Hemodialysis Adequacy Dwi

Hemodialysis Adequacy
and Prescription
Dwi Lestari Partiningrum
What is
Adequacy of Hemodialysis ?
Adequacy of dialysis :
refers to how well we remove toxins and
waste products from the patients blood,
and has a major impact on their well-being
(remove + well being)
Adequacy of dialysis
Adequate dialysis maximizes well-being,
minimizes morbidity, and helps a patient retain
social independence.
Adequate dialysis is not simply a dose of dialysis
exceeding a given number, and should not be
defined by solute clearance alone.
Optimum dialysis is a method of delivering
dialysis producing results that cannot be further
improved.
Dialysis prescription should be individualized,
monitored, and reassessed regularly.
Recommendations for Adequacy

assessment
Should be assessed using a combination
(subjective, objective and dialysis dose
assessment)
The recommended frequency : 3-monthly
in stable patients
Monthly in unstable patients
Assessment of Dialysis
Adequacy
Subjective assessment:
Sense of well being (no tiredness)
Good appetite (no nausea)
More normal weight
Feeling like dialysis is not necessary,
except to remove fluid
More natural skin color
Adequacy
Objective assessment:
Volume / Blood pressure control
Not Acidotic (mid-week predialysis
bicarbonat level not low)
Controlled of blood phosphate levels
Normal serum albumin level
Adequacy
Dialysis dose assessment
Is the desired level of urea removal
being met?
Under-Dialyzed Patients May Experience
Weakness, Tiredness
Loss of body weight
Poor appetite
Nausea / Vomiting
Feeling better after treatmen
Yellowish skin color
More infections
Prolonged bleeding
Premature death
How Do We Know if a Patient is

Adequately Dialyzed?
K/DOQI Guidelines
Define Adequate Dialysis as:
KT/V = 1.2 or greater
URR = 65% or greater
URR% - Urea Reduction Ratio :

the percentage of urea removed
during the treatment
KT/V :
Formula utilizing dialyzer urea
clearance, treatment time and total
body fluid
Example URR
Initial (predialysis) urea level: 50 mg/dL
The postdialysis urea level: 15 mg/dL
The amount of urea removed: 50 mg/dL15 mg/dL = 35mg/dL
URR% = Ur pre Ur post x 100%

Ur Pre
35/50 = 70/100 = 70%
Recommended a minimum URR of 65 percent.
The URR is usually measured only a month.
Kt/V
K : the dialyzer clearance in milliliters
per minute (mL/min)
t : time
Kt : is clearance multiplied by time
representing the volume of fluid
completely cleared of urea during a single
treatment
V : is the volume of water a patients body
contains ( 50%)
The Kt/V is mathematically related to the URR,

except that the Kt/V also takes into account two additional
factors:
urea generated by the body during dialysis
extra urea removed during dialysis along with excess
fluid
The Kt/V is more accurate than the URR in measuring how
much urea is removed during dialysis, primarily because
the Kt/V also considers the amount of urea removed with
excess fluid. (Consider two patients with the same URR
and the same postdialysis weight, one with a weight loss
of 1 kg during the treatment and the other with a weight
loss of 3 kg.)
Patients who lose more weight during dialysis will have a
higher Kt/V for the same level of URR.
Blood sampling for UKM

Predialysis sample
Postdialysis sample
Take before any dialysis has Set the UF rate to zero

begun from fistula needle
Slow blood pump to 50
ml/min for at least 15s
Stop blood pump
Take sample within the next
20s (Alternatively slow pump
to 100 ml/min, over-ride
alarm to keep blood flowing,
wait 15-30s then take
sample from A line)
Other markers of adequacy:

protein catabolic rate
PCR (usually normalized for weight: nPCR:
g/kg/day) is derived from the urea generation
rate and is usually calculated during UKM.
Patients with nPCR < 0.8 g/kg/day have
increased morbidity and mortality, and generally
patients need an nPCR >1.0 g/kg/day to maintain
positive nitrogen balance.
Patients with a low nPCR need a careful
assessment for protein malnutrition.
PCR can be calculated approximately from:

PCR = (pre-post BUN)x(0.045/T)
Where T = number of days between blood
samples.
Other markers of adequacy

Acidosis
UF should be sufficient to keep the patient euvolaemic.
Compliance with salt and fluid restriction is important.
Increased oedema or ascites increases V, and hence
reduces Kt/V if K and t are not increased. Increased
dialysis time is also necessary to allow redistribution of
fluid from interstitial compartments into the vascular
compartment during dialysis.
Malnutrition is a key marker of dialysis inadequacy and is
easily missed. Early weight loss is often accompanied by
fluid retention as the dry weight is not reduced in line
with loss in muscle mass.
Methods to increase delivered

dialysis dose
Most effrctive methods
Increase dialysis time
Change to dialysis membrane of larger
size anf/ or permeability
Less effective methods
Increase blood flow during dialysis
Increase dialysate flow during dialysis
Hemodialysis Prescription
Determines Adequacy
Hemodialysis Prescription Components:
Duration of treatment (not < 4 hours at each
treatment)
Frequency of dialysis
Desired dry weight
Membrane type, membrane size
Blood pump speed
Dialysate flow rate
Anticoagulation protocol to be used
Access
Assessment of adequacy should include:

patient well-being (physically, mentally,
socially);
nutrition (lack of malnutrition);
small solute clearance (urea kinetic
modelling: UKM);
adequacy of UF;
control of BP;
control of anaemia, acidosis, and bone
disease.
Example Kt/V:
If the dialyzers clearance is 300 mL/min
and a dialysis session lasts for 180
minutes (3 hours)
Kt = 300mL/min x 180min
Kt = 54,000mL = 54 liters
The body 60% water by weight. If a
patient weighs 70 kilograms
V = 70 kg x 60 = 42 liters
Kt/V = 54/42 = 1.3

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Hemodialysis Adequacy

Recommendations for Adequacy

Under-Dialyzed Patients May Experience

How Do We Know if a Patient is

URR% - Urea Reduction Ratio :

URR% = Ur pre Ur post x 100%

The Kt/V is mathematically related to the URR,

Blood sampling for UKM

Take before any dialysis has Set the UF rate to zero

Other markers of adequacy:

PCR can be calculated approximately from:

Other markers of adequacy

Methods to increase delivered

Assessment of adequacy should include:

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