This document discusses optimizing dialysis outcomes through various aspects of dialysis prescription and management. It covers: 1. Providing adequate dialysis dose as measured by Kt/V targets of 1.2-1.4 to reduce mortality risk and ensure solute clearance. 2. Controlling fluid status and electrolytes through achieving dry weight targets, avoiding excessive fluid gains and sodium intake between sessions. 3. Managing anemia through iron supplementation and erythropoiesis-stimulating agents to maintain hemoglobin in target ranges. 4. Addressing other factors like nutrition, blood pressure control, and bone mineral disease management to further optimize patient outcomes on dialysis.

1. OPTIMIZING HD
OUTCOME
Magdy ElSharkawy
Prof. of Int. Med & Nephrology
Ain-Shams University

2. ESNT Outreach Program, Sohag, December 4-7, 2014

3. ESNT Outreach Program, Sohag, December 4-7, 2014

4. Are we giving our patient
enough dialysis?

5. Global dialysis population
2012

6. Mortality
Hospitalizations
Costs

7. Mortality USRDS 2013

8. USRDS 2009 ADR
Adjusted all-cause mortality in the first
year of hemodialysis, by month & age
Figure 1.2 (Volume 2)
Incident hemodialysis patients age 20 and older; followed from the day of onset of ESRD; adjusted for gender, race, &
primary diagnosis. Incident hemodialysis patients, 2005, used as reference.
The Boston meeting concluded that – now – we can do better than this.

9. Dialysis Mortality:
General Population vs ESRD Dialysis Patients
RN Foley, PS Parfrey, and MJ Sarnak; Clinical epidemiology of cardiovascular disease in
chronic renal disease AJKD, 1998 32(5):S112-S119
0.001
0.01
0.1
1
10
100
25-34 35-44 45-54 55-64 66-74 75-84 >85
GP Male
GP Female
GP Black
GP White
Dialysis Male
Dialysis Female
Dialysis Black
Dialysis White
Age (years)
AnnualCVDMortality(%)

10. Hospitalizations

11. USRDS 2009 ADR
Adjusted admissions
& days, by modality
Figure 6.3 (Volume 2)
Period prevalent ESRD patients; rates adjusted for age, gender, race, & primary diagnosis. ESRD patients, 2005, used
as reference cohort.

12. Costs
$34B if other payers included

13. Are we giving our patient
adequate dialysis?

15. •Lab results are not within the
recommended levels; eg, KDIGO,
EBPG…etc

16. Optimizing Dialysis
Outcome/Prescription
Anemia
management
Good
nutrition
BP control
Adequate
solute
removal
Fluid and
electrolytes
hemostasis
BMD
management
Dialysis
adequacy

17. Optimizing Dialysis
Outcome/Prescription
Anemia
management
Good
nutrition
BP control
Adequate
solute
removal
Fluid and
electrolytes
hemostasis
BMD
management
Dialysis
adequacy
Dialysis
dose
Kt/v

18. DIALYSIS
DOSE
Kt/V;
Measurement
Guidelines

19. First Randomised Controlled Trial In Dialysis
NCDS 1980
Predialysis urea 38 vs 26 mmol. Dialysis 2.5-3.5h vs 4.5-5 h
high kt/v and long
dialysis
high kt/v and short
dialysis
low kt/v and long
dialysis
low kt/v and short
dialysis

20. Dialysis Adequacy
Dialysis Dose:
KT/V,
URR

21. Increasing dialysis dose
improved survival
Kidney Int 1996; 50:550

23. ESNT Outreach Program, Sohag, December 4-7, 2014
Eknoyan et al. NEJM. 2002; 347(25):2010-2019
Conclusion Of HEMO
Dialysis prescription of KT/V values less
than 1.2 may carry a high mortality and
morbidity.
Increasing the dose of dialysis of a KT/V
more than 1.4 does not carry any significant
benefit.
Recommended dose is a KT/V
which lies between 1.3 and 1.4
(single pool)
Eknoyan et al,. N Engl J Med 2002

24. Kt/V has been criticized
(1) Kt/V scaling of dialysis dose to total body water may
not be the optimal method of adjusting for body size;
(2) Kt/V urea reflects poorly the removal of lower-weight-
range middle molecules, for example, those in the 300–
3000KDa molecular range;
(3) Kt/V urea gives no or very little information about
removal of upper-weight-range middle molecules such as
β2-microglobulin (β2-M) and of protein-bound uremic
toxins;
(4) Kt/V urea does not reflect control of serum
phosphorus;
(5) Kt/V is a poor measure of control of extracellular fluid
overload, and it certainly does not reflect the rate of fluid
removal.
John T Daugirdas, KI 2015

25. Hypothesized diminishing of effect of dialysis dose.
Friedrich K. Port et al. CJASN 2006;1:246-255
©2006 by American Society of Nephrology

26. ESNT Outreach Program, Sohag, December 4-7, 2014

27. GUIDELINE 3
MEASUREMENT OF DIALYSIS: UREA KINETICS
3.1 We recommend a target single pool Kt/V (spKt/V) of 1.4 per
hemodialysis session for patient treated thrice weekly, with a minimum
delivered spKt/V of 1.2. (1 B)
3.2 In patients with significant residual native kidney function (Kr), the dose
of hemodialysis may be reduced provided Kr is measured periodically.
(ungraded)
3.3 For hemodialysis schedules other than thrice weekly, a target standard
Kt/V of 2.3 volumes per week with a minimum delivered dose of 2.1 using a
method of calculation that includes the contributions of ultrafiltration and
residual kidney
function. (ungraded)
Update of the KDOQI™ Clinical Practice
Guideline for Hemodialysis Adequacy
PUBLIC REVIEW DRAFT 2015

28. Optimizing Dialysis
Outcome/Prescription
Anemia
management
Good
nutrition
BP control
Adequate
solute
removal
Fluid and
electrolytes
hemostasis
BMD
management
Dialysis
adequacy

29. Optimizing Dialysis
Outcome/Prescription
Anemia
management
Good
nutrition
BP control
Adequate
solute
removal
Fluid and
electrolytes
hemostasis
BMD
management
Dialysis
adequacy
Fluid and
electrolytes
hemostasis

30. Carrero et al., NDT-E to date 2011

32. Unadjusted and adjusted associations between ultrafiltration rate (UFR) and all-
cause mortality based on Cox regression models
Flythe et al., Kidney Int. 2011

33. Correlation between the difference between dialysate and plasma sodium (sodium
gradient) and the interdialytic weight gain adjusted to the estimated dry weight
(IDWG/DW) in the standard dialysate Na+ (138 mEq/L) phase of the study.
Paula et al., KI. 2004

34. Salt Intake with consequent water
intake

36. Addressing fluid intake and volume control requires a “Volume
First” approach.
The following overarching consensus opinions emerged.
(1)Extracellular fluid status should be a component of
sufficient dialysis, such that normalization of extracellular fluid
volume should be a primary goal of dialysis care.
(2)Fluid removal should be gradual and dialysis treatment
duration should not routinely be less than 4 hours without
justification based on individual patient factors.
(3)Intradialytic sodium loading should be avoided by
dialysate sodium concentrations in the range of 134-138
mEq/L, avoidance of routine use of sodium modeling, and
avoidance of hypertonic saline solution.
(4)Dietary counseling should emphasize sodium avoidance.

37. UF Based dialysis time
Minimum hemodialysis time may best be
considered in respect to ultrafiltration rate, and
a maximum target ultrafiltration rate unscaled
to body size may be optimal.
John T Daugirdas, KI September 2015

38. Optimizing Dialysis outcome
Anemia
management
Good
nutrition
BP control
Adequate
solute
removal
Fluid and
electrolytes
hemostasis
BMD
management
Dialysis
adequacy
Anemia
management

40. Kalantar-Zadeh K et al, Ad Chronic Kidney Dis. 2009;16: 143-151
Hazard Ratio For All-cause Mortality Based on Time-
dependent Hb Levels Over 8 Calendar Quarters

42. USRDS

43. KDIGO 2012
Iron to treat anemia in CKD:
When prescribing iron therapy, balance the potential benefits
against the risks of harm in individual patients (Not Graded).
For adult CKD patients with anemia not on iron or ESA therapy
we suggest a trial of IV iron (or in CKD patients alternatively a
1–3 month trial of oral iron) (2C) if:
An increase in Hb without starting ESA treatment is desired and
TSAT is ≤30% and ferritin is ≤500 ng/ml.
For adult CKD patients on ESA therapy who are not receiving
iron, we suggest a trial of IV iron (or in CKD ND patients
alternatively a 1–3 month trial of oral iron (2C) if:
An increase in Hb or a decrease in ESA dose is desired and
TSAT is ≤30% and ferritin is ≤500 μg/ml.
(KDIGO, Kidney Int, 2012)

44. Optimizing Dialysis
Outcome/Prescription
Anemia
management
Good
nutrition
BP control
Adequate
solute
removal
Fluid and
electrolytes
hemostasis
BMD
management
Dialysis
adequacy

45. Optimizing Dialysis outcome
Anemia
management
Good
nutrition
BP control
Adequate
solute
removal
Fluid and
electrolytes
hemostasis
BMD
management
Dialysis
adequacy
Good
nutrition

46. DWYER ET AL., Kidney International (2005(

47. Figure 3. Kaplan Meier survival curves.
Qureshi A R et al. JASN 2002;13:S28-S36
©2002 by American Society of Nephrology
serum albumin Insulin like growth factor C-reactive protein

49. Kamyar Kalantar-Zadeh et al., Kidney International (2003(

50. DWYER ET AL., Kidney International (2005(

51. DWYER ET AL., Kidney International (2005(

52. DWYER ET AL., Kidney International (2005(

53. DWYER ET AL., Kidney International (2005(

54. Clinical Nutrition (2006) 25, 295–310
Water-soluble vitamin replacement:
folic acid (1 mg/day), pyridoxin
(10–20 mg/day) and vitamin C
(30–60 mg /day)

55. Optimizing Dialysis outcome
Anemia
management
Good
nutrition
BP control
Adequate
solute
removal
Fluid and
electrolytes
hemostasis
BMD
management
Dialysis
adequacy

56. Optimizing Dialysis outcome
Anemia
management
Good
nutrition
BP control
Adequate
solute
removal
Fluid and
electrolytes
hemostasis
BMD
management
Dialysis
adequacy
CKD-
BMD

57. Gheun-Ho Kim, Electrolyte Blood Press, 2014

59. Optimizing Dialysis outcome
Anemia
management
Good
nutrition
BP control
Adequate
solute
removal
Fluid and
electrolytes
hemostasis
BMD
management
Dialysis
adequacy

60. Optimizing Dialysis outcome
Anemia
management
Good
nutrition
BP control
Adequate
solute
removal
Fluid and
electrolytes
hemostasis
BMD
management
Dialysis
adequacy
BP
control

61. Prevalence of hypertension in chronic HD pts
(N=65393, mean age 61 yr, mean duration on HD 8 yr(
Iseki et al. Ther Apher Dial 2007;11:183-188

62. Relationship between blood pressure and mortality in
dialysis patients.
Luther JM Kidn Int 2008;73:667-668

63. Lancet Published Online February 26, 2009
Risk of cardiovascular mortality for blood pressure
lowering treatment vs control regimens

64. The effect of dry weight reduction on interdialytic
ambulatory systolic and diastolic BP in hypertensive
hemodialysis pts.
Agarwal et al. Hypertension 2009; 53: 500-507

65. K/DOQI 2005 guidelines on cardiovascular disease in
dialysis patients
Predialysis and postdialysis blood pressure goals should be
<140/90mmHg and <130/80mmHg respectively (C(
K/DOQI 2006 update of hemodialysis adequacy guidelines
Focus on volume control, dietary sodium restriction and avoidance of
high dialysate sodium
DO NOT recommend specific blood pressure targets in hemodialysis
patients
K/DOQI 2007 clinical practice guidelines for diabetes and
CKD
Target blood pressure in diabetes and CKD stages 1-4 should be
<130/80mmHg (B(
Targets for patients on dialysis are not recommended.
Definition of Hypertension

66. Optimizing Dialysis
Prescription
Anemia
management
Good
nutrition
BP control
Adequate
solute
removal
Fluid and
electrolytes
hemostasis
BMD
management
Dialysis
adequacy

67. Hemodialysis prescription

68. ESNT Outreach Program, Sohag, December 4-7, 2014
Guides to dialysis
prescription
 Patient weight
 dry weight
 IDWG
 Co-morbidities.
 Recent lab work.
 Medications.
 Current clinical condition.
 Dietary status
 Mode

69. Basic goals of adequate dialysis:
Fluid removal to expected 'dry weight' at end of dialysis.
Predialysis BP < 140/90 mmHg with or without antihypertensive drugs.
Predialysis plasma concentrations:
-Potassium: ≤5.5 mmol/l without using ion exchange resins.
-Bicarbonate: ≥24 mmol/l .
-Inorganic phosphate: ≤5.5 mg/dl without oral binding agents.
-Urea: <35 mmol/l with daily protein-intake1.2 g/kg/BW .
-Albumin: ≥40 g/l & Cholesterol= 200-300 mg%
-Haemoglobin: 11–12 g/100ml with or without ESA.
Rodriegaz handbook of dialysis 2012

70. TECHNICAL REQUIREMENTS FOR
DELIVERY OF ADEQUATE
DIALYSIS:
Vascular access: blood flow ≥ 300 ml/min .
Dialysis fluid: bicarbonate buffered, sterile, pyrogen-free.
Volumetric machine.
Dialyzer: -Highly permeable, biocompatible membrane.
- Surface area: ≥1.3 m2
.
Dose of dialysis:
-Minimum Kt/V urea: 1.2–1.3 (single pool).
-Minimum URR : 65–70%.
-Measurement of dialysis dose: once / month.
- Weekly dialysis time:
- HD Vs HDF
Rodriegaz handbook of dialysis 2012

71. ESNT Outreach Program, Sohag, December 4-7, 2014
Pump speed
Blood Flow
(ml/min(
%of
Patients
URR (% ±
SD(
%with URR
<65%
>250 0 — —
250to 300 6.9 69.9±9.9 22.2
301to 350 34.4 73.2±8.1 13.5
351to 400 46.3 74.7±6.6 6.7
<400 12.4 74.5±6.5 6.3
Total 100.0 73.8±7.5 10.0

72. ESNT Outreach Program, Sohag, December 4-7, 2014
Pump speed
Blood Flow
(ml/min(
%of
Patients spKt/V(±SD(
%with
spKt/V
<1.2
%with
Diascan
Kt/V <1.0a
>250 1.1 1.28 0 100.0
250to 300 3.4 1.37±0.49 33.3 33.3
301to 350 26.4 1.64±0.23 0 19.0
351to 400 52.9 1.67±0.030 4.8 23.9
<400 16.1 1.71±0.33 7.1 0.0
Total 100.0 1.66±0.30 5.9 20.0

73. Sieving curves for low-flux and high-flux dialysis membranes and human glomerular basement
membrane.
Ledebo I , Blankestijn P J NDT Plus 2010;3:8-16
© The Author 2009. Published by Oxford University Press [on behalf of ERA-EDTA].

74. CLEARANCE DATA IN HD,HF,HDFCLEARANCE DATA IN HD,HF,HDFCLEARANCE DATA IN HD,HF,HDFCLEARANCE DATA IN HD,HF,HDF

75. Serum phosphate in hemodialysis and hemodiafiltration cohorts.
Davenport A et al. Nephrol. Dial. Transplant. 2010;25:897-
901
© The Author 2009. Published by Oxford University Press on behalf of ERA-EDTA. All rights
reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

79. 7.5% of all of the 28,950 sessions were complicated by ISH. In the evaluation period
compared with the basal run-in, there was a statistically significant decrease of sessions
with ISH in HF (9.8 to 8.0%, decrease of 18.4%; P = 0.011( and in HDF (10.6 to 5....
Locatelli F et al. JASN 2010;21:1798-1807
©2010 by American Society of Nephrology

81. UF

82. Better survival with long
dialysis
UpToDate 2013

83. Mortality in Hemodialysis Patients in
Europe, Japan, and the United States
DOPPS 2006

84. Patient-Centeredness Promotes
Patient Engagement

85. Patient Engagement at the
Facility Level