What is the recommended treatment protocol for patients requiring hemodialysis (HD) due to impaired renal function?

Recommended Hemodialysis Treatment Protocol

For patients with end-stage kidney disease requiring hemodialysis, prescribe three sessions per week with a minimum duration of 3 hours per session, targeting a prescribed single-pool Kt/V of 1.3 (to ensure delivered Kt/V ≥1.2), using biocompatible high or low flux membranes. 1, 2

Standard Prescription Parameters

Frequency and Duration

• Three times per week is the standard frequency for all patients requiring hemodialysis unless residual kidney function (RKF) exceeds 2 mL/min urea clearance 1, 2
• Minimum 3 hours per session for patients with low residual kidney function (<2 mL/min) 1, 2
• Twice-weekly hemodialysis is inadequate and associated with higher mortality unless substantial RKF is present (≥5 mL/min GFR), and this requires serial monitoring every 3-4 months 1, 3

Dialysis Adequacy Targets

• Prescribe Kt/V of 1.3 to ensure the delivered dose does not fall below the minimum adequate level of 1.2 1, 2
• Target single-pool Kt/V of 1.4 per session for thrice-weekly treatments 2
• The prescribed dose must exceed the minimum because only 50% of patients receive their full prescribed dose due to access recirculation, inadequate blood flow, dialyzer clotting, or pump calibration errors 1

Membrane Selection

• Use biocompatible membranes, either high or low flux 2

Residual Kidney Function Integration

Assessment Protocol

• Measure RKF at baseline for all new HD patients using 24-hour urine collections to calculate urea clearance 3
• Reassess every 3-4 months in patients with RKF >2 mL/min 3
• Include residual kidney urea clearance (Kru) in the standardized Kt/V calculation only when measured clearance is ≥2 mL/min and measurement was done within 3 months, as this increases calculated stdKt/V by approximately 7% 1, 3

RKF-Based Modifications

• For patients with RKF >2 mL/min, twice-weekly dialysis may be permissible if function is stable and interdialytic weight gains are not excessive, but this requires close monitoring 3
• Critical pitfall: Adding Kru to dose calculations without recent measurement (within 3 months) risks underdialysis if function has declined 3

Indications for Treatment Intensification

Extend session duration or increase frequency beyond standard prescription when patients exhibit: 1, 2

• Large interdialytic weight gains
• High ultrafiltration rates causing hemodynamic instability
• Poorly controlled blood pressure despite adequate sodium/water removal
• Difficulty achieving dry weight
• Poor metabolic control (hyperphosphatemia, metabolic acidosis, hyperkalemia)

Intensification Options

• More frequent dialysis (5-7 days per week) provides superior outcomes compared to simply extending session duration, particularly for blood pressure control, left ventricular mass reduction, and phosphate management 4
• Short daily hemodialysis: 2-3 hours per session, 5-7 days per week 1, 4
• Long hemodialysis: 5.5+ hours per session, 3-4 days per week 1
• Long-frequent hemodialysis: 5.5+ hours per session, 5 days per week 1

Volume and Blood Pressure Management

Ultrafiltration Strategy

• Prescribe ultrafiltration rates that balance achieving euvolemia and adequate blood pressure control while minimizing hemodynamic instability 1, 2
• Avoid intradialytic hypotension, which damages residual kidney function through ischemic injury 3
• Use lower dialysate temperatures, slower blood flow initiation, and gentle fluid removal to minimize hemodynamic instability 3

Sodium Management

• Combine dietary sodium restriction with adequate sodium/water removal during hemodialysis to manage hypertension, hypervolemia, and left ventricular hypertrophy 1, 2

Vascular Access Recommendations for Intensive HD

For patients on intensive hemodialysis regimens: 1

• Use arteriovenous fistula (AVF) or arteriovenous graft (AVG) over tunneled central venous catheter (CVC)
• For AVF access, use rope-ladder cannulation over buttonhole cannulation unless topical mupirocin antimicrobial prophylaxis is used
• If buttonhole cannulation is used, apply mupirocin antibacterial cream to reduce infection risk
• For CVC access, use closed connector devices over usual care

Beyond Kt/V: Comprehensive Adequacy Assessment

Adequate dialysis must address more than just urea removal: 1, 2

• Potassium removal
• Correction of metabolic acidosis
• Adequate protein/caloric intake to prevent malnutrition
• Sufficient fluid removal to achieve euvolemia
• For pediatric patients: school/vocational performance, growth, and emotional development

Critical Pitfalls to Avoid

• Never ignore RKF >2 mL/min when calculating dialysis adequacy, as this leads to unnecessary dialysis time and compromises quality of life 3
• Never assume RKF is stable without serial measurements, as function typically declines over time and prescription adjustments must follow 3
• Never base dialysis dose solely on minimum acceptable Kt/V or URR, as patients may still be inadequately dialyzed in terms of other solute removal or volume management 1
• Never prescribe twice-weekly hemodialysis without documented RKF ≥5 mL/min GFR and a plan for serial monitoring 1