What is the recommended treatment plan for individuals undergoing hemodialysis?

Hemodialysis Treatment Plan

Standard Prescription Parameters

For patients undergoing hemodialysis, prescribe three sessions per week with a minimum duration of 3 hours per session, targeting a single-pool Kt/V of 1.4 (minimum delivered 1.2), using biocompatible high or low flux membranes. 1, 2

Core Treatment Components

Frequency and Duration:

• Three times weekly is the standard frequency for all patients requiring hemodialysis 1, 2
• Each session must last a bare minimum of 3 hours for patients with residual kidney function <2 mL/min 1
• Prescribe a target Kt/V of 1.4 to ensure the delivered dose does not fall below the minimum adequate level of 1.2 1, 2

Membrane Selection:

• Use biocompatible membranes, either high or low flux, for all intermittent hemodialysis 1, 2

Volume and Blood Pressure Management

Combine dietary sodium restriction (85-100 mmol/day) with adequate ultrafiltration to control hypertension, hypervolemia, and left ventricular hypertrophy. 1

Fluid Management Strategy

Sodium and Water Control:

• Restrict dietary sodium intake to 85-100 mmol/day 1
• Do not advise water restriction without simultaneous sodium limitation, as excessive sodium stimulates thirst and leads to isotonic fluid gain 1
• Prescribe ultrafiltration rates that balance achieving euvolemia and adequate blood pressure control while minimizing hemodynamic instability 1

Clinical Evidence:

• The Tassin experience demonstrated that combining sodium restriction with 8-hour dialysis sessions three times weekly reduced hypertension from 89% to only 5% requiring antihypertensive medications after 3 months 1
• This approach achieved average interdialytic weight gains of only 1.7 kg (less than 3% of body weight) 1

When to Intensify Treatment Beyond Standard Prescription

Consider extending session duration or increasing frequency for patients with large interdialytic weight gains, high ultrafiltration rates, poorly controlled blood pressure, difficulty achieving dry weight, or poor metabolic control (hyperphosphatemia, metabolic acidosis, hyperkalemia). 1, 2

Alternative Intensive Regimens

For patients failing conventional therapy despite maximal ultrafiltration:

• Short daily hemodialysis: 2-3 hours per treatment, 6-7 treatments per week 1
• Long nocturnal thrice-weekly: 8 hours per session, 3 times per week 1
• Long nocturnal frequent: 8 hours per session, 6-7 nights per week 1

Benefits of intensive regimens:

• Increased frequency provides superior outcomes compared to simply extending session duration, particularly for blood pressure control, left ventricular mass reduction, and phosphate management 3
• More frequent dialysis reduces intradialytic hypotension risk by 20% (short daily) to 68% (nocturnal) compared to conventional schedules 4
• Recovery time after dialysis improves dramatically, from 8 hours to 1 hour with short daily HD, and to minutes with nocturnal HD 4

Residual Kidney Function Considerations

In patients with significant residual kidney function (Kru), reduce the dialysis dose provided Kru is measured periodically (within 3 months) to avoid inadequate dialysis. 1, 2

• 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, 2
• Twice-weekly hemodialysis is inadequate unless residual kidney function is substantial, and this must be monitored serially to guide appropriate timing for transition to thrice-weekly sessions 2

Critical Monitoring Beyond Kt/V

Adequate dialysis must address multiple parameters beyond urea clearance alone:

• Potassium removal 2
• Correction of metabolic acidosis 2
• Adequate protein/caloric intake to prevent malnutrition 2
• Sufficient fluid removal to achieve euvolemia 2

Common Pitfalls to Avoid

Do not rely solely on Kt/V as a measure of dialysis adequacy - this only measures small molecule clearance and does not account for ultrafiltration adequacy, larger molecule removal, or hemodynamic tolerance 5

Do not prescribe water restriction without sodium restriction - this causes unnecessary suffering from thirst without addressing the underlying problem of sodium-driven fluid retention 1

Do not use loop diuretics without caution - ototoxicity risk is greater with furosemide and torsemide compared to bumetanide 1