Hemodialysis Adequacy Dwi

7/23/2019 Hemodialysis Adequacy Dwi

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Hemodialysis Adequacy

and Prescription

Dwi Lestari Partiningrum



What isAdequacy of Hemodialysis ?

Adequacy of dialysis :

refers to how well we remove toxins and

waste products from the patient’s blood,and has a maor impact on their well!being

"remove # well being$



Adequacy of dialysis

% Adequate dialysis maximi&es well!being,

minimi&es morbidity, and helps a patient retain

social independence'

% Adequate dialysis is not simply a dose of dialysis

exceeding a given number, and should not bedefined by solute clearance alone'

% (ptimum dialysis is a method of delivering

dialysis producing results that cannot be further

improved'

% Dialysis prescription should be individuali&ed,

monitored, and reassessed regularly'









Recommendations for Adequacy

assessment

% )hould be assessed using a combination

"subective, obective and dialysis dose

assessment$

% *he recommended frequency : +!monthly

in stable patients

% onthly in unstable patients



Assessment of Dialysis

Adequacy

Subjective assessment:

% )ense of well being "no tiredness$% -ood appetite "no nausea$

% ore normal weight

% .eeling li/e dialysis is not necessary,except to remove fluid

% ore natural s/in color




AdequacyObjective assessment:

% 0olume 1 2lood pressure control

% 3ot Acidotic "mid!wee/ predialysis

bicarbonat level not low$

% 4ontrolled of blood phosphate levels% 3ormal serum albumin level




Adequacy

Dialysis dose assessment

% 5s the desired level of urea removal

being met6



nder!Dialy"ed Patients #ay $%perience

% 7ea/ness, *iredness

% Loss of body weight

% Poor appetite

% 3ausea 1 0omiting% .eeling better after treatmen

% 8ellowish s/in color

% ore infections% Prolonged bleeding

% Premature death



Ho& Do We 'no& if a Patient is

Adequately Dialy"ed?

'(DO)* +uidelines

Define Adequate Dialysis as,

% '-(. / 012 or 3reater % RR / 456 or 3reater



RR6 ! rea Reduction Ratio ,

the percenta3e of urea removed

durin3 the treatment

'-(. ,

7ormula utili"in3 dialy"er urea

clearance8 treatment time and totalbody fluid



$%ample RR5nitial "predialysis$ urea level: 9 mg1dL

*he postdialysis urea level: ;9 mg1dL

*he amount of urea removed: 9 mg1dL<;9 mg1dL = +9mg1dL

>??@ = >r pre < >r post x ;@

>r Pre

+919 = 1; = @

?ecommended a minimum >?? of B9 percent'

*he >?? is usually measured only a month'



't(.

C : the dialy&er clearance in millilitersper minute "mL1min$

t : time

Ct : is clearance multiplied by time representing the volume of fluidcompletely cleared of urea during a single

treatment 0 : is the volume of water a patient’s body

contains " 9@$





*he Ct10 is mathematically related to the >??,except that the Ct10 also ta/es into account two additional

factors:

% urea generated by the body during dialysis% extra urea removed during dialysis along with excess

fluid

*he Ct10 is more accurate than the >?? in measuring howmuch urea is removed during dialysis, primarily becausethe Ct10 also considers the amount of urea removed withexcess fluid' "4onsider two patients with the same >??and the same postdialysis weight, one with a weight lossof ; /g during the treatment and the other with a weight

loss of + /g'$

Patients who lose more weight during dialysis will have ahigher Ct10 for the same level of >??'



9lood samplin3 for '#

Predialysis sample Postdialysis sample

*a/e before any dialysis hasbegun from fistula needle

)et the >. rate to &ero

)low blood pump to 9

ml1min for at least ;9s)top blood pump

*a/e sample within the nextEs "Alternatively slow pumpto ; ml1min, over!ridealarm to /eep blood flowing,wait ;9!+s then ta/esample from A line$



Other mar:ers of adequacy,

protein catabolic rate

P4? "usually normali&ed for weight: nP4?:

g1/g1day$ is derived from the urea generation

rate and is usually calculated during >C'% Patients with nP4? F 'G g1/g1day have

increased morbidity and mortality, and generally

patients need an nP4? H;' g1/g1day to maintain

positive nitrogen balance'% Patients with a low nP4? need a careful

assessment for protein malnutrition'



P4? can be calculated approximately from:

P4? = "pre!post 2>3$x"'I91*$

7here * = number of days between blood

samples'



Other mar:ers of adequacy

% Acidosis

% >. should be sufficient to /eep the patient euvolaemic'4ompliance with salt and fluid restriction is important'5ncreased oedema or ascites increases 0, and hence

reduces Ct10 if C and t are not increased' 5ncreaseddialysis time is also necessary to allow redistribution offluid from interstitial compartments into the vascularcompartment during dialysis'

% alnutrition is a /ey mar/er of dialysis inadequacy and iseasily missed' Jarly weight loss is often accompanied byfluid retention as the dry weight is not reduced in linewith loss in muscle mass'



#ethods to increase delivered

dialysis doseost effrctive methods

% 5ncrease dialysis time

% 4hange to dialysis membrane of largersi&e anf1 or permeability

Less effective methods

% 5ncrease blood flow during dialysis

% 5ncrease dialysate flow during dialysis



Hemodialysis Prescription

Determines Adequacy

Kemodialysis Prescription 4omponents:

< Duration of treatment "not F I hours at each

treatment$

< .requency of dialysis

< Desired dry weightM

< embrane type, membrane si&e

< 2lood pump speed < Dialysate flow rate

< Anticoagulation protocol to be used

< Access



Assessment of adequacy should include,

% patient well!being "physically, mentally,socially$N

% nutrition "lac/ of malnutrition$N

% small solute clearance "urea /ineticmodelling: >C$N

% adequacy of >.N

% control of 2PN% control of anaemia, acidosis, and bone

disease'







$%ample 't(.,

5f the dialy&er’s clearance is + mL1minand a dialysis session lasts for ;Gminutes "+ hours$

Ct = +mL1min x ;Gmin

Ct = 9I,mL = 9I liters*he body O B@ water by weight' 5f a

patient weighs /ilograms

0 = /g x B = IE litersCt10 = 9I1IE = ;'+

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Hemodialysis Adequacy Dwi