Standard Treatment Protocol for Hemodialysis
The standard hemodialysis protocol consists of thrice weekly sessions lasting a minimum of 3 hours per session, with a target single pool Kt/V of 1.4 and minimum delivered spKt/V of 1.2, using biocompatible dialysis membranes. 1
Core Components of Standard Hemodialysis Protocol
Frequency and Duration
- Conventional hemodialysis consists of three sessions per week, each lasting a minimum of 3 hours for patients with low residual kidney function (<2 mL/min) 1
- Longer treatment times (>3 hours) should be considered for patients with large interdialytic weight gains, high ultrafiltration rates, poorly controlled blood pressure, or poor metabolic control 1
- For pregnant women with end-stage kidney disease, long frequent hemodialysis is recommended either in-center or at home 1
Dialysis Adequacy Targets
- Target single pool Kt/V (spKt/V) of 1.4 per session for thrice weekly treatments, with a minimum delivered spKt/V of 1.2 1
- For schedules other than thrice weekly, target standard Kt/V of 2.3 volumes per week with a minimum delivered dose of 2.1 1
- In patients with significant residual kidney function, the dialysis dose may be reduced, provided residual function is measured periodically (at least every 3 months) 1
Dialysis Membranes and Modality
- Use biocompatible, either high or low flux hemodialysis membranes for intermittent hemodialysis 1
- Consider hemodiafiltration for hypotension-prone patients, as it combines diffusion with high convection 1
Volume and Blood Pressure Management
Ultrafiltration and Dry Weight
- Prescribe an ultrafiltration rate that balances achieving euvolemia and adequate blood pressure control while minimizing hemodynamic instability 1
- Combine dietary sodium restriction with adequate sodium/water removal during hemodialysis to manage hypertension and left ventricular hypertrophy 1
- Avoid excessive ultrafiltration rates that may lead to intradialytic hypotension and symptoms 1
Dietary Management
- Implement sodium restriction (85-100 mmol/day) to limit interdialytic weight gain 1
- Water restriction alone without sodium limitation is not recommended as it causes unnecessary thirst 1
- For patients with protein-energy wasting, nutritional assessment and intervention are essential 1
Medication Management During Hemodialysis
Anticoagulation
- Provide appropriate anticoagulation to prevent circuit clotting while minimizing bleeding risk 2
- Monitor for potential complications related to anticoagulation during the session 2
Electrolyte Management
- Monitor and manage potassium levels carefully, especially in patients with cardiac issues, as rapid shifts can trigger arrhythmias 3
- Consider phosphate binders for patients with hyperphosphatemia, with dosing adjusted based on serum phosphate levels 1, 4
Alternative Hemodialysis Schedules
More Frequent Dialysis Options
- Consider in-center short frequent hemodialysis (more than three times weekly but shorter duration) for selected patients after discussing potential benefits and risks 1
- Home long hemodialysis (6-8 hours, 3-6 nights per week) may be considered for patients who prefer this therapy for lifestyle considerations 1, 4
- Daily dialysis (six sessions per week) may provide better clinical outcomes including improved uremic toxin removal, but patient acceptance may be limited 5, 4
Less Frequent Options
- For patients with significant residual kidney function, incremental approaches such as twice-weekly hemodialysis may be considered with careful monitoring 6
Monitoring and Complications
Regular Assessments
- Monitor dialysis adequacy through regular measurement of Kt/V 1
- Assess volume status and adjust dry weight targets regularly 1
- Monitor for cardiovascular complications, which are a major cause of morbidity and mortality 1, 2
Common Complications
- Watch for intradialytic hypotension, which can be minimized by appropriate ultrafiltration rates and longer treatment times 1
- Monitor for vascular access complications, particularly in patients on more frequent dialysis schedules 1
- Be alert for accelerated decline in residual kidney function, especially with more frequent dialysis regimens 1
Special Considerations
Residual Kidney Function
- Preserve residual kidney function when possible, as it contributes to better outcomes 1, 6
- Measure residual kidney function at least every 3 months if it's being factored into the dialysis prescription 1