Standard Hemodialysis Prescription for Patients with End-Stage Kidney Disease
For a typical patient with minimal residual kidney function requiring maintenance hemodialysis, prescribe three sessions per week, with each session lasting a minimum of 3 hours, targeting a single-pool Kt/V of 1.4 per session (minimum delivered 1.2), using biocompatible high or low flux membranes. 1
Frequency and Duration
Three times per week is the standard frequency for all patients requiring hemodialysis unless significant residual kidney function (GFR ≥5 mL/min) is present. 1
Minimum session duration is 3 hours for patients with low residual kidney function (<2 mL/min). 1
Twice-weekly hemodialysis is inadequate unless residual kidney function is substantial (GFR ≥5 mL/min), and this residual function must be monitored serially to guide appropriate timing for transition to thrice-weekly sessions. 1
Dialysis Adequacy Targets
The prescribed Kt/V should be 1.3 to ensure the delivered dose does not fall below the minimum adequate level, as not all patients receive their prescribed dose due to technical factors. 1
Target single-pool Kt/V (spKt/V) of 1.4 per session for thrice-weekly treatments. 1
Minimum delivered spKt/V of 1.2 must be achieved. 1
In terms of urea reduction ratio (URR), a Kt/V of 1.3 corresponds to approximately 70% URR, though this varies with ultrafiltration volume. 1
Common Pitfalls in Achieving Prescribed Dose
The delivered dose frequently falls short of prescription due to: 1
- Access recirculation reducing effective clearance
- Inadequate blood flow from vascular access
- Dialyzer clotting during treatment
- Blood pump/dialysate flow calibration errors
- Treatment time reductions from interruptions or inaccurate time measurement
- Dialyzer performance being less than manufacturer specifications
Membrane Selection
- Use biocompatible membranes (either high or low flux) for intermittent hemodialysis. 1
Treatment Time Modifications
Consider extending session duration or increasing frequency beyond the standard prescription for patients with: 1
- Large interdialytic weight gains
- High ultrafiltration rates
- Poorly controlled blood pressure
- Difficulty achieving dry weight
- Poor metabolic control (hyperphosphatemia, metabolic acidosis, hyperkalemia)
Volume and Blood Pressure Management
Prescribe ultrafiltration rates that balance achieving euvolemia and adequate blood pressure control while 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
Residual Kidney Function Considerations
In patients with significant residual kidney function (Kru), dialysis dose may be reduced provided Kru is measured periodically (within 3 months) to avoid inadequate dialysis. 1
For non-thrice-weekly schedules, target a standard Kt/V of 2.3 volumes per week with minimum delivered dose of 2.1, including contributions from ultrafiltration and residual kidney function. 1
Alternative Regimens
While standard thrice-weekly hemodialysis remains the foundation, the KDOQI guidelines acknowledge alternative approaches: 1
- Short frequent hemodialysis (more than 3 times per week) may be offered after discussing potential quality of life benefits and risks including increased vascular access procedures and potential hypotension
- Home long hemodialysis (6-8 hours, 3-6 nights per week) for patients preferring this for lifestyle considerations, with counseling about increased vascular access complications and caregiver burden
Critical Monitoring Points
Beyond Kt/V alone, adequate dialysis must address: 1
- Potassium removal
- Correction of acidosis
- Adequate protein/caloric intake to prevent malnutrition
- Sufficient fluid removal to achieve euvolemia
The duration of dialysis should involve shared decision-making with the patient, though a minimum adequate dose must be maintained to prevent deleterious outcomes. 1