Hemodialysis Prescription and Kavita Jintanapramote, MD Anticoagulant Management Renal Division Internal medicine department Bhumibol Adulyadej Hospital
Outlines Goal of hemodialysis Optimal Hemodialysis prescription Example of Hemodialysis prescription
Hemodialysis Dialysis is defined as the diffusion of molecules in solution across a semipermeable membrane along an electrochemical concentration gradient. Red blood cell Urea Bicarbonate Blood Dialysate N Engl J Med. 2010 Nov 4;363(19):1833-45.
Goal of Hemodialysis Dialysis is defined as the diffusion of molecules in solution across a semipermeable membrane along an electrochemical concentration gradient. To restore the intracellular and extracellular fluid environment that is characteristic of normal kidney function. 1. No uremic symptoms 2. Normal acid-base and electrolyte 3. Maintain body weight with euvolemic status 4. Prevent Malnutrition 5. Better quality of life and increase life expectancy 6. Prevent dialysis complication N Engl J Med. 2010 Nov 4;363(19):1833-45.
Hemodialysis Adequacy KDOQI CLINICAL PRACTICE GUIDELINE FOR ขอ้ แนะนําเวชปฏบิ ตั ิการฟอกเลอื ดด้วยเคร่ืองไตเทียม พ.ศ. 2565 HEMODIALYSIS ADEQUACY: 2015 UPDATE Schedule Kru < 2 ml/min/1.73 m2 Am J Kidney Dis. 2015;66(5):884-930 3/wk • Target: SpKt/V 1.4 per session Schedule Adequacy • Minimun: SpKt/V 1.2 per session 3/wk Target: SpKt/V 1.4 per session • URR > 65% • Target: SpKt/V 2.1 per session Minimun: SpKt/V 1.2 per session 2/wk Others Target StdKt/V 2.3 per week • Minimun: SpKt/V 1.8 per session Minimum: StdKt/V 2.1 per week Others • Target StdKt/V 2.4 per week ** Always include Kru for calculated adequacy or • Minimum: StdKt/V 2.1 per week prescription (if significant residual native kidney function) • EKRc ≥ 12 ml/min/35 L * ถ้า Kru ≥ 2 ml/min/1.73 m2 สามารถนาํ มาร่วมประเมนิ ความเพียงพอในการ ฟอกเลือดได้ โดยรวมคํานวณกบั การขจดั โดยการฟอกเลือด ส่งผลให้ไม่ จาํ เปน็ ตอ้ งเพิ่มการฟอกเลอื ดจนมากเกินความจาํ เปน็
Hemodialysis Prescription Overprescription Underprescription Nutritional loss Vascular access Uremia Acidosis Hypophosphatemia Electrolyte imbalance Intradialytic hypotension Anemia Others complication Uncontrolled HT Cost Burden Volume overload QoL Malnutrition
Outlines Goal of hemodialysis Optimal Hemodialysis prescription Example of Hemodialysis prescription
Optimal HD Prescription 1. Duration and frequency 2. Vascular access 3. Dialyzer 4. Blood flow rate 5. Dialysate flow rate 6. Dialysate solution 7. Dialyate temperature 8. Fluid removal (Ultrafiltration) 9. Anticoagulant 10. Intradialytic medication
Optimal HD Prescription 1. Duration and frequency Affect urea removal 2. Vascular access 3. Dialyzer 4. Blood flow rate 5. Dialysate flow rate 6. Dialysate solution 7. Dialyate temperature 8. Fluid removal (Ultrafiltration) 9. Anticoagulant 10. Intradialytic medication
Optimal HD Prescription 1. Duration and frequency 2. Vascular access Proposed Name Time of Day Duration Frequency 3. Dialyzer (hours per session) (session per week) 4. Blood flow rate Conventional HD Daytime 5. Dialysate flow rate Frequent HD 3-5 3-4 6. Dialysate solution - Short Daytime 7. Dialyate temperature - Standard Daytime <3 5-7 8. Fluid removal (Ultrafiltration) - Long Nighttime 3-5 5-7 9. Anticoagulant Long HD >5 5-7 10. Intradialytic medication - Long thrice weekly Nighttime or daytime - Long every other night Nighttime >5 3 - Long frequent Nighttime >5 3-5 >5 5-7 Am J Kidney Dis. 2015;66(5):884-930
Optimal HD Prescription 1. Duration and frequency Proposed Name Time of Day Duration Frequency Conventional HD Daytime (hours per session) (session per week) 2. Vascular access 3-5 3-4 3. Dialyzer KDOQI CLINICAL PRACTICE GUIDELINE FOR HEMODIALYSIS ADEQUACY: 2015 UPDATE 4. Blood flow rate 5. Dialysate flow rate We recommend that patients with low residual kidney function (< 2 mL/min) undergoing 6. Dialysate solution thrice weekly hemodialysis be prescribed a bare minimum of 3 hours per session. (1D) 7. Dialyate temperature Consider additional hemodialysis sessions or longer hemodialysis treatment times for 8. Fluid removal (Ultrafiltration) patients with large weight gains, high ultrafiltration rates, poorly controlled blood 9. Anticoagulant pressure, difficulty achieving dry weight, or poor metabolic control (such as hyperphosphatemia, metabolic acidosis, and/or hyperkalemia). (Not Graded) 10. Intradialytic medication
Optimal HD Prescription 1. Duration and frequency Proposed Name Time of Day Duration Frequency Conventional HD Daytime (hours per session) (session per week) 2. Vascular access 3-5 3-4 3. Dialyzer 4. Blood flow rate < 240 min Kidney Int . 2013 Jan;83(1):104-13. ≤ 180 min ≤ 240 min Kidney Int . 2010 Apr;77(7):630-6 5. Dialysate flow rate 6. Dialysate solution 1.26 (1.07-1.48) 1.30 (1.02-1.68) 1.57 1.62 7. Dialyate temperature (1.30-1.91) 1.32 (1.34-1.97) 1.37 (1.15-1.52) (1.19-1.58) 8. Fluid removal (Ultrafiltration) 9. Anticoagulant 10. Intradialytic medication
Optimal HD Prescription 1. Duration and frequency HD Prescription FHN Daily FHN Nocturnal Population (Short frequent in center) (Long frequent at home) 2. Vascular access Positive Prevalence cases Incident cases 3. Dialyzer outcomes BP control BP control 4. Blood flow rate Phosphate control Phosphate control 5. Dialysate flow rate Long term F/U LV mass index 6. Dialysate solution mortality Physaical health score Increased 7. Dialyate temperature Complications 8. Fluid removal (Ultrafiltration) Decreased 9. Anticoagulant 10. Intradialytic medication Vascular access Vascular access (Only AVF) ↓Residual renal function N Engl J Med 2010; 363:2287-2300 Am J Kidney Dis. 2015 Sep;66(3):459-68
Incremental Hemodialysis 1. Duration and frequency Potential benefits Obstacles • Preservation of RKF • Need close monitoring all aspects of 2. Vascular access 3. Dialyzer • Lower mortality risk adequacy 4. Blood flow rate • Uncertain patient adherence to 5. Dialysate flow rate • Improved HRQOL 6. Dialysate solution urine collection 7. Dialyate temperature • Improved nutrition status • Uncertain patient adherence to 8. Fluid removal (Ultrafiltration) 9. Anticoagulant • Vascular access preservation increment of frequency 10. Intradialytic medication • Better anemia indices • Uncertain patient adherence to • Economic benefits protein restriction • Additional workload to dialysis staff • Lack of RCTs confirm benefits • Shortfall in reimbursement Am J Nephrol 2019;50:411–421 Kidney International (2016) 90, 262–271
Current vascular access routes for hemodialysis 1. Duration and frequency AVF AVG Central venous catheter 2. Vascular access Desired characteristic High primary patency rate Autogenous AV Fistula AV Graft Central venous catheter 3. Dialyzer Instant usability 4. Blood flow rate Long survival ★ ★★ ★★★ 5. Dialysate flow rate Low thrombosis rate ★ ★★ ★★★ 6. Dialysate solution Low infection rate ★★★ ★★ 7. Dialyate temperature High blood flow rate on ★★★ ★★ ★ 8. Fluid removal hemodialysis ★★★ ★★ ★ 9. Anticoagulant Patient comfort ★★★ ★★★ ★ 10. Intradialytic medication Patient bathing/hygiene ★ Minimize needles ★ ★ Nat Rev Nephrol. 2020 Oct;16(10):586-602 Minimal cosmetic affect ★★★ ★★★ ★★★ Brenner & Rector’s The Kidney 2 – Volume Set 11th Edition 2020 ★ ★ ★ ★ ★★ ★★★ ★★
Current vascular access routes for hemodialysis 1. Duration and frequency KDOQI suggests AV access (AVF or AVG) in preference to a CVC in most incident and prevalent HD 2. Vascular access patients due to the lower infection risk associated with AV access use. (Conditional Recommendation, Low Quality of Evidence) 3. Dialyzer KDOQI considers it reasonable that the choice of AV access (AVF or AVG) be based on the operator’s/clinician’s 4. Blood flow rate best clinical judgment that considers the vessel characteristics, patient comorbidities, health circumstances, 5. Dialysate flow rate and patient preference. (Expert Opinion) 6. Dialysate solution 7. Dialyate temperature KDOQI suggests that most incident HD patients starting dialysis with a CVC should convert to 8. Fluid removal either an AVF or AVG, if possible, to reduce their risk of infection/bacteremia, infection-related 9. Anticoagulant 10. Intradialytic medication hospitalizations, and adverse consequences. (Conditional Recommendation, Very Low–Moderate Quality of Evidence) Site of AV access: Forearm > Brachiocephalic > upper arm Site of CVC: Internal jugular > External jugular > Femoral > Subclavian
Dialysis Membrane Properties 1. Duration and frequency Ideal Hemodialyzer membrane 2. Vascular access 1. High clearance of solute (small, middle molecules) 3. Dialyzer 2. Adequate Ultrafiltration 3. High biocompatibility 4. Low blood volume compartment 4. Blood flow rate Membrane Membrane Name High or Low flux Biocompatibility Cellulose Cuprophane Low Low 5. Dialysate flow rate Semisynthetic cellulose Cellulose acetate High and Low Intermediate Cellulose triacetate High Good 6. Dialysate solution - Cellulose diacetate Hemophane High Intermediate - Cellulose triacetate PMMA High Good 7. Dialyate temperature - Diethylaminoethyl-substituted cellulose PAN High Good Synthetic polymers PAN/AN-69 High Good Polyflux High and Low Good 8. Fluid removal - Polymethylmethacrylate Gambrane High Good - Polyacrylonitrile methacrylate copolymer EVAL High Good Polysulfone High and Low Good 9. Anticoagulant - Polyacrylonitrile methallyl sulfonate copolymer - Polyamide 10. Intradialytic medication - Polycarbonate-polyether - Ethylene vinyl alcohol copolymer Brenner & Rector's the Kidney. 10th edition, 2016. - Polysulfone Comprehensive Clinical Nephrology. 6th edition, 2019.
Dialysis Membrane Properties 1. Duration and frequency Factors effect diffusion 2. Vascular access KoA (Membrane) 3. Dialyzer • Porosity • Surface area 4. Blood flow rate • Membrane thickness 5. Dialysate flow rate 6. Dialysate solution 7. Dialyate temperature 8. Fluid removal 9. Anticoagulant 10. Intradialytic medication Brenner & Rector's the Kidney. 10th edition, 2016. Comprehensive Clinical Nephrology. 6th edition, 2019.
Dialysis Membrane Properties 1. Duration and frequency Standard High Efficiency High flux 2. Vascular access Membrane 3. Dialyzer Blood flow rate (ml/min) 250 ≥350 ≥350 4. Blood flow rate Dialysate flow rate (ml/min) 500 ≥500 ≥500 5. Dialysate flow rate KoA Urea 300-500 ≥600 Variable 6. Dialysate solution Urea clearance (ml/min) <200 >210 Variable 7. Dialyate temperature Beta-2 microglobulin clearacne <10 Variable >20 8. Fluid removal (ml/min) 9. Anticoagulant UF coefficient (Kuf) 3.5-5.0 Variable >20 10. Intradialytic medication Membrane Cellulose Variable Variable Brenner & Rector's the Kidney. 10th edition, 2016. Comprehensive Clinical Nephrology. 6th edition, 2019.
High flux vs Low flux dialysis 1. Duration and frequency Hemo study 2. Vascular access Survival % 3. Dialyzer Relative risk = 0.92 4. Blood flow rate (95% = 0.81 to 1.05; P=0.23) 5. Dialysate flow rate 6. Dialysate solution Subgroup of dialysis 7. Dialyate temperature - ↓ Risk of death among pt. with ≥ 3.7 yr of dialysis in high-flux group 8. Fluid removal 9. Anticoagulant 10. Intradialytic medication N Engl J Med 2002;347:2010-9
High flux vs Low flux dialysis 1. Duration and frequency MPO study Serum albumin ≤ 4 g/dL 2. Vascular access All High flux 3. Dialyzer Low flux 4. Blood flow rate 5. Dialysate flow rate Survival probabilities High flux p = 0.032 6. Dialysate solution Low flux 7. Dialyate temperature 8. Fluid removal p = 0.214 Diabetic pts 9. Anticoagulant 10. Intradialytic medication High flux Low flux p = 0.039 J Am Soc Nephrol. 2009 Mar;20(3):645-54
High flux vs Low flux dialysis 1. Duration and frequency Hemo study ↔ Mortality Subgroup: ↓ Mortality in pts who dialysis ≥ 3.7 yrs 2. Vascular access MPO study ↔ Mortality Subgroup: ↓ Mortality in DM, serum albumin ≤ 4 g/dL44 3. Dialyzer KDOQI CLINICAL PRACTICE GUIDELINE FOR HEMODIALYSIS ADEQUACY: 2015 UPDATE 4. Blood flow rate 5. Dialysate flow rate We recommend the use of biocompatible, either high or low flux hemodialysis 6. Dialysate solution 7. Dialyate temperature membranes for intermittent hemodialysis. (1B) 8. Fluid removal 9. Anticoagulant Note: Patients with diabetes, lower serum albumin, or longer dialysis vintage should be 10. Intradialytic medication considered a priority for selection of high-flux dialyzers. N Engl J Med 2002;347:2010-9 J Am Soc Nephrol. 2009 Mar;20(3):645-54
Medium and High cut-off membranes 1. Duration and frequency High flux Medium cut off 2. Vascular access (MCO) 3. Dialyzer High cut off Plasmafilter (HCO) 4. Blood flow rate 5. Dialysate flow rate 6. Dialysate solution 7. Dialyate temperature 8. Fluid removal 9. Anticoagulant 10. Intradialytic medication Nefrologia (Engl Ed). 2018 Jan-Feb;38(1):4-7. Claudio Ronco, William R. Clark. Nature revuew, Nephrology, 2018, 14(394-410)
Optimal HD Prescription 1. Duration and frequency Normally, BFR is set at 200-600 ml/min 2. Vascular access depend on vascular access and dialyzer type 3. Dialyzer ⇧ BFR ⇧ Clearance Limited by 4. Blood flow rate - Dialyzer type - Vascular access (↑Flow resistance -> Limited the augmented clerance) 5. Dialysate flow rate 6. Dialysate solution N Engl J Med. 2010 Nov 4;363(19):1833-45. 7. Dialyate temperature 8. Fluid removal (Ultrafiltration) 9. Anticoagulant 10. Intradialytic medication
Current vascular access routes for hemodialysis 1. Duration and frequency Recommended needle size for the state blood flow rate settings 2. Vascular access 3. Dialyzer Blood flow rate Needle gauze Inner diameter, mm 4. Blood flow rate 200 ml/min 18 0.838 5. Dialysate flow rate <300 ml/min 17 1.067 300-350 ml/min 16 1.194 350-400 ml/min 15 1.372 >450 ml/min 14 1.600 6. Dialysate solution Blood recirculation rate in relation to the real blood flow rate 7. Dialyate temperature 8. Fluid removal (Ultrafiltration) 9. Anticoagulant 10. Intradialytic medication ASAIO Journal 50(1):p 94-97, January 2004
Optimal HD Prescription 1. Duration and frequency ⇧ DFR ⇧ Efficiency of diffusion of urea from blood to dialysate 2. Vascular access 3. Dialyzer BFR 300 ml/min BFR 500 ml/min DFR > 800 mL/min -> 4. Blood flow rate Dialyzer cerance (ml/min) ↑urea clearance ~ 5%–8% 5. Dialysate flow rate (high efficiency dialyzer & 6. Dialysate solution BFR > 350 ml/min) 7. Dialyate temperature 8. Fluid removal (Ultrafiltration) The optimum DFR 1.5–2.0x of BFR 9. Anticoagulant 10. Intradialytic medication Handbook of Dialysis. 5th ed, 2015.
Optimal HD Prescription 1. Duration and frequency ComposiCon of a Standard Hemodialysis SoluCon 2. Vascular access 3. Dialyzer Sodium 4. Blood flow rate Potassium 5. Dialysate flow rate Calcium Magnesium 6. Dialysate solution Bicarbonate 7. Dialyate temperature Glucose 8. Fluid removal (Ultrafiltration) 9. Anticoagulant 10. Intradialytic medication
Optimal HD Prescription 1. Duration and frequency Sodium High Dialysate Na 2. Vascular access 3. Dialyzer Potassium ↓ Cramping ↓ Disequilibrium 4. Blood flow rate Calcium 5. Dialysate flow rate Magnesium ↓ IDH ↓ EEG abnormal Bicarbonate 6. Dialysate solution Glucose ↑ Pt preference (Citrate, Acetate) 7. Dialyate temperature ↑ IDWG ↑ Hypertension 8. Fluid removal 9. Anticoagulant 10. Intradialytic medication Semin Dial. 2017 Mar;30(2):99-111.
Optimal HD Prescription 1. Duration and frequency Sodium Low Dialysate Na 2. Vascular access 3. Dialyzer Potassium ↑ Symptoms 4. Blood flow rate ↑ IDH 5. Dialysate flow rate C↓alcHiuympertension 6. Dialysate solution Magn↓esiIuDmWG Bicarbonate Glucose (Citrate, Acetate) 7. Dialyate temperature 8. Fluid removal 9. Anticoagulant 10. Intradialytic medication Semin Dial. 2017 Mar;30(2):99-111.
Optimal HD Prescription 1. Duration and frequency Sodium 2. Vascular access SodiuPComatalcsisPuiummrofile 3. Dialyzer 4. Blood flow rate A- AimvosMi:daDgDnSeasniudmmuscle cramps 5. Dialysate flow rate -vaImscpuBrloaicvraesrdtbaSbooinldiatiyutem removal and Glucose 6. Dialysate solution (Citrate, Acetate) 7. Dialyate temperature Decreasing: prevent IDH and 8. Fluid removal post dialytic hypotension 9. Anticoagulant Increasing: prevent cramp in late session 10. Intradialytic medication
Optimal HD Prescription Sodium 1. Duration and frequency 2-4• Usual dialysis solution sodium potassium is mEq/L 2. Vascular access Potassium 3. Dialyzer • Diffusion > Convection 4. Blood flow rate Calcium 5. Dialysate flow rate • Depends on the predialysis potassium concentration. Magnesium Bicarbonate Glucose (Citrate, Acetate) 4.6-5.3 mEq/L 6. Dialysate solution 7. Dialyate temperature 8. Fluid removal 9. Anticoagulant 10. Intradialytic medication Clin J Am Soc Nephrol 2: 999-1007, 2007 Am J Kidney Dis. 2015 Jul;66(1):125-32.
Optimal HD Prescription Sodium 1. Duration and frequency 2-4• Usual dialysis soluhon sodium potassium is mEq/L 2. Vascular access Potassium 3. Dialyzer • Diffusion > Convechon 4. Blood flow rate Calcium 5. Dialysate flow rate Magnesium • Depends on the predialysis potassium concentrahon. Bicarbonate 6. Dialysate solution Rule of 7’s Glucose (Citrate, Acetate) Predialysis Potassium level, mEq/L Dialysate K, mEq/L <4 4 4.1-5.5 3 or 2 mEq/L 7. Dialyate temperature 5.6-6.4 1 mEq/L >6.5 1 or 0 mEq/L 8. Fluid removal * Both Dialysate K 0 and 1 mEq/L can be used in situations with life threatening acute hyperkalemia but only with extreme caution and 9. Anticoagulant frequent check serum K level to avoid severe hypokalemia ** Avoid hypokalemia in pts on digoxin or U/D Heart disease 10. Intradialytic medication Am J Kidney Dis. 2015 Jul;66(1):125-32.
Optimal HD Prescription Sodium 1. Duration and frequency 2-4• Usual dialysis solution sodium potassium is mEq/L 2. Vascular access Potassium 3. Dialyzer • Diffusion > Convection 4. Blood flow rate Calcium 5. Dialysate flow rate Magnesium • Depends on the predialysis potassium concentration. Bicarbonate 6. Dialysate solution Predialysis Potassium level, Dialysate K, mEq/L Glucose (Citrate, Acetate) mEq/L ≤4 3-4 (based on individual trends) 4.1-5.5 2-3 (based on individual trends) 7. Dialyate temperature >5.5-8.0 2 8. Fluid removal >8 1 + telemetry monitoring + 9. Anticoagulant 30 min K checks and switch to K 2 if serum K < 7 *Avoid dialysate K < 3 in arrhythmia prone pts 10. Intradialytic medication Hemodialysis International 2020: 24:282-289
Optimal HDSodium Prescription 1. Duration and frequency Potassium • Usual dialysis solution calcium level is 2.5-3.5 mEq/L Calcium 2. Vascular access MaDginaelyssiautme • Advantages Disadvantages 3. Dialyzer BicaCrablcoinumate • 4. Blood flow rate Reduced risk of hypercalcemia • Potential for negative calcium balance and 5. Dialysate flow rate Lower Allows greater use of vitamin D and calcium- stimulation of PTH containing phosphate binders 6. Dialysate solution (2G.5lu-3comsEeq/L) Benefit in adynamic bone disease • Increase in intradialytic hypotension Improve hemodynamic stability • Greater risk of hypercalcemia (Citrate, Acetate) • Suppression of PTH • Limits use of vitamin D and calcium based Higher • Beneficial for bone protection on nocturnal hemodialysis binders (3-3.5 mEq/L) • • Possible risk of vascular calcification • 7. Dialyate temperature KDIGO In patients with CKD G5D, we suggest using a dialysate calcium 8. Fluid removal CKD-MBD 2017 concentration between 1.25 and 1.50 mmol/l (2.5 and 3.0 mEq/l) 9. Anticoagulant CKD-MBD ในผู้ป่วยท่ไี ดร้ บั การฟอกเลือดด้วยเคร่ืองไตเทียม และล้างไตทางช่องท้อง แนะนาํ ใหใ้ ช้น้าํ ยาฟอกไตทม่ี ีความเข้มขน้ ของ 10. Intradialytic medication NST 2022 แคลเซียมต่ําอยูร่ ะหวา่ ง 2.5-3.0 mEq/L ในผู้ปว่ ยทม่ี ภี าวะ osteitis fibrosa (คุณภาพหลกั ฐาน C) แนะนาํ ใหล้ ดความเขม้ ข้นของแคลเซียมในน้าํ ยาฟอกเลอื ดและน้าํ ยาลา้ งไตทางชอ่ งท้องให้อย่รู ะหว่าง 2.5-3.0 mEq/L ในผู้ปว่ ยท่ีมภี าวะ adynamic bone disease (คุณภาพหลกั ฐาน C) Hemodial Int. 2006 Oct;10(4):326-37.
Optimal PHoSotadDsisuimumPrescription 1. Duration and frequency Calcium A “neglected cation” Magnesium 2. Vascular access Bicarbonate 3. Dialyzer 4. Blood flow rate Glucose • Oversuppression of parathyroid hormone levels and adynamic bone disease 5. Dialysate flow rate Hypotension • Bradycardia and heart block (Citrate, Acetate) • Neuromuscular toxicity • 6. Dialysate solution • QT-interval prolongation and atrial ventricular arrhythmias • Seizure 7. Dialyate temperature 8. Fluid removal 9. Anticoagulant To maintain normal-range serum magnesium levels, a dialysate magnesium 10. Intradialytic medication concentrahon of 1.0 meq/L (0.5 mmol/L) is recommended **May be higher concentrajon in pts with GI loss (e.g., diarrhea), on PPI, malnutrijon Semin Nephrol. 2018 November ; 38(6): 570–581
Optimal Potassium HD PrescriptionCalcium Magnesium 1. Duration and frequency Bicarbonate Increased protein ⇧ Mortality 2. Vascular access catabolism 3. Dialyzer Glucose 4. Blood flow rate (Muscle wasting) (Citrate, Acetate) Bone disorders Chronic metabolic acidosis (Bone loss, Osteomalacia) Cardiovascular disease 5. Dialysate flow rate Impaired growth 6. Dialysate solution KDOQI Changes in glucose Nutrition 2020 metabolism 7. Dialyate temperature 8. Fluid removal In adults with CKD 3-5D, it is reasonable to maintain serum bicarbonate levels at 24-26 mmol/L (OPINION) 9. Anticoagulant ข้อแนะนาํ เวชปฏิบัติการฟอกเลือด เป้าหมายของระดับไบคาร์บอเนตก่อนการฟอกเลือดคือ 10. Intradialytic medication ดว้ ยเคร่อื งไตเทียม พ.ศ. 2565 22-24 มิลลิโมล/ลติ ร (คําแนะนาํ ระดบั 1, คณุ ภาพหลกั ฐาน B)
Optimal Potassium HD PrescriptionCalcium Magnesium 1. Duration and frequency Bicarbonate 30-35• Usual dialysis solution HCO3- level is approximately mEq/L 2. Vascular access MeGtlaucbooselic alkalosis Neurological system 3. Dialyzer 4. Blood flow rate (Citrate, Acetate) • Arterial vasoconstriction 5. Dialysate flow rate Cardiovascular system • Reduce Cerebral blood flow 6. Dialysate solution • Arterial vasoconstriction • Delerium • Reduce Coronary blood flow • Reduce Angina treshold • Lethargy/Stupor • Arrhythmias (QT prolong) • Seizure/Tetany 7. Dialyate temperature Respiratory system Metabolic 8. Fluid removal 9. Anticoagulant • Depress respira`on • Anaerobic glycolysis 10. Intradialytic medication • HypovenSlaSon • Organic acid production • Hypoxia • Hypocalcemia (enhanced alb bound to Ca2+) • ShiT O2 curve dissociaSon to the Lt • Hypokalemia • Increase V/Q mismatch J. Bras. Nefrol. 39 (03) • Jul-Sep 2017 Precipitate CaP in soft tissue
OptimaMl aHCganlcDeiusmiuPmrescription Bicarbonate 1. Duration and frequency Glucose 2. Vascular access (Citrate, Acetate) 3. Dialyzer The current standard glucose dialysate concentraion is 100-200 mg/dL 4. Blood flow rate Glucose free dialysate • More episodes of hypoglycemia in diabetic pts during HD 5. Dialysate flow rate Glucose-containing dialysate • Prevent hypoglycemia 6. Dialysate solution • Energy • Metabolic syndrome 7. Dialyate temperature • Shift K into cells (decrease K removing) 8. Fluid removal • Increase risk of infection 9. Anticoagulant >200 mg/dL • More episode of hyperglycemia • Increase vagal tone -> ↑ IDH 10. Intradialytic medication Handbook of Dialysis. 5th ed, 2015.
Composition of Dialysate 1. Duration and frequency Component Concentration 2. Vascular access 3. Dialyzer Electrolyte (mmol/L) Range Typical 4. Blood flow rate • Sodium 5. Dialysate flow rate • Potassium 135-145 138 • Calcium 1.0-4.0 2.0 6. Dialysate solution • Magnesium 1.0-1.75 (2.0-3.5 mg/dL) 1.25 (2.5 mg/dL) • Chloride 0.5-1.0 0.75 7. Dialyate temperature Buffers (mmol/L) 87-124 105 8. Fluid removal • Acetate 9. Anticoagulant • Bicarbonate 2-4 3 10. Intradialytic medication • pH 20-40 35 • pCO2 (mmHg) 7.1-7.3 7.2 • Glucose 40-100 0-200 mg/dL 100 mg/dL Comprehensive Clinical Nephrology. 6th edi\\on, 2019.
Composition of Dialysate 1. Duration and frequency Component Advantage Disadvantage 2. Vascular access Sodium 3. Dialyzer Increased • Hemodynamic stability • Postdialytic thirst; • Increased postdialytic serum sodium levels • Increased intradialytic weight gain • High blood pressure 4. Blood flow rate Decreased • Reduced osmotic stress in the presence of • Intradialytic hemodynamic instability predialytic hyponatremia 5. Dialysate flow rate Potassium • Fewer arrhythmias in digoxin intoxication • Hyperkalemia Increased with hypokalemia • Arrhythmias; risk for sudden death 6. Dialysate solution • May improve hemodynamic stability 7. Dialyate temperature Decreased • Increased dietary potassium intake 8. Fluid removal Calcium 9. Anticoagulant Increased • Suppresses PTH • Hypercalcemia, vascular calcification, adynamic 10. Intradialytic medication • Increased hemodynamic stability bone disease resulting from PTH suppression Decreased • Permits more liberal use of calcium- • Stimulation of PTH containing phosphate binders • Reduced hemodynamic stability Comprehensive Clinical Nephrology. 6th edi\\on, 2019.
Composition of Dialysate 1. Duration and frequency Component Advantage Disadvantage 2. Vascular access Bicarbonate 3. Dialyzer Increased • Acidosis control improved • Postdialytic alkalosis; increased mortality 4. Blood flow rate Decreased • No postdialytic alkalosis • Promotes acidosis; increased mortality Magensium Increased • Hemodynamic stability • Altered nerve conduction, pruritus, renal bone • Fewer arrhythmias disease 5. Dialysate flow rate Decreased • Suppresses PTH • Arrhythmias 6. Dialysate solution • Permits use of magnesium-containing • Muscle weakness and cramps phosphate binders • Elevated PTH 7. Dialyate temperature • Improved bone mineralization; less bone 8. Fluid removal pain Glucose • Avoidance of intradialytic hyperglycemia • Increased risk for disequilibrium (rare), Increased and hyperinsulinemia • Hypoglycemia • Intradialytic hyperglycemia and hyperinsulinism 9. Anticoagulant Decreased • Lower risk for disequilibrium • High blood citrate levels in liver failure 10. Intradialytic medication Citrate • Heparin-sparing effect Comprehensive Clinical Nephrology. 6th edi\\on, 2019.
Optimal HD Prescription 1. Duration and frequency ↑ 0.5 ◦C during dialysis – Normal (not necessary sign of infection) 2. Vascular access 3. Dialyzer Hemodialysis Heat gain ↑ BT about 0.5 ◦C 4. Blood flow rate 5. Dialysate flow rate IDH Reflex vasodilatation 6. Dialysate solution Dialysate Temperature should be set as low as as possible without engendering 7. Dialyate temperature patient discomfort, generally in the range of 34.5°C–36.5°C 8. Fluid removal (Ultrafiltration) Individualizahon: 0.5 ◦C lower than tympanic membrane Temp. 9. Anticoagulant 10. Intradialytic medication Benefits: - Protection from intradialytic hypotension - Shortening of postdialysis recovery time - May reduce the incidence of myocardial stunning and dialysis-associated ischemic damage to brain white matter. - ↓ Morbidity and Mortality (Hsu, 2012) Handbook of Dialysis. 5th ed, 2015.
Optimal HD Prescription 1. Duration and frequency Dry weight Post-dialysis weight 2. Vascular access 3. Dialyzer The postdialysis weight at which all or most excess body fluid has been removed. 4. Blood flow rate Too high: Fluid overload, pulmonary congesaon 5. Dialysate flow rate Too low: Frequent hypotensive episodes, malaise, a 6. Dialysate solution washes-out feeling, cramps, dizziness after HD 7. Dialyate temperature Estimation: 8. Fluid removal (Ultrafiltration) Clinical asscessment, Trial-and-Error basis, 9. Anticoagulant Bioelectrical impedance (BIA), Lungs ultrasound 10. Intradialytic medication Handbook of Dialysis. 5th ed, 2015.
Fluid Removal Rate 1. Duration and frequency 2. Vascular access > 13 ml/kg/h > 13 ml/kg/h Data from HEMO Study 3. Dialyzer 1.20 4. Blood flow rate 1.59 1.33 1.71 5. Dialysate flow rate (1.03-1.41) (1.29-1.96) (1.03-1.72) (1.23-2.38) 6. Dialysate solution 7. Dialyate temperature 8. Fluid removal (Ultrafiltration) 9. Anticoagulant UF > 13 ml/kg/hr increased all-cause and CV-related mortality 10. Intradialytic medication Kidney Int . 2011 Jan;79(2):250-7.
Fluid Removal Rate 118,394 hemodialysis patients dialyzing in a large dialysis organization, 2008-2012 1. Duration and frequency 2. Vascular access 10 ml/kg/hr 3. Dialyzer 10 x 60 x 4 = 2,400 ml = 2.4 L 4. Blood flow rate 5. Dialysate flow rate High UF rate associated with greater mortality 6. Dialysate solution 7. Dialyate temperature Am J Kidney Dis. 2016 Dec;68(6):911-922. 8. Fluid removal (Ultrafiltration) 9. Anticoagulant 10. Intradialytic medication
Ultrafiltration Profile 1. Duration and frequency UF Profile RBV Constant 2. Vascular access Decreasing 3. Dialyzer Alternating 4. Blood flow rate 5. Dialysate flow rate 6. Dialysate solution 7. Dialyate temperature 8. Fluid removal (Ultrafiltration) 9. Anticoagulant 10. Intradialytic medication Am J Kidney Dis. 2000 Jul;36(1):115-23.
Optimal HD Prescription Occluding microthrombi (suspected clots in tubing or dialyzer membranes) and m1.aDcurorathtiroonmabnid(vfirseuqaulelynecvyident clots in tubing or dialyzers) • Dialysis efficiency 2. Vasc••ularIAnanccercemeasisasevcioasbtlood loss (100-150 ml) 3. Dialyzer 4. Blood flow rate 5. Dialysate flow rate 6. Dialysate solution 7. Dialyate temperature 8. Fluid removal (Ultrafiltration) 9. Anticoagulant 10. Intradialytic medication Seminars in Dialysis. 2021;34:103–115
Monitoring anticoagulant during dialysis 1. Duration and frequency • Signs of clotting in the extracorporeal circuit 2. Vascular access 3. Dialyzer • Pressure of extracorporeal circuit 4. Blood flow rate • Clot in dialyzer after HD 5. Dialysate flow rate • Residual dialyzer volume 6. Dialysate solution • Clotting time test 7. Dialyate temperature • Clinical of patient 8. Fluid removal (Ultrafiltration) Textbook of Hemodialysis (1):2010 9. Anticoagulant Blood Purif 2019;47:361–368 10. Intradialytic medication
Monitoring anticoagulant during dialysis 1. Duration and frequency • Signs of clotting in the extracorporeal circuit 2. Vascular access • Pressure of extracorporeal circuit 3. Dialyzer 4. Blood flow rate • Clot in dialyzer after HD 5. Dialysate flow rate 6. Dialysate solution • Residual dialyzer volume 7. Dialyate temperature • Clotting time test 8. Fluid removal (Ultrafiltration) • Clinical of patient 9. Anticoagulant 10. Intradialytic medication Textbook of Hemodialysis (1):2010 Blood Purif 2019;47:361–368
Anticoagulant 1. Duration and frequency Activating surface Heparin LMWH XII XIIa 2. Vascular access 3. Dialyzer Intrinsic XI XIa TF 4. Blood flow rate pathway Ca2+ Ca2+ Extrinsic PL pathway IX IXa 5. Dialysate flow rate Ca2+ VIIa VII PL Ca2+ 6. Dialysate solution PL X Xa 7. Dialyate temperature Ca2+ 8. Fluid removal V Va Prothrombin II IIaPL Thrombin Common Ca2+ pathway 9. Anticoagulant Fibrin 10. Intradialytic medication Fibrinogen I Ia Fibrin clot formation
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