Presentation done at Dialysis workshop at Indus Hospital Derabassi

1. Dr Narinder Sharma
Indus International Hospital, Derabassi

5.  The delivered dose of hemodialysis that will
optimize the survival and well-being of the
patient
 Numerous studies have demonstrated a
correlation between the delivered dose of
hemodialysis and patient mortality and
morbidity

6. Adequacy is a measure of how well
the dialysis is working

7. How to prove
that the
dialysis is
adequate?

8. How to evaluate adequacy of dialysis?
Improved signs and
symptoms
• Tiredness, weakness
• Nausea or poor
appetite
• Shortness of breath
• Losing body weight
• Anemia
Monitoring the patient's symptoms alone is also
insufficient, since the combination of dialysis plus
erythropoietin to correct anemia can eliminate most
uremic symptoms although the patient may be
underdialyzed

9.  Bood urea nitrogen – pre and post dialysis, to
see whether dialysis is removing enough urea
 It is a marker of solute clearance.
Why UREA?
An ideal clearance
marker:
• Accumulates in
uremia;
• Easily measured
• Easily removed by
the dialyzer.

10.  URR stands for urea reduction ratio.
 The URR is one measure of how
effectively a dialysis treatment
removed waste products from the
body
 expressed as a percentage.
 Blood is sampled at the start of
dialysis and at the end. The levels of
urea in the two blood samples are
then compared.

11.  Although no fixed percentage
can be said to represent an
adequate dialysis, patients
generally live longer and have
fewer hospitalizations if the URR
is at least 60 percent.
The URR may vary considerably from treatment to
treatment. Therefore, a single value should not be of
great concern, but a patient's average URR should
exceed 60 percent.
only once every 12 to
14 treatments, which
is once a month.

12. following the blood
urea nitrogen
(BUN) is
insufficient
because a low BUN
can reflect
inadequate
nutrition rather
than sufficient
dialytic urea
removal

15.  EquilibratedKt/v
 Unequilibrated Kt/v ( 1.4)- KDOQI
 Standard Kt/v

16.  Kt/V (Dose of Dialysis)
K = Urea clearance through dialysis
K depends on K0A- dialyser
clearance(membrane characterstics), blood
flow and dialysate flow
t = Time of dialysis in minutes
V = Volume of body water cleared of
urea

17.  Total weekly time is the major determinant
for removal of
 solutes such as phosphorus
 middle molecules
 excess salt and water from patients safely
and effectively

18.  US KDOQI 2006 adequacy work group
recommended a minimum session length of 3
hours.
 Studies have shown little benefit of doing
dialysis more than 4.5 hours.
 New studies of longer duration dialysis (4.25
hours) – TIME trial are in progress.

19.  Treatment Week Month Year
 5 Minutes 15 Minutes 65 Minutes 780 Minutes
 (1.08 Hours) (13 Hours/0.54
Days)
 10 Minutes 30 Minutes 130 Minutes 1,560 Minutes
 (2.17 Hours) (26 Hours/1.08
Days)
 15 Minutes 45 Minutes 195 Minutes 2,340 Minutes
 (3.25 Hours) (39 Hours/1.63
Days)
 20 Minutes 60 Minutes 260 Minutes 3,120 Minutes
 (1 Hour) (4.33 Hours) (52 Hours/2.17
Days)
 25 Minutes 75 Minutes 325 Minutes 3,900 Minutes
 (1.25 Hours) (5.42 Hours) (65 Hours/2.71
Days)
 30 Minutes 90 Minutes 390 Minutes 4,680 Minutes
 (1.5 Hours) (6.5 Hours) (78 Hours/3.25
Days)

20.  Studies have shown that wide fluctuations in
solutes and the inability to remove
appropriate amounts of retention toxins are
the cause of inadequacy of IHD.
 Potassium-higher risk with both higher and
lower serum potassium levels for sudden
cardiac arrest (lowest at 5 meq/l)

21.  Mineral- bone disorder -Most phosphate is
intracellular, with only a small amount easily
removable by dialysis, particularly during
shorter hemodialysis
 High Phosphorous levels are associated with
high cardiovascular mortality

22.  Middle molecules- removed by high flux
dialysers.
 Studies are neutral.
 Survival benefit in few subgroup like longer
vintage, cerebrovascular disease.
 Need further studies

23.  Patient-reported outcomes (PROs) comprise
symptoms like pain, depression
 These unwanted symptoms affect quality of
life and poor survival.

24.  So, improving these symptoms , might
increase survival, further studies are needed.
But definitely these issues need to be taken
care of.

25.  General consensus that increases in dialysis
dose measurable by small molecule clearance
alone are unlikely to yield further major
advances in patient health and survival.
 Dialysis schedule, duration, management of
extracellular volume and hemodynamics,
range of solutes larger than urea and
creatinine are areas for investigation.

26. Components:
 Duration of Treatment ( knowing the V and
k)
 Dialyzer ( knowing v and t)
- dialyzer efficiency (KOA)
- dialyzer Kuf
 Blood flow rate
 Dialysate Flow Rate
 Dialysis solution composition
 Access
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