From the Guidelines
To write a dialysis order, it is essential to specify the type of dialysis, frequency, and duration of each session, as well as the dialyzer type and size, blood flow rate, and dialysate flow rate and composition, with the goal of achieving optimal fluid removal and metabolic correction while minimizing complications, as recommended by the most recent guidelines 1. When writing a dialysis order, consider the following key components:
- Type of dialysis (hemodialysis, peritoneal dialysis, or continuous renal replacement therapy)
- Frequency (e.g., three times weekly for standard hemodialysis)
- Duration of each session (typically 3-4 hours, with a minimum of 3 hours per session for patients with low residual kidney function, as recommended by 1)
- Dialyzer type and size
- Blood flow rate (usually 300-400 mL/min)
- Dialysate flow rate (typically 500-800 mL/min)
- Dialysate composition, including sodium, potassium, calcium, bicarbonate, and glucose concentrations based on the patient's needs
- Ultrafiltration goal in kilograms or liters to achieve the target dry weight, taking into account the patient's weight gain, blood pressure control, and metabolic status, as suggested by 1
- Anticoagulation orders (e.g., heparin loading dose of 1000-2000 units followed by 500-1000 units/hour, or regional citrate anticoagulation protocol)
- Access type (arteriovenous fistula/graft or catheter) and care instructions
- Vital sign monitoring parameters
- Laboratory tests to be drawn (pre- and post-dialysis electrolytes, BUN, creatinine)
- Specific medications to be administered during dialysis (e.g., antibiotics, erythropoietin) It is also important to consider the patient's individual needs and clinical condition, including their residual kidney function, weight gain, and metabolic status, when writing a dialysis order, as emphasized by 1. Some patients may require additional hemodialysis sessions or longer hemodialysis treatment times, as suggested by 1, while others may benefit from peritoneal dialysis, with the initial prescription based on the patient's weight, residual kidney function, and lifestyle constraints, as outlined in 1. However, the most recent and highest quality study 1 provides the best guidance for writing a dialysis order, with a focus on achieving optimal fluid removal and metabolic correction while minimizing complications.
From the Research
Dialysis Order Components
- Patient identification and medical history
- Type of dialysis (hemodialysis or peritoneal dialysis)
- Dialysis schedule and frequency
- Dialyzer specifications (e.g., membrane type and size)
- Dialysate composition (e.g., electrolyte concentration and buffer)
- Anticoagulation therapy (e.g., heparin dose and administration route) 2
- Ultrafiltration goals and rate
- Blood flow rate and dialysate flow rate
- Monitoring parameters (e.g., blood pressure, temperature, and electrolyte levels)
Hemodialysis Order Considerations
- Initiation timing: earlier initiation (at estimated creatinine clearance of 10-14 mL/min) did not reduce mortality compared to later initiation (at estimated creatinine clearance of 5-7 mL/min) 3
- Duration and frequency: more frequent (>3 times a week) or longer duration (>4.5 hours) hemodialysis did not improve clinical outcomes compared to conventional hemodialysis 3
- Membrane type: high-flux membranes reduced cardiovascular mortality compared to low-flux membranes 3
Peritoneal Dialysis Order Considerations
- Dialysate composition: hyperosmolar solution with added osmotic agents (e.g., glucose) to facilitate ultrafiltration 4
- Infusion and drainage schedule: continuous ambulatory peritoneal dialysis (CAPD) or automated peritoneal dialysis (APD) 4
- Peritoneal transport characteristics: assessment of solute clearance and ultrafiltration rate to guide prescription and follow-up 4