Hemodialysis Consultation Considerations for Patients Already on MWF Hemodialysis
For patients already established on a Monday-Wednesday-Friday hemodialysis schedule, consultation should focus on optimizing treatment parameters to improve mortality, morbidity, and quality of life outcomes rather than simply maintaining the current regimen.
Assessment of Current Dialysis Adequacy
Solute Clearance Parameters
- Verify current single-pool Kt/V (target should be 1.4 per session with minimum delivered spKt/V of 1.2) 1
- Assess standard Kt/V for non-thrice weekly schedules (target 2.3 volumes/week, minimum 2.1) 1
- Evaluate residual kidney function, which may allow for reduced dialysis dose if significant (measure every 3-4 months) 1, 2
Treatment Time and Frequency
- Confirm minimum treatment time of 3 hours per session for patients with low residual kidney function (<2 mL/min) 1
- Consider whether the patient would benefit from:
- Longer sessions (>3 hours) for better volume control and metabolic parameters
- More frequent sessions (short daily or nocturnal) based on clinical needs 1
Volume Status and Blood Pressure Management
Volume Assessment
- Evaluate interdialytic weight gain patterns
- Assess for signs of hypervolemia (edema, hypertension, pulmonary congestion)
- Review ultrafiltration rates (should balance achieving euvolemia while minimizing hemodynamic instability) 1
Blood Pressure Control
- Review pre- and post-dialysis blood pressure trends
- Evaluate sodium restriction compliance (recommend 85-100 mmol/day for persistent hypertension) 2
- Consider if current dialysis prescription adequately addresses volume-dependent hypertension 1
Metabolic Control
- Assess phosphorus control (may require longer/more frequent sessions if persistently elevated)
- Review acid-base status (metabolic acidosis may indicate need for prescription adjustment)
- Evaluate potassium levels (pre- and post-dialysis) 1
Dialysis Tolerance
- Evaluate for intradialytic hypotension episodes (occurs in ~8% of HD sessions) 3
- Assess recovery time after dialysis (41% of patients require 2-6 hours, 27% require >6 hours) 3
- Consider if more frequent but shorter sessions would improve tolerance 3
Vascular Access Evaluation
- Assess current access function (blood flow rates, recirculation)
- Evaluate for signs of access complications (infection, stenosis, "steal syndrome")
- Consider impact of dialysis prescription on access longevity 4
Alternative Dialysis Modalities to Consider
In-Center Short Frequent Hemodialysis
- May improve blood pressure control, anemia management, quality of life 1
- Inform patients about potential risks including increased vascular access procedures 1
Home Long Hemodialysis
- Consider for lifestyle benefits (6-8 hours, 3-6 nights per week) 1
- Discuss potential risks: access complications, caregiver burden, faster decline in residual function 1
Hemodiafiltration
- Recent evidence shows lower mortality risk compared to conventional high-flux hemodialysis 5
- Consider for patients with adequate vascular access to support higher blood flow rates
Special Considerations
Pregnancy
- Recommend long frequent hemodialysis either in-center or at home for pregnant patients 1
Elderly/High Comorbidity Patients
- Focus on dialysis tolerance rather than maximum efficiency 6
- Consider personalized approach based on comorbidity and nutritional status 6
Common Pitfalls to Avoid
- Focusing solely on Kt/V while neglecting other aspects of adequate dialysis (potassium removal, acid-base balance, fluid removal) 1
- Neglecting residual kidney function in prescription adjustments 1, 2
- Using a "one size fits all" approach rather than personalizing based on patient characteristics 6
- Inadequate attention to dialysis tolerance issues that significantly impact quality of life 3
Remember that while maintaining minimum adequacy standards is important, optimizing the dialysis prescription to address the patient's specific clinical needs, comorbidities, and quality of life concerns should be the primary focus of the consultation.