NW, Port FK, et al. Clinical outcome relative to the dose of dialysis is not what you think: the fallacy of the mean. Am J Kidney Dis 1997; 30:1.
- Spiegel DM, Baker PL, Babcock S, et al. Hemodialysis urea rebound: the effect of increasing dialysis efficiency. Am J Kidney Dis 1995; 25:26.
- Daugirdas JT, Depner TA, Gotch FA, et al. Comparison of methods to predict equilibrated Kt/V in the HEMO Pilot Study. Kidney Int 1997; 52:1395.
- Rocco MV, Cheung AK, Greene T, et al. The HEMO Study: applicability and generalizability. Nephrol Dial Transplant 2005; 20:278.
- Blake PG. Adequacy of dialysis revisited. Kidney Int 2003; 63:1587.
- Coyne DW, Delmez J, Spence G, Windus DW. Impaired delivery of hemodialysis prescriptions: an analysis of causes and an approach to evaluation. J Am Soc Nephrol 1997; 8:1315.
- Ifudu O, Mayers JD, Matthew JJ, et al. Standardized hemodialysis prescriptions promote inadequate treatment in patients with large body mass. Ann Intern Med 1998; 128:451.
- Sehgal AR, Snow RJ, Singer ME, et al. Barriers to adequate delivery of hemodialysis. Am J Kidney Dis 1998; 31:593.
- Eknoyan G, Beck GJ, Cheung AK, et al. Effect of dialysis dose and membrane flux in maintenance hemodialysis. N Engl J Med 2002; 347:2010.
- Locatelli F. Dose of dialysis, convection and haemodialysis patients outcome--what the HEMO study doesn't tell us: the European viewpoint. Nephrol Dial Transplant 2003; 18:1061.
- Greene T, Daugirdas J, Depner T, et al. Association of achieved dialysis dose with mortality in the hemodialysis study: an example of "dose-targeting bias". J Am Soc Nephrol 2005; 16:3371.
- Flythe JE, Curhan GC, Brunelli SM. Shorter length dialysis sessions are associated with increased mortality, independent of body weight. Kidney Int 2013; 83:104.
- Tentori F, Zhang J, Li Y, et al. Longer dialysis session length is associated with better intermediate outcomes and survival among patients on in-center three times per week hemodialysis: results from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Nephrol Dial Transplant 2012; 27:4180.
- Saran R, Bragg-Gresham JL, Levin NW, et al. Longer treatment time and slower ultrafiltration in hemodialysis: associations with reduced mortality in the DOPPS. Kidney Int 2006; 69:1222.
- National Kidney Foundation. KDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 Update. Am J Kidney Dis 2015; 66:884.
- Weiner DE, Brunelli SM, Hunt A, et al. Improving clinical outcomes among hemodialysis patients: a proposal for a "volume first" approach from the chief medical officers of US dialysis providers. Am J Kidney Dis 2014; 64:685.
- Movilli E, Gaggia P, Zubani R, et al. Association between high ultrafiltration rates and mortality in uraemic patients on regular haemodialysis. A 5-year prospective observational multicentre study. Nephrol Dial Transplant 2007; 22:3547.
- Powers KM, Wilkowski MJ, Helmandollar AW, et al. Improved urea reduction ratio and Kt/V in large hemodialysis patients using two dialyzers in parallel. Am J Kidney Dis 2000; 35:266.
- Hauk M, Kuhlmann MK, Riegel W, Köhler H. In vivo effects of dialysate flow rate on Kt/V in maintenance hemodialysis patients. Am J Kidney Dis 2000; 35:105.
- Mehta HK, Deabreu D, McDougall JG, Goldstein MB. Correction of discrepancy between prescribed and actual blood flow rates in chronic hemodialysis patients with use of larger gauge needles. Am J Kidney Dis 2002; 39:1231.
- Lambie SH, Taal MW, Fluck RJ, McIntyre CW. Analysis of factors associated with variability in haemodialysis adequacy. Nephrol Dial Transplant 2004; 19:406.
- Ahmed J, Besarab A, Lubkowski T, Frinak S. Effect of differing blood lines on delivered blood flow during hemodialysis. Am J Kidney Dis 2004; 44:498.
- Frankenfield DL, McClellan WM, Helgerson SD, et al. Relationship between urea reduction ratio, demographic characteristics, and body weight for patients in the 1996 National ESRD Core Indicators Project. Am J Kidney Dis 1999; 33:584.
- Chand DH, Brier M, Strife CF. Comparison of vascular access type in pediatric hemodialysis patients with respect to urea clearance, anemia management, and serum albumin concentration. Am J Kidney Dis 2005; 45:303.
- I. NKF-K/DOQI Clinical Practice Guidelines for Hemodialysis Adequacy: update 2000. Am J Kidney Dis 2001; 37:S7.
- Schulman G, Delmez J, Greene T, et al. Experience with two dialyzers in series in the HEMO study (abstract). J Am Soc Nephrol 2000; 11:177A.
- Splendiani G, Zazzaro D, Tullio T, et al. Bidialysis: a new technique. Int J Artif Organs 2001; 24:70.
- Fritz BA, Doss S, McCann LM, Wrone EM. A comparison of dual dialyzers in parallel and series to improve urea clearance in large hemodialysis patients. Am J Kidney Dis 2003; 41:1008.
- Definition and calculation
- Non-normalized dialysis dose (Kt) and the effect of volume as an independent variable
- ALTERNATIVES TO KT/V
- Urea reduction ratio
- Solute removal index
- THE OPTIMAL AMOUNT OF DIALYSIS
- Target Kt/V
- Minimum dialysis frequency and time
- Patient-specific parameters
- CAUSES OF INADEQUATE DIALYSIS
- Low Kt/V
- Inadequate fluid removal
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS