What substances are administered during Hemodialysis (HD)?

From the Guidelines

During hemodialysis, patients typically receive intravenous iron supplements, such as iron dextran or ferric sodium gluconate, to support red blood cell production and manage anemia, with doses ranging from 500 to 1,000 mg diluted in 250 mL of normal saline and infused over 1 hour, as necessary to maintain adequate iron stores 1.

Medications and Treatments

• Anticoagulants, such as heparin, are administered to prevent blood clotting in the dialysis circuit, with doses tailored to individual patient needs.
• Erythropoiesis-stimulating agents, like epoetin alfa, are given to treat anemia, with typical doses ranging from 50-300 units/kg three times weekly.
• Intravenous iron supplements, such as iron sucrose, are provided to support red blood cell production, with doses of 100-200 mg per session.
• Vitamin D analogs, like paricalcitol or calcitriol, help manage bone metabolism, with doses of 2-5 mcg or 0.5-3 mcg, respectively.
• Phosphate binders, such as sevelamer, control phosphate levels, with doses of 800-1600 mg taken with meals.
• Blood pressure medications may be adjusted during dialysis to ensure optimal blood pressure control.
• A dialysate solution containing electrolytes, including sodium, potassium, calcium, magnesium, chloride, and bicarbonate, is carefully balanced to correct electrolyte imbalances.
• Glucose may be added to the dialysate to prevent hypoglycemia, and the solution is warmed to body temperature to prevent hypothermia during the procedure.

Administration of Intravenous Iron

The administration of intravenous iron should depend on the form of iron preparation used and the amount, with consideration of potential adverse effects, such as myalgias and arthralgias, as well as the risk of "oversaturation" of transferrin, which can lead to hypotension 1.

From the FDA Drug Label

2.2 Adult Patients with Hemodialysis Dependent-Chronic Kidney Disease (HDD-CKD)

Administer Venofer 100 mg undiluted as a slow intravenous injection over 2 to 5 minutes, or as an infusion of 100 mg diluted in a maximum of 100 mL of 0.9% NaCl over a period of at least 15 minutes, per consecutive hemodialysis session Administer Venofer early during the dialysis session (generally within the first hour).

Iron sucrose (Venofer) is given during hemodialysis, specifically:

• 100 mg undiluted as a slow intravenous injection over 2 to 5 minutes
• or as an infusion of 100 mg diluted in a maximum of 100 mL of 0.9% NaCl over a period of at least 15 minutes, per consecutive hemodialysis session 2

Ferrlecit administration was identical to Study A Ferrlecit at a dose of 1.5 mg/kg or 3.0 mg/kg (up to a maximum dose of 125 mg of elemental iron) in 25 mL 0.9% sodium chloride was infused intravenously over 1 hour during each hemodialysis session for eight sequential dialysis sessions.

Ferric gluconate (Ferrlecit) is also given during hemodialysis, specifically:

• at a dose of 1.5 mg/kg or 3.0 mg/kg (up to a maximum dose of 125 mg of elemental iron) in 25 mL 0.9% sodium chloride
• infused intravenously over 1 hour during each hemodialysis session for eight sequential dialysis sessions 3

From the Research

Anticoagulants Given During Hemodialysis

• Heparin is the anticoagulant most widely used to prevent clotting while blood is in the dialysis circuit 4, 5, 6, 7.
• The goal is to give enough, but not too much anticoagulant during the dialysis procedure to prevent the thrombosis/hemorrhage dilemma 4.
• Unfractionated (UF) heparin remains the mainstay of anticoagulant therapy in both human and veterinary intermittent hemodialysis 7.
• Low-molecular-weight heparin (LMWH) may also be used as an additional anticoagulation to prevent clotting during hemodialysis 8.

Dosage Regimens for Heparin

• The preferred dosage regimen for heparin is an initial loading dose, followed by a constant infusion 6.
• Dosage regimens based on intermittent boluses of heparin are associated with periods of under- and over-anticoagulation and require more staff attention during dialysis 6.
• Patient responses to heparin differ markedly, and the doses required to achieve suitable anticoagulation must be determined on an individual basis 6.

Safety and Efficacy of Heparin

• Heparin use is associated with lower erythropoiesis stimulating agent (ESA) dose, higher hemoglobin levels, and lower monthly intravenous (IV) iron dose 5.
• Heparin use is also associated with lower rates of clotting during treatment and hospitalization for gastrointestinal (GI) bleeding 5.
• The safety and efficacy of heparin in the presence of systemic anticoagulants and antiplatelet agents is unclear, but heparin use is safe and effective in the presence and absence of these medications 5.