How to adjust the dialysis order to target 2.5L ultrafiltration during Hemodialysis (HD)?

Adjusting Hemodialysis Order to Target 2.5L Ultrafiltration

Modify the Net UF order from "2 L as tolerated" to "2.5 L as tolerated" to match your consultant's target. 1

Specific Chart Order

Write the following in the chart:

Dialysis Orders:

• Td 6 hours
• Standard bath + 10 g KCl
• Low flux dialyzer
• Qb 150 mL/min
• Qd 300 mL/min
• Net UF 2.5 L as tolerated (changed from 2 L)
• CBG Q2 hours
• No anticoagulation
• Saline flushing 100 mL every 30 minutes

Communication to Nursing Staff

Say to the nurse:

"The consultant wants to target 2.5 liters of ultrafiltration for this patient's first HD session. I've updated the order from 2 L to 2.5 L as tolerated. Please monitor closely for hypotension and intradialytic symptoms given this is their first treatment. If the patient develops symptomatic hypotension (MAP drop >15 mmHg or symptoms), reduce the UF rate but try to achieve as close to 2.5 L as safely possible. Document the actual UF achieved and any hemodynamic issues. Hold saline boluses unless absolutely necessary for symptomatic hypotension, as we're trying to remove fluid." 1

Critical Considerations for First HD Session

Ultrafiltration Rate Monitoring

• The UF rate for 2.5 L over 6 hours = 417 mL/hour, which is generally well-tolerated for most patients 1
• Monitor mean arterial pressure (MAP) every 30 minutes during this first session, as hypotension is a common risk with initiation 1
• The "as tolerated" qualifier is essential because KDOQI guidelines emphasize balancing euvolemia achievement against hemodynamic instability 1

Why This Approach Is Appropriate

• KDOQI guidelines recommend prescribing an ultrafiltration rate that allows optimal balance among achieving euvolemia, adequate blood pressure control, and solute clearance while minimizing hemodynamic instability 1
• For patients with large weight gains or difficulty achieving dry weight, longer treatment times or adjusted UF targets are appropriate 1
• The 6-hour treatment time provides adequate duration to achieve 2.5 L removal at a moderate rate, reducing risk of intradialytic hypotension 1

Common Pitfalls to Avoid

• Do not attempt aggressive UF (>2.5 L) on the first session without assessing hemodynamic tolerance, as this increases risk of hypotension and potential access complications 1
• Avoid excessive saline boluses (the current order allows 100 mL every 30 min = up to 1.2 L over 6 hours), as this defeats the purpose of fluid removal 1
• Do not ignore intradialytic symptoms - cramping, nausea, or dizziness indicate the UF rate may be too aggressive 1
• Ensure accurate pre- and post-dialysis weights to confirm actual UF achieved 2

Fluid Space Considerations

• Ultrafiltration removes fluid almost exclusively from the extracellular space (approximately 82% of removed volume), not intracellular fluid 3
• This extracellular fluid removal directly impacts blood pressure and hemodynamic stability, explaining why monitoring is critical 3

Documentation Requirements

• Record actual UF volume achieved, pre/post weights, and any hemodynamic complications for future prescription adjustments 2
• Document blood pressure readings every 30 minutes to establish this patient's tolerance pattern 1