What is the recommended assessment and management approach for a patient undergoing hemodialysis?

Assessment of Hemodialysis Patients

Hemodialysis patients require systematic assessment before, during, and after each treatment session, with monthly evaluation of dialysis adequacy through Kt/V or URR measurements to ensure adequate solute clearance and prevent complications.

Pre-Dialysis Assessment

Vital Signs and Clinical Status

• Measure blood pressure, but recognize that pre-dialysis readings alone are imprecise estimates of interdialytic blood pressure and should not be relied upon exclusively 1
• Assess for signs of volume overload (edema, dyspnea, jugular venous distension) or dehydration (hypotension, poor skin turgor) 1
• Document patient's weight and compare to target dry weight 1

Vascular Access Evaluation

• Inspect access site for patency and signs of infection or complications 1
• Review arteriovenous needle placement, proximity, and orientation with patient care staff 1
• Assess fistula integrity to determine if there may be recirculation using hydraulic compression test 2
• Verify graft flow configuration 2

Laboratory Sampling

• Obtain predialysis BUN sample immediately prior to dialysis using a technique that avoids dilution with saline or heparin 1
• This sample is critical for calculating dialysis adequacy (Kt/V or URR) 1

Intra-Dialysis Monitoring

Hemodynamic Surveillance

• Monitor blood pressure throughout the session to detect intradialytic hypotension, which is more common in patients with low residual kidney function 1, 3
• Document extracorporeal pressures and compare to previous sessions with prescribed blood flow rate (Qb) 1
• Check if prepump arterial pressures exceed 200 mmHg or approach upper limits per dialysis unit policy 1

Treatment Parameters Verification

• Review hemodialysis log to compare prescribed versus actual parameters including recorded blood flow rate (Qb), dialysate flow rate (Qd), and type of hemodialyzer 2
• Track effective hemodialysis treatment time (Td) to ensure delivery of prescribed treatment duration 1
• Review hemodialyzer reuse log to evaluate total cell volume (TCV) if applicable 2
• Review maintenance log for machine to check last calibration date and results 2

Clinical Events Documentation

• Document any clinical events such as hypotension, muscle cramps, or chest pain that may result in changes to treatment parameters 2

Post-Dialysis Assessment

Immediate Clinical Evaluation

• Assess patient for symptoms of dialysis disequilibrium syndrome 1
• Evaluate for signs of excessive ultrafiltration 1
• Document patient's post-dialysis weight and compare to target dry weight 1

Laboratory Sampling

• Obtain postdialysis BUN sample using the slow flow/stop pump technique to prevent sample dilution with recirculated blood 1
• This sample is essential for accurate Kt/V or URR calculation 1

Dialysis Adequacy Evaluation

Monthly Monitoring Requirements

• Calculate Kt/V or URR using properly collected pre and post-dialysis BUN samples 1
• Measure delivered dose of dialysis at least monthly to ensure adequate treatment 1
• Target minimum delivered single pool Kt/V (spKt/V) of 1.2 per hemodialysis session for thrice weekly treatment 3

Troubleshooting Inadequate Dialysis

When Kt/V or URR falls below target, investigate systematically 2, 1:

Clearance (K) Issues:

• Dialyzer permeability problems or reduced effective surface area 2
• Inadequate blood flow or dialysate flow rates 2
• Access recirculation 2

Treatment Time (Td) Issues:

• Patient arrived late for hemodialysis treatment 2
• Facility/staff late starting dialysis 2
• Treatment interrupted or shortened 2

Sampling or Processing Errors:

• Improper BUN sample collection technique 1
• Laboratory processing errors 2

Response to Inadequate Delivery

• Significant underdelivery of the hemodialysis prescription by 20% should initiate immediate attempts to determine the cause 2
• More frequent measurements of Kt/V or URR will assist in identifying problems and necessary corrective actions 2
• Increasing the prescribed hemodialysis dose until appropriate minimum targets are reached will improve patient outcomes 2

Special Considerations for Intensive Hemodialysis

Vascular Access Management

• For patients receiving intensive home hemodialysis with an AVF, use rope-ladder cannulation over buttonhole cannulation unless topical antimicrobial prophylaxis is used 2
• If using buttonhole cannulation, apply mupirocin antibacterial cream to reduce infection risk 2
• Prefer arteriovenous access (AVF or AVG) over tunneled central venous catheter 2
• For patients using CVC, employ "closed connector" devices over usual care 2

Electrolyte Management

• For patients treated with long or long-frequent hemodialysis, use dialysate calcium of 1.50 mmol/L or higher to maintain neutral or positive calcium balance while avoiding predialysis hypercalcemia and oversuppression of PTH 2
• Use phosphate dialysate additive to maintain predialysis phosphate in normal range if hypophosphatemia persists after stopping phosphate binders and liberalizing diet 2

Common Pitfalls to Avoid

• Do not assume achieving dialysis adequacy (Kt/V targets) means comprehensive patient care is complete 3
• Do not rely solely on pre-dialysis blood pressure readings as they are imprecise 1
• Avoid errors that contribute to apparent overdelivery of hemodialysis, as this may lead to dangerous reductions in prescribed dose 2
• Promptly investigate and correct problems resulting in inadequate hemodialysis, as delays mean multiple inadequate treatments will occur 2