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Prescribing and assessing adequate hemodialysis

Wajeh Y Qunibi, MD
William L Henrich, MD, MACP
Section Editor
Steve J Schwab, MD
Deputy Editor
Alice M Sheridan, MD


Survival in patients with end-stage renal disease (ESRD) is made possible by removal of uremic solutes by dialysis. The amount of dialysis that a patient receives and the amount of uremic toxin removal can impact morbidity and mortality [1,2].

Uremic toxins include small, water-soluble compounds such as urea, protein-bound solutes such as indoles and phenols, or larger middle molecules such as beta2-microglobulin. Assessment of solute removal during dialysis has always been based on urea removal. However, evidence from experimental and clinical studies points to an adverse effect of middle molecules and protein-bound solutes on patient survival [3,4].

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 "Treatment of anemia in nondialysis chronic kidney disease" and "Hyporesponse to erythropoiesis-stimulating agents (ESAs) in chronic kidney disease".)

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Literature review current through: Oct 2017. | This topic last updated: Jan 20, 2017.
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