From the Guidelines
There is no specific goal creatinine level for patients with end-stage renal disease (ESRD) on dialysis. Unlike in earlier stages of kidney disease, creatinine levels in dialysis patients typically remain elevated between dialysis sessions and fluctuate based on the dialysis schedule. For hemodialysis patients, creatinine levels are highest just before a dialysis session and lowest immediately after. Rather than targeting a specific creatinine value, dialysis adequacy is assessed using other measures such as Kt/V (which quantifies dialysis dose), urea reduction ratio, and clinical parameters like fluid status, electrolyte balance, and symptom control.
Key Considerations
- The minimally adequate dose of HD given 3 times per week to patients with Kr less than 2 mL/min/1.73 m2 should be an spKt/V (excluding RKF) of 1.2 per dialysis, or a URR of 65% for treatment times less than 5 hours 1.
- The target dose for HD given 3 times per week with Kr less than 2 mL/min/1.73 m2 should be an spKt/V of 1.4 per dialysis not including RKF, or URR of 70% 1. Healthcare providers focus on achieving adequate clearance of waste products through appropriate dialysis prescription, managing complications of ESRD, and monitoring for residual kidney function. The elevated creatinine in dialysis patients reflects their underlying kidney failure rather than serving as a treatment target, and successful dialysis management is determined by overall clinical status rather than by normalizing creatinine levels.
Clinical Parameters
- Fluid status
- Electrolyte balance
- Symptom control are important in assessing dialysis adequacy, rather than relying solely on creatinine levels.
From the Research
Goal Creatinine for ESRD on Dialysis
- There is no specific goal creatinine value for patients with End-Stage Renal Disease (ESRD) on dialysis, as creatinine levels are influenced by various factors such as muscle mass, age, and sex 2.
- Creatinine values can be used as a surrogate for time in the course of renal failure when dialysis commences, but they are not a significant predictor of mortality in incident patients with ESRD 2.
- The decision to initiate dialysis should not be based solely on estimated Glomerular Filtration Rate (eGFR) or creatinine levels, but rather on the assessment of patients' symptoms and signs 3.
- For patients with ESRD, the focus should be on managing complications such as hyperkalemia, hypervolemia, metabolic acidosis, anemia, mineral and bone disorders, and protein-calorie malnutrition, rather than achieving a specific goal creatinine value 4, 5.
- The use of total effluent (PD, RRF, and HD) sampling method to yield Kt/Vef and creatinine clearance (CCref) can help accurately track dialysis dose, but this is not directly related to a goal creatinine value 6.