3. Elements Of HD Prescription
1. Session Length
2. Blood Flow Rate
3. Dialyzer
4. Dialysate Composition
5. Dialysate Flow Rate
6. Dialysate Temperature
7. Ultrafiltration Orders
8. Anticoagulation
4. HD Session Length & Blood Flow Rate
Most important determinant of the amount of dialysis
Initial dialysis session
For initial 1 or 2 sessions, specially when pre-dialysis
SUN >125 mg/dl
Both dialysis session length and blood flow rate
should be reduced
Target URR <40%
QB – 250 ml/min for adults. 200 ml/min for small pts.
2 hour length sessions.
5. To prevent DDS, aim for urea clearance of –
30% for 1st treatment (Kt/V= 0.7)
50% for 2nd treatment (Kt/V = 1.0)
70% for 3rd and subsequent treatments (Kt/V = 1.2)
For initial BUN <100 mg/dl, aim for urea clearance of
50% for 1st tt
70% for 2nd and subsequent tt
6. 2nd hemodialysis
Increased to 3 hrs, when pre dialysis sun<100 mg/dl
Length of single dialysis treatment rarely exceeds 6
hours unless dialysis for drug overdose.
7. A typical 3 – 4 hr acute dialysis session will deliver a spKt/V
of only 0.9 with eKt/V of 0.7.
This low level of Kt/V, if given 3/week, is a/w high mortality in
chronic stable pts.
Options-
Dialyse sick patients of AKI on daily basis (6/week) with
each session length of 3 – 4 hrs.
Mortality is reduced( schiffl- 2002).
8. VA/NIH (2008) study compared outcomes in acute pts
dialysed either 3 or 6 times per week.
The intensity in 3/week group was substantially higher
(Kt/V of 1.3 or more) than in the schiffl artcle.
For this reason the KIGO workgroup on AKI 2012,
recommened Kt/V of 1.3 or more for each HD session
for acute pts on 3/wk HD.
9. We can verify HD adequacy by
URR
Measured by
Blood test
Ionic coductance
UV absorption technology
10. Choosing A Dialyzer
Membrane material –
Not studied as a separate factor
Ultrafiltration coefficient (Kuf)-
Use dialyzers of high water permeability ( Kuf >6.0).
11. Choosing A Dialyzer contd.
Dialyzer urea clearance
For first couple of HD sessions we should avoid using
very high efficiency dialyzers.
A dialyzer with a K0A of 500 – 600 ml/min is
recommended.
After initial 1 – 2 sessions, particularly when high QB
is being used, normal sized dialyzer should be used.
12. The Dialysis Solution
Bicarbonate = 25 mmol/l
Sodium = 145 mmol/l
Potassium = 3.5 mmol/l
Calcium = 1.5 mmol/l
Magnesium = 0.375 mmol/l
Dextrose = 100 mg/dl
No phosphorus
May be altered as per circumstances.
13. Dialysate Bicarbonate Level
Pre HD
acidosis
Metabolic
HCO3: 20-25
Respiratory
HCO3 : high
Pre HD
alkalosis
Metabolic
Low HCO3
Respiratory
Low HCO3
14. Dialysis Solution Sodium Level
Hyponatremia
Pre HD sodium>130 mmol/l
Dialysate sodium = 140+ (140- prehd s. Na+)
Pre HD sodium <130 mmol/l
Dialysate sodium level 15-20 mmol above plasma
level.
15. Hyper-natremia
Safest approach – 1st dialyze with dialysate sodium
level close (within 2 mmol) to that of plasma.
Slow administration of slightly hyponatremic fluids.
16. Dialysate K level
Usual dialysate K conc. for dialysis
2.0 – 4.0 mmol
Predialysis serum K<4.0 mmol/l
Dialysate k : 4.0 mmol
Pre dialysis serum K >5.5 mmol/l
Dialysate K
For stable pts : 2.0 mmol
For risk of arrhythmia : 2.5 – 3.0 mmol
17. Pre dialysis serum K > 7.0 mmol/l
Dialysate K : <2.0 mmol
Monitor plasma K hourly
K rebound
Increase in serum K is seen withi 1 – 2 hr after HD
Do not treat post dialysis hypokalemia with K
supplements
18. Dialysate Calcium Level
Normal level for HD
1.25 – 1.75 mmol (3.0 – 3.5 meq/l)
Dialysis solution Ca<1.5 mmol (3.0 meq/l) in AKI
Pre dispose to hypotension during HD
Predialysis hypocalcemia
Use high dialysis soution calcium
19. Dialytic treatment of acute hypercalcemia
Dialysate calcium : 1.25 to 1.75 mmol (2.5 – 3.5 eq/l)
Frequent measurement of serum ionised calcium and
physical examination to avoid the complications.
20. Dialysate Magnesium Levels
Usual dialysate Mg level :
0.25 – 0.75 mmol (0.5 to 1.5 meq/l)
Study for BP control in acute dialysis
Dialysate Mg – 0.375 mmol (0.75meq/l) is better than
0.75 mmol (1.5 meq/l) (Roy and Danziger,1996).
Best dialysate Mg for acute dialysis in terms of blood
pressure control is unknown.