Sample Hemodialysis Prescription for CKD Stage 5
A standard hemodialysis prescription for a CKD stage 5 patient should include thrice-weekly sessions of 3.5-4 hours duration, targeting a minimum delivered spKt/V of 1.2 per session, using a high-flux dialyzer with appropriate blood and dialysate flow rates. 1
Core Prescription Parameters
Frequency and Duration
- Schedule: 3 sessions per week (Monday-Wednesday-Friday or Tuesday-Thursday-Saturday) 1
- Duration: 3.5 to 4.5 hours per session 1
- Total weekly time: Minimum 12 hours 1
Dialysis Adequacy Targets
- Minimum delivered spKt/V: 1.2 per session 1
- Target delivered spKt/V: 1.4-1.5 to provide safety margin 1
- Monitor weekly until stable, then monthly 2
Dialyzer Specifications
- Membrane type: High-flux dialyzer 1
- Surface area: Based on patient body surface area (typically 1.5-2.1 m² for adults) 1
- Biocompatible membrane to minimize inflammatory response 1
Blood and Dialysate Parameters
Flow Rates
- Blood flow rate (Qb): 300-450 mL/min (adjust based on vascular access capability) 1
- Dialysate flow rate (Qd): 500-800 mL/min 1
- Higher flow rates improve small-solute clearance 1
Dialysate Composition
- Sodium: 138-140 mEq/L 1
- Potassium: 2-3 mEq/L (adjust based on serum levels and dietary intake) 1
- Calcium: 2.5-3.0 mEq/L 1
- Bicarbonate: 35-38 mEq/L 1
- Temperature: 36-36.5°C 1
Ultrafiltration Management
Volume Removal
- Target dry weight: Establish clinically based on blood pressure, edema assessment, and volume status 1
- Ultrafiltration rate: Keep below 13 mL/kg/hour to minimize cardiovascular stress 1
- Interdialytic weight gain: Ideally less than 5% of dry weight between sessions 1
Anticoagulation
Standard Heparin Protocol
- Loading dose: 1000-2000 units IV bolus at start 1
- Maintenance: 500-1500 units/hour continuous infusion 1
- Discontinue: 30-60 minutes before end of session 1
- Adjust based on bleeding risk and clotting tendency 1
Monitoring Requirements
During Each Session
- Blood pressure and heart rate every 30-60 minutes 1
- Monitor for symptoms of hypotension, cramping, or chest pain 1
Monthly Laboratory Monitoring
- Adequacy: spKt/V or URR (urea reduction ratio ≥65%) 1
- Hemoglobin: Target 10-11 g/dL (avoid exceeding 11 g/dL) 2
- Serum phosphorus: Target 3.5-5.5 mg/dL 1
- Serum calcium: Target 8.4-9.5 mg/dL 1
- Intact PTH: Target range based on CKD-MBD guidelines 1
- Serum potassium, bicarbonate, albumin 1
Iron Status Assessment
- Serum ferritin: Maintain >100 mcg/L 2
- Transferrin saturation: Maintain >20% 2
- Supplemental iron therapy required for most patients 2
Vascular Access
- Preferred: Arteriovenous fistula (first choice) 1
- Alternative: Arteriovenous graft or tunneled dialysis catheter 1
- Needle size: 15-16 gauge for fistula/graft 1
Special Considerations
When Standard Prescription is Inadequate
If patient fails to achieve target Kt/V, has persistent hyperphosphatemia, uncontrolled hypertension, or volume overload despite standard prescription 1:
- Increase session duration to 4.5-5 hours 1
- Consider more frequent dialysis (4-6 sessions per week) 1
- Increase blood flow rate if vascular access permits 1
- Use larger surface area dialyzer 1
Residual Kidney Function
- Preserve any remaining kidney function 1
- May allow for less aggressive initial prescription if significant residual function present 1
- Reassess adequacy as residual function declines 1
Critical Pitfalls to Avoid
- Do not target hemoglobin >11 g/dL with ESA therapy due to increased cardiovascular mortality risk 2
- Avoid excessive ultrafiltration rates (>13 mL/kg/hour) which increase cardiovascular stress and mortality 1
- Do not increase dialysis dose more frequently than every 4 weeks to avoid unnecessary adjustments 2
- Monitor for dialysis-associated hypotension, hypokalemia, and hypophosphatemia which may cause cardiac events 1