Your HD Machine: Opportunities to ensure better outcomes Sep 23 2011.pdf · Your HD Machine: Opportunities to ensure better outcomes ... UF Goal UF Rate ... SVS profiles and Na balance

Confidential

Your HD Machine:

Opportunities to ensure better outcomes

Jeffrey J Sands MD MMM

Associate Medical Director Devices

Renal Therapies Group

Confidential 2

Agenda

• Sodium balance– Dialysis prescription– Delivery, SVS

• Bicarbonate– Prescription– Relationship with cardiac events

• Dialysis adequacy– Variation– OLC

Confidential 3

Topic 1: Na balance

What is the most commonly prescribed

dialysate Na?

a. 136

b. 137

c. 138

d. 139

e. 140

Confidential

What is the most common patient predialysis

Na?

a. 134-135

b. 136-137

c. 138-139

d. 140-141

e. 142-143

4

Confidential

What percentage of patients have Na gradient

(dialysate Na – patient Na) ≥5 mEQ/L?

a. 0-5%

b. 6-10%

c. 11-15%

d. 16-20%

e. ≥21%

5

Confidential 6

Dialysate Sodium Distribution# of Patients = 77,616 (July, 2011)

0.7 0.3

74.5

5.80.9

16.2

0.2 0.7 0.0 0.2 0.60

10

20

30

40

50

60

70

80

130-135 136 137 138 139 140 141 142 143 144 ≥145

Dialysate Sodium

%

Prescribed dialysate Na (mEq/L)

• 137: 74.5% of patients

• 140: 16.2% of patients

• ≥141: 1.7% of patients• ≤136: 1.0% of patients

Note: Proton Only

Confidential 7

Serum Sodium Distribution# of Patients = 82,775 (July, 2011)

2.31.3

1.92.8

4.4

6.5

8.8

11.3

13.1 13.5

12.0

9.2

6.4

3.6

1.8 1.4

0

2

4

6

8

10

12

14

16

120-130

131 132 133 134 135 136 137 138 139 140 141 142 143 144 ≥145

Serum Sodium

%

Patient predialysis Na (mEq/L)

• 136-137: 20.1% of patients

• 138-139: 26.6% of patients

• 140-141: 21.2% of patients

• ≥142: 13.2% of patients• ≤135: 19.2% of patients

Note: Proton Only

Confidential 8

Sodium Gradient Distribution# of Patients = 77,616 (July, 2011)

10.6

7.6

10.1

12.1 12.311.5

9.8

7.7

5.8

4.0

8.6

0

2

4

6

8

10

12

14

≤-5 -4 -3 -2 -1 0 1 2 3 4 ≥5

Sodium Gradient

%

Dialysis Na gradient (mEq/L)

• -1 to -4: 42.6% patients

• 1 to 2: 17.5% patients

• 3 to 4: 10.8% patients

• ≥ 5: 8.6% patients

• ≤ -5: 10.8% patients

Note: Proton Only

Confidential 9

F Gotch, 2009

Patient

Dialysate

132

142

137

Na loading and weight gain

• Constant positive dialysate Na gradient of + 5 mEq/L

will add ~8.7 gms NaCl to the patient

• Significant increase in intradialytic weight gain

– ~0.6 L extracellular fluid volume expansion1

– ~70 mL2 to 1201 mL per mEq/L Na gradient

135

140

145

0 50 100 150 200 250

Dialysis time min

So

diu

m C

on

cen

trat

e m

Eq

/L

CdiNa CptNa CspNa

~ 8.7 gm NaCl added

Projected

1. Keen M, et al. Int J Artif Organs 30: 971-979, 20072. Mendoza JM et al. Nephrol Dial Transplant 0:1–6 2011

Confidential 10

Na Flux correlates with hospitalization

Hospital Admissions per Patient Year ( with 95% CI)2007, RRI Patients, N=6852

0.00

0.50

1.00

1.50

2.00

2.50

3.00

<-4 -4 to -2 -2 to 0 0 to 3 (incl 0)

3 to 6 >6

Dialysate Sodium - Serum Sodium (mmol/L)

Hos

pita

l Adm

issi

ons

per

Pat

ient

Yea

r

N=88

N=338 N=1194N=2838

N=1493N=631

Sodium flux into patient from dialysate

Sodium flux out of the patient

P Kotanko Personel communication

Confidential 11

Survival and Na gradient

• Survival was shorter in patients with a high Na gradient

Penne EL, Sergeyeva O. Blood Purif 31:1-3:86-91 2011

Na Gradient (mEq/L

Mean Survival (yrs)

< - 1.5 5.3

-1,5 to 0 5.4

0 to 1.5 5.6

1.5 to 3.0 5.4

3.0 to 6.0 4.8

>6.0 4.6

Confidential 12

Reducing sodium gradient

• Individualized dialysate Na reduced intradialytic symptoms1

• Greater % decline in extracellular volume and extracellular

volume/total body volume ratio on low Na+ dialysate2

1. De Paula FM, et al. Kidney Int 66:1232–1238, 2004

2. Ozturk S, et al. Nephrol Dial Transplant 23(11):3629-34

2008

Standard Na+

Individualized Na+

Pvalue

Hypotension 23 (9%) 6 (2%) <0.001

Cramps 12 (5%) 5 (2%) 0.072

Headaches 11 (5%) 3 (1%) 0.010

Nausea/vomiting 0 (0%) 0 (0%) –

Interdialytic thirst

Nil 0 (0%) 4 (15%) 0.043

Mild 1 (4%) 17 (63%) <0.001

Moderate 11 (41%) 5 (18%) 0.07

Severe 15 (55%) 1 (4%) <0.001

Standard Na+ = 138 mmol/LMean individualized Na+ = 135 mmol/L

Volume Changes w ith differing Dialysate Na, Glucosen = 17

-3.8%

-9.2%

-8.2%

-3.5%

-6.6%

-12.7%

-11.6%

-3.3%

-5.6%

-9.9%-9.1%

-3.9%

-14.0%

-12.0%

-10.0%

-8.0%

-6.0%

-4.0%

-2.0%

0.0%

ICV ECV TBV TBW

Dialysate Na 140 mmol/L; glucose 200 mg/dL



*p < 0.05

Confidential 13

2008 Series hemodialysis machine specifications

• Base Na (130 to 155 mEq/L Na)

– Once set, remains unchanged until reset

• Conductivity reflects dialysate Na (~Na/10)– Accuracy ± 1.5%

• Alarm windows ±0.5 mS/cm around TCD– Can adjust an additional ±0.5 mS/cm asymetrically– Range of Display: 10.0 to 17.0 mS/cm

– Alarm limits will not go below 12.5 or above 16.0 mS/cm

Dialysis Paused

Conc 2231 45x

Conductivity Limits

SVS Profile

14.1

13.1

Alarm

Position

Alarm

Width

Acid/Bicarb

Alert

Dialysate HeparinBlood

Pressure

Test,

OptionsHome

Dex.

mEq/L

Ca++

K+

Mg++

Ac.

mEq/L

mEq/L

mEq/L

mg/dL

1.02.2

4.0

2.0

99

mS/cmTCD 13.6

Bicarbonate

mEq/L35

mEq/L

Base Na+

138

Dialysate Composition

Trends

13.8 mS/ cm

Kt/V

AF

BTM

BVM

None

Blood Pressure 9:05

9:00 100/70 53Dialysis Paused

Conc 2231 45x

Conductivity Limits

SVS Profile

14.1

13.1

Alarm

Position

Alarm

Width

Acid/Bicarb

Alert


Pressure

Test,

OptionsHome

Dex.

mEq/L

Ca++

K+

Mg++

Ac.

mEq/L

mEq/L

mEq/L

mg/dL

1.02.2

4.0

2.0

99

mS/cmTCD 13.6

Bicarbonate

mEq/L35

mEq/L

Base Na+

138


Trends

13.8 mS/ cm

Kt/V

AF

BTM

BVM

None

Blood Pressure 9:05


ArterialPressure

VenousPressure

260

-80

500

0

-160 mmHg

300

-280

0

TMP

190mmHg mmHg

UF Goal

UF Rate

UF Removed

UF Time

Dialysate Flow

Temperature

Conductivity

RTD

UF Profile

ml/min500

hr:min3:00 oC37.0

mS/cm13.8ml/hr1000

ml0 hr:min3:00

ml3000

60

520

SVS Profile

Tx Paused

Blood Pressure 9:05

Home Dialysate HeparinBlood

Pressure

Test,

OptionsTrends

Kt/V

AF

BTM

BVM

Blood Pump Rate

ml/min250 NoneNone

9:00 100/70 53Dialysis PausedArterial

PressureVenous

Pressure

260

-80

500

0

-160 mmHg

300

-280

0

TMP

190mmHg mmHg

UF Goal

UF Rate

UF Removed

UF Time

Dialysate Flow

Temperature

Conductivity

RTD

UF Profile

ml/min500 ml/min500

hr:min3:00 hr:min3:00 oC37.0 oC37.0

mS/cm13.8 mS/cm13.8ml/hr1000 ml/hr1000

ml0 ml0 hr:min3:00 hr:min3:00

ml3000

60

520

SVS Profile

Tx Paused

Blood Pressure 9:05Blood Pressure 9:05


Pressure

Test,

OptionsTrends

Kt/V

AF

BTM

BVM

Blood Pump Rate

ml/min250 ml/min250 NoneNone

9:00 100/70 53

Confidential 14

Na % From Nominal 11/09-05/10

-3.00

-2.00

-1.00

0.00

1.00

2.00

3.00

1 27 53 79 105 131 157 183 209 235 261 287 313 339 365 391 417 443 469 495 521 547 573 599 625 651 677 703 729 755

1st Sample

Last Sample

% Deviation of daily samples of acid concentratefrom the target over 6 months

Acid concentrate and Na variability

• Acid concentrate: Within ±2.5% specifications• Concentrate delivery requirements

– Maximum supplied pressure 2 psi

– Maximum suction height 3 feet

F Gotch 2010

Confidential 15

SVS profiles and Na balance

• SVS profiles are Na balance positive (PS) unless the base Na is set lower than the patients Na

• Balance positive Na+ profiles can easily be overused

– Prescribed PRN without systematic review

Confidential 16

Increased weight gain and higher serum Na with

Na positive profiles (PS)

• Use of Na+ balance positive profiles should be avoided

unless specifically directed by the physician

– Greater weight gain, serum Na increased (p < 0.05)

• Balance–neutral Na+ profiles (NS, NA) achieved lower

post dialysis weight, closest to EDW with less UF

Song JH, et al. J Am Soc Nephrol 16:1, 237-246, 2005

Confidential 17

Topic 2: Bicarbonate

What is the most commonly prescribed dialysate bicarbonate?

a. 35

b. 36

c. 37

d. 38

e. 39

f. 40

Confidential

What is the most common patient pre-dialysis bicarbonate?

a. 22

b. 23

c. 24

d. 25

e. 26,

f. 27

g. 28

18

Confidential

What level of bicarbonate correlates with increased risk of sudden death in incident patients (Pick all that apply)?

a. <20,

b. 20-21.9

c. 22-23.9

d. 24-25.9

e. 26-27.9

f. ≥28

19

Confidential 20

Dialysate Bicarbonate Distribution# of Patients = 86,617 (July, 2011)

0.8 0.3 0.4

10.9

1.9

10.0

2.9

60.7

4.2 4.3 3.9

0

10

20

30

40

50

60

70

≤30 31 32 33 34 35 36 37 38 39 40

Dialysate Bicarbonate

%

Prescribed base bicarbonate (mEq/L)

• ≤32: 1.5% patients• 33 to 34: 12.8% patients• 35 to 36: 12.9% patients• 37: 60.7% patients• 38 to 39: 8.5% patients• 40: 3.9% patients

Note: Proton Only

Confidential 21

Bicarbonate Lab Result Distribution# of Patients = 91,984 (July. 2011)

2.5 2.2

3.5

5.4

7.8

10.1

11.712.4

11.7

10.2

8.2

5.8

3.8

2.3 2.5

0

2

4

6

8

10

12

14

≤17 18 19 20 21 22 23 24 25 26 27 28 29 30 ≥31

Serum Bicarbonate

%

Patient pre-dialysis bicarbonate (mEq/L)

• ≤20: 13.6% patients• 21 to 22: 14.2% patients• 23 to 25: 35.8% patients• 26 to 27: 18.4% patients• ≥28: 14.4% patients

Note: Proton Only

Confidential 22

Pre-HD Bicarbonate and sudden death risk

Relative Risk of CP Arrest: Bicarbonate

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

<20 20-21.9 22-23.9 24-25.9 26-27.9 ≥28

Bicarbonate

Od

ds

Rat

io E

stim

ates

0

6

12

18

24

30

36

% o

f Pat

ient

s

Unadjusted

Case-Mix Adj.

Case-Mix+Lab Adj.

Case-Mix+Lab+VA Adj.

% of Patients

Ref

*

*

*

*

* : P < 0.0001

^ : P < 0.05

Labs included for Adjustment:alb, calcium, glucose, hgb, phosphorus, & wbc

Vascular Access Adjustment:catheter = 1, fistula & graft = 0

*

^

*

****

**

*

Confidential 23

Incident patients, cardiac arrest and mortality



Relative Risk of CP Arrest: Potassium

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

<4 4.0-4.5 4.6-5.0 5.1-5.5 5.6-6.0 >6

Potassium

Od

ds

Rat

io E

stim

ates

0

7

14

21

28

35

% o

f Pat

ient

s

Unadjusted

Case-Mix Adj.

Case-Mix+Lab Adj.


% of Patients

Ref

*

* ^

^

^^ ^

*

*

*

*

*

*

*

*

** : P < 0.0001

^ : P < 0.05

N=81457

Confidential 24

Incident patients, cardiac arrest and mortality


*


Relative Risk of CP Arrest: Potassium & Bicarbonate

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

k<4 & Bicarb<28 k<4 & Bicarb≥28 k≥4 & Bicarb<28 k≥4 & Bicarb≥28

Potassium & Bicarbonate

Od

ds

Rat

io E

stim

ates

0

10

20

30

40

50

60

70

80

90

% o

f Pat

ient

s

Unadjusted

Case-Mix Adj.

Case-Mix+Lab Adj.


% of Patients

Ref

*

*

*

*

*

*

*

**

*

*

*

*

*

* : P < 0.0001

^ : P < 0.05

N=81457

Confidential 25

Serum bicarbonate and mortality risk

0.0

1.0

2.0

3.0

4.0

5.0

<=17 17.1-18

18.1-19

19.1-20

20.1-21

21.1-22

22.1-23

23.1-24

24.1-25

25.1-26

26.1-27

27.1-28

28.1-29

>29

Three-Month Average Bicarbonate (mmol/L)KDOQI Goal: ≥ 22 (mmol/L)

Haz

ard

Rat

ios

of D

eath

0

2.5

5

7.5

10

12.5

15

17.5

20

% o

f P

atie

nts

UnadjustedCase-Mixed Case-Mixed + Labs% of Patients

Ref** ^ ^

**^

**^^ ^ ^ *

^*

*** **

* : P < 0.0001

^ : P < 0.05

CSER 2008 Mortality StudyN=110,271

2008 FMS Data from 2009 Med. Dir. Report

Confidential 26

Machine and concentrate

• Bicarbonate– Adjustment Range 20 to 40 mEq/L Bicarbonate

– Total base includes bicarb + acetate and/or citrate

• Naturalyte 4mEq/L acetate, Granuflo 8mEq/L acetate

• Concentrate supply– Maximum supplied pressure 2 psi

– Maximum suction height 3 feet

Dialysis Paused

Conc 2231 45x

Conductivity Limits

SVS Profile

14.1

13.1

Alarm

Position

Alarm

Width

Acid/Bicarb

Alert


Pressure

Test,

OptionsHome

Dex.

mEq/L

Ca++

K+

Mg++

Ac.

mEq/L

mEq/L

mEq/L

mg/dL

1.02.2

4.0

2.0

99

mS/cmTCD 13.6

Bicarbonate

mEq/L35

mEq/L

Base Na+

138


Trends

13.8 mS/ cm

Kt/V

AF

BTM

BVM

None

Blood Pressure 9:05


Conc 2231 45x

Conductivity Limits

SVS Profile

14.1

13.1

Alarm

Position

Alarm

Width

Acid/Bicarb

Alert


Pressure

Test,

OptionsHome

Dex.

mEq/L

Ca++

K+

Mg++

Ac.

mEq/L

mEq/L

mEq/L

mg/dL

1.02.2

4.0

2.0

99

mS/cmTCD 13.6

Bicarbonate

mEq/L35

mEq/L

Base Na+

138


Trends

13.8 mS/ cm

Kt/V

AF

BTM

BVM

None

Blood Pressure 9:05


PressureVenous

Pressure

260

-80

500

0

-160 mmHg

300

-280

0

TMP

190mmHg mmHg

UF Goal

UF Rate

UF Removed

UF Time

Dialysate Flow

Temperature

Conductivity

RTD

UF Profile

ml/min500

hr:min3:00 oC37.0

mS/cm13.8ml/hr1000

ml0 hr:min3:00

ml3000

60

520

SVS Profile

Tx Paused

Blood Pressure 9:05


Pressure

Test,

OptionsTrends

Kt/V

AF

BTM

BVM

Blood Pump Rate

ml/min250 NoneNone


PressureVenous

Pressure

260

-80

500

0

-160 mmHg

300

-280

0

TMP

190mmHg mmHg

UF Goal

UF Rate

UF Removed

UF Time

Dialysate Flow

Temperature

Conductivity

RTD

UF Profile

ml/min500 ml/min500

hr:min3:00 hr:min3:00 oC37.0 oC37.0

mS/cm13.8 mS/cm13.8ml/hr1000 ml/hr1000

ml0 ml0 hr:min3:00 hr:min3:00

ml3000

60

520

SVS Profile

Tx Paused

Blood Pressure 9:05Blood Pressure 9:05


Pressure

Test,

OptionsTrends

Kt/V

AF

BTM

BVM

Blood Pump Rate

ml/min250 ml/min250 NoneNone

9:00 100/70 53

Confidential 27

Topic 3: Dialysis adequacy

What percentage of patients have spKt/V < 1.4 by

UKM in any given month?

a. 0-3.9%

b. 4-6.9% 7-9.9%

c. 10-12.9%

d. ≥ 13%

Confidential

What percentage of patients have mean spKt/V <

1.4 by OLC in any given month?

• 0-3.9%

• 4-6.9%

• 7-9.9%

• 10-12.9%

• ≥ 13%

28

Confidential

What % of patients in a month with spKt/V by

OLC < 1.4 on 0% treatments?

a. <20%

b. 20-34.9%

c. 35-49.9%

d. 50-64.9%

e. 65-84.9%

f. ≥ 85%

29

Confidential 30

Single Pool Kt/V Value (spKt/V) Distribution# of Patients = 93,861 (July, 2011)

1.4 1.21.9

3.4

7.2

12.9

16.4 15.9

13.1

9.6

6.5

4.0

2.51.5

0.91.6

0

2

4

6

8

10

12

14

16

18

≤1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2 2.1 2.2 2.3 2.4 ≥2.5

spKt/V Value

%

% spKt/V <1.4 = 7.9%

Note: Proton Only

Dialysis adequacy (spKt/V) by UKM

• 7.9% spKt/V < 1.4• 3.5% ≤ 1.2• 1.4% ≤ 1.0

Confidential 31

Mean & Median OLC Distribution of All Available Treatments per Patient

# of Patients = 93,280(July, 2011)

2.0 2.1

3.7

6.6

11.8

17.2 17.3

13.9

9.9

6.2

3.82.3

1.3 0.8 0.5 0.92.2 2.0

3.3

16.3

10.5

7.0

4.4

2.7

1.10.60.9

1.6

14.4

17.2

10.5

5.4

0

2

4

6

8

10

12

14

16

18

20

≤1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2 2.1 2.2 2.3 2.4 ≥2.5

OLC Value

%

mean median

% spKt/V <1.4 >14.3%

Dialysis adequacy (spKt/V) by OLC

• 14.3% spKt/V < 1.4 (mean for month)• 7.7% ≤ 1.2• 2.0% ≤ 1.0

Note: Proton Only

Confidential 32

% of Treatments w. OLC <1.4# of Patients = 93,280 (July, 2011)

38.4

17.3

10.8

6.7 6.54.2

2.6 3.3 2.3 2.3

5.8

0

5

10

15

20

25

30

35

40

45

0 1-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 91-100

% of Treatments w. OLC < 1.4

%

Note: Proton Only

% Treatments with spKt/V by OLC < 1.4

• 0% Tx < 1.4: 38.4% patients• 1 -20%: 28.6% patients• 21-40%: 13.2% patients• >40% 21.3% patients

Confidential 33

Distribution of OLC spKt/V Standard Deviation(July, 2011)

6.2

24.7 24.2

17.5

11.3

7.2

4.12.2 1.1 0.7 1.0

0

5

10

15

20

25

30

35

40

45

0-.05 .06-.10 .11-.15 .16-.20 .21-.25 .26-.30 .31-.35 .36-.40 .41-.45 .46-.50 >.50

OLC Standard Deviation

%

Note: Proton Only

Intra-patient variation in spKt/V by OLC

• Mean OLC spKt/V = 1.61• Mean SD = 0.17 (in individual patients)• Mean CV =10.69% (in individual patients)

Confidential 34

15105Subgroup 0

1.7

1.6

1.5

Indi

vidu

al V

alue

Mean=1.612

UCL=1.716

LCL=1.508

0.15

0.10

0.05

0.00

Mo

ving

Ran

ge

R=0.03923

UCL=0.1282

LCL=0

Normal Variation

Confidential 35

0Subgroup 5 10

1.0

1.5

2.0

Indi

vidu

al V

alue

1

Mean=1.473

UCL=2.026

LCL=0.9188

0.00.10.20.30.40.50.60.7

Mo

ving

Ran

ge

R=0.2082

UCL=0.6802

LCL=0

I and MR Chart for July OLC spKt/V

Improved Qb Improved Qb

spKt/V by OLC: Example 1

Confidential 36

105Subgroup 0

2.32.22.12.01.91.81.71.61.51.41.3

Indi

vidu

al V

alue

1

Mean=1.804

UCL=2.206

LCL=1.403

0.6

0.5

0.4

0.3

0.2

0.1

0.0

Mo

ving

Ran

ge

1

R=0.1509

UCL=0.4931

LCL=0

Incorrect VolumeIncorrect Volume


Confidential 37

105Subgroup 0

1.7

1.6

1.5

1.4

1.3

Indi

vidu

al V

alue

1 1 1

2Mean=1.475

UCL=1.625

LCL=1.325

0.3

0.2

0.1

0.0

Mo

ving

Ran

ge

1

R=0.05636

UCL=0.1842

LCL=0

Different Dialyzer


Confidential 38

8765432Subgroup 1

1.35

1.30

1.25

1.20

1.15

1.10

1.05

1.00

Indi

vidu

al V

alue

Mean=1.174

UCL=1.330

LCL=1.018

0.2

0.1

0.0

Mo

ving

Ran

ge

R=0.05857

UCL=0.1914

LCL=0

Needs Prescription ChangeNeeds Prescription Change


Confidential 39

Practical steps to ensure better outcomes

• Follow manufacturers recommendations

– Check conductivity and pH with an independent meter

– "On-line Pressure Holding Test" must be activated

• Consider the alarm limits

– Shifting conductivity limits from ±0.5 mE/L theoretical can allow up to a 10 mEq/L variation in Na from prescribed

• Consider the dialysis prescription

– Na: What is the patients Na gradient?

• Contribution: ~8.7 gms NaCl for every 5 mEq/L gradient• Na profiles (SVS) result in a positive Na gradient unless base Na is lower than the patients pre-HD Na

– Bicarb: Avoid pre and post HD alkalosis

• Remember: Total buffer = base bicarbonate plus up to 8 mEq/L of base (acetate, citrate) from acid concentrate

• Use machine information (OLC, TCD, conductivity etc)

– Observe AMP lights; obtain adequate OLC Kt/V every Tx

Confidential 40

Conclusions

• Na balance, volume control and and dialysis

adequacy remain areas with potential for

outcomes improvement

– More emphasis on preventing Na loading

• Serum bicarbonate and the risk of alkalosis are

also potentially overlooked

• Machines settings and alarms are designed to

provide range of prescriptions safely and

effectively

• HD machine information can provide insight

into the specifics of dialysis delivery and

facilitate improved dialysis outcomes

Documents

Your HD Machine: Opportunities to ensure better outcomes Sep 23 2011.pdf · Your HD Machine: Opportunities to ensure better outcomes ... UF Goal UF Rate ... SVS profiles and Na balance