What is the optimal approach to manage hemodialysis?

Optimal Management of Hemodialysis

The optimal approach to hemodialysis management requires a target single pool Kt/V (spKt/V) of 1.4 per session for patients treated thrice weekly, with a minimum delivered spKt/V of 1.2, using biocompatible membranes and sessions lasting at least 3 hours for patients with low residual kidney function. 1

Hemodialysis Prescription Fundamentals

Frequency and Duration

• Standard prescription: Three sessions per week, minimum 3 hours per session 1
• For patients with low residual kidney function (<2 mL/min): Minimum 3 hours per session 1
• Consider additional sessions or longer treatment times for patients with:
  • Large interdialytic weight gains
  • High ultrafiltration rates
  • Poorly controlled blood pressure
  • Difficulty achieving dry weight
  • Poor metabolic control (hyperphosphatemia, acidosis, hyperkalemia) 1

Dialysis Adequacy Targets

• Target spKt/V: 1.4 per session for thrice weekly treatment 1
• Minimum delivered spKt/V: 1.2 1
• For schedules other than thrice weekly: Target standard Kt/V of 2.3 volumes per week with minimum delivered dose of 2.1 1
• For patients with significant residual kidney function: Dose may be reduced if residual function is measured periodically 1

Membrane Selection and Ultrafiltration

Membrane Type

• Use biocompatible, either high or low flux hemodialysis membranes 1

Ultrafiltration Management

• Prescribe ultrafiltration rate that balances:
  • Achieving euvolemia
  • Adequate blood pressure control
  • Solute clearance
  • Minimizing hemodynamic instability and intradialytic symptoms 1
• Combine dietary sodium restriction with adequate sodium/water removal to manage hypertension, hypervolemia, and left ventricular hypertrophy 1

Volume and Blood Pressure Control

Strategies for Volume Control

1. Reduce dietary sodium intake 1
2. Ensure adequate sodium/water removal during dialysis 1
3. Balance ultrafiltration rate to minimize hemodynamic instability while achieving target dry weight 1

Managing Intradialytic Hypotension

• Intradialytic hypotension occurs in almost 8% of HD sessions and can lead to myocardial stunning and cardiac arrhythmias 2
• Consider cooling the dialysate and raising dialysate sodium concentration to mitigate hemodynamic instability 3
• Intensive or more frequent hemodialysis may reduce the likelihood of intradialytic hypotension 2

Special Populations

Pregnant Patients

• Women with end-stage kidney disease should receive long frequent hemodialysis either in-center or at home during pregnancy 1

Home Hemodialysis Considerations

• Consider home long hemodialysis (6-8 hours, 3-6 nights per week) for patients who prefer this therapy for lifestyle considerations 1
• Inform patients about potential risks of home long frequent hemodialysis:
  • Increased vascular access complications
  • Potential for increased caregiver burden
  • Accelerated decline in residual kidney function 1

Medication Management During Hemodialysis

Erythropoietin Management

• Monitor for hypertension when initiating erythropoietin therapy 4
• Patients may require increased anticoagulation with heparin to prevent clotting of the extracorporeal circuit 4
• Monitor transferrin saturation and serum ferritin; administer supplemental iron when ferritin is <100 mcg/L or transferrin saturation is <20% 4

Monitoring and Adjustments

Residual Kidney Function

• Measure residual kidney function using timed urine collection 1
• Adjust dialysis dose based on residual kidney function measurements 1

Dialysis Recovery Time

• Long recovery time after treatment (>2 hours) is common and associated with increased risks for death and hospitalization 2
• More frequent or longer dialysis sessions may reduce recovery time 2

Personalized Approach Based on Patient Characteristics

For Younger Patients with Lower Comorbidity

• Focus on efficiency and kinetic adequacy 5
• Target higher clearance goals 5

For Older Patients with Higher Comorbidity

• Focus on tolerance and stability during treatment 5
• Consider more frequent but shorter sessions to improve hemodynamic stability 5
• Balance between adequate clearance and minimizing treatment-related complications 5

Common Pitfalls to Avoid

1. Focusing solely on Kt/V: Patients may still be inadequately dialyzed in terms of potassium removal, correction of acidosis, or fluid removal despite achieving target Kt/V 6

2. Neglecting residual kidney function: Failure to measure and account for residual function can lead to inappropriate dialysis prescriptions 1

3. Aggressive ultrafiltration: High ultrafiltration rates can lead to intradialytic hypotension, myocardial stunning, and increased mortality risk 2, 7

4. Inadequate monitoring of vascular access: Regular assessment of access function is essential to ensure adequate blood flow and prevent complications 1

5. Ignoring patient recovery time: Post-dialysis fatigue significantly impacts quality of life and is associated with worse outcomes 2

By following these evidence-based guidelines for hemodialysis management, clinicians can optimize treatment outcomes while minimizing complications and improving patient quality of life.