HEMODIALYSIS PRESCRIPTION and TREATMENT Sonny L. Antonio,M.D.

HEMODIALYSIS PRESCRIPTION Session Length ( Duration ) Blood Flow Rate ( BFR, QB ) Dialyzer Dialysis Solution Composition Dialysate Flow Rate ( DFR, QD ) Dialysis Solution Temperature Fluid Removal Orders Anticoagulation Orders

SESSION LENGTH / DURATION SESSION LENGTH and BLOOD FLOW RATE - most important determinants of the amount of dialysis to be given. (Dialyzer efficiency is also a factor) 1. Reduce the amount of dialysis for the initial one or two sessions ( Acute hemodialysis ) Initial treatment: when the preHD BUN is very high (>130 mg/dL) - URR of about 40% - BFR = 3X Kg BW - Duration: 2 hours Longer initial dialysis session + use of excessively high blood flow rates = may result in dysequilibrium syndrome If longer initial dialysis session is needed ( for purposes of fluid removal ): DO isolated ultrafiltration

Length of 2nd Hemodialysis session : can be increased to 3 hours ( provided that preHD BUN <100 mg/dL ) Subsequent sessions : up to 6 hours

2. Dialysis frequency and dose for subsequent treatments and Dialysis adequacy - difficult to deliver a large amount of dialysis in the acute setting: 1. True delivered BFR through a venous catheter rarely exceeds 350 mL/min: often substantially lower 2. Recirculation occurs in venous catheters: greatest femoral position 3. Treatment interruptions due to hypotension 4. Increased urea sequestration in muscle: patients on pressors: decreased blood flow to muscle and skin 5. Concomittant IV infusions: dilute BUN levels

- typical 3-4 hour acute HD session: Kt/V 0.9 only; If given 3x/week: associated with high mortality - standard therapy: 3-4 hour session given every other day - option: daily basis (6x/week); 3-4 hour duration if every other day: 4-6 hours; Kt/V 1.2 - 1.3 - Sustained low-efficiency dialysis (SLED): becoming popular; 6-12 hour daily sessions

BLOOD FLOW RATE At the start of the dialysis session: BFR is initially set at 50 mL/min, then 100 mL/min until the entire blood circuit fills with blood BFR should be increased promptly to the desired level.

 DIALYZER Dialyzer Membranes a. Cellulose obtained from processed cotton various names: regenerated cellulose Cuprammonium cellulose (Cuprophane) Cuprammonium rayon Saponified cellulose ester b. Substituted cellulose - cellulose polymer whose large numbers of free hydroxyl groups at its surface are chemically bonded to acetate - Cellulose acetate - Cellulose diacetate - Cellulose triacetate c. Cellulosynthetic a tertiary amino compound (synthetic material) is added to liquefied cellulose during membrane formation Cellosyn or Hemophan

d. Synthetic - not cellulose-based - materials: polyacrylonitrile (PAN) polysulfone polycarbonate

polyamide polymethylmethacrylate (PMMA)

Biocompatibility: Complement activation with different membrane materials 1.Unsubstituted cellulose - free hydroxyl groups: activate the complement system - complement activation is reduced when reused, provided dialyzers have not been exposed to bleach 2. Substituted cellulose 3. Cellulosynthetic 4. Synthetic membranes lesser complement activation

Membrane permeability to solutes and to water - altered by adjusting the thickness of the membrane and the pore size Dialyzer membrane efficiency and Dialyzer membrane flux Membrane surface area determines the ability of a dialyzer to remove small molecular weight solutes (urea) High efficiency dialyzer - a dialyzer with high surface area: high ability to remove urea; can have small or large pores; can have either high or absent clearance for larger molecular weight solutes (B2 microglobulin) High flux dialyzer- have large pores capable of passing larger molecules (1,000-15,000 MW); have high water permeability: Kuf (Coefficient of ultrafiltration) >10 mL/hr/mmHg Kuf (Coefficient of ultrafiltration) - permeability of dialyzer membrane to water: function of membrane thickness and pore size; - number of milliliters of fluid per hour that will be transferred across the membrane per mmHg pressure gradient across the membrane Desired Kuf (Coefficient of ultrafiltration) to be chosen depends on whether an ultrafiltration controller is available Ultrafiltration controller accurately controls the ultrafiltration rate by means of special pumps and circuits

Most machines with volumetric ultrafiltration controllers: designed to use dialyzers with high water permeability; may lose accuracy if a high fluid removal rate is attempted using a dialyzer that is relatively impermeable to Desired Fluid Removal Rate Ideal dialyzer Kuf water. < 500 mL/hour < 3.0 500-1000 mL/hour >1000 mL/hour 3-4 4-5 IF dialysis machine with UF

controller is not available: choose dialyzer with low Kuf

If the Kuf is low, example: Kuf 2.0 To remove 1000 mL/hour : 500 mmHg TMP will be needed If the Kuf is 4.0 (moderate permeability) To remove 1000 mL/hour : required TMP 250 mmHg If the Kuf is 8.0 To remove 1000 mL/hour : TMP 125 mmHg Transmembrane pressure (TMP) During hemodialysis, water along with small solutes moves from the blood to dialysate in the dialyzer : Hydrostatic pressure gradient between the blood and dialysate compartments. The rate of ultrafiltration will depend on the total pressure difference across the membrane

DIALYSIS SOLUTION COMPOSITION standard composition: designed for acidotic, hyperphosphatemic, hyperkalemic chronic dialysis patients; inappropriate in an acute setting Components of Standard Bicarbonate-containing Solution:

Sodium Potassium Calcium Magnesium Chloride Acetate Bicarbonate Dextrose

135-145 meq/L 0 4 meq/L 2.5 3.5 meq/L 0.5 0.75 meq/L 98-124 meq/L 2-4 meq/L 30 40 meq/L 100 200 mg/L

Dialysate Bicarbonate concentration 30 40 meq/L Higher Bicarbonate levels required in treating acidotic patients. If preHD plasma bicarbonate level is 28 meq/L or higher or if patient has respiratory alkalosis: standard dialysis solution containing 35 or 38 meq/L bicarbonate should not be used. Use lower bicarbonate level: e.g. 20-28 meq/L Dangers of metabolic alkalosis: soft-tissue calcificatioin cardiac arrhythmia adverse symptoms such as nausea, lethargy, headache

Dialysate Sodium Concentration 135-145 meq/L 145 meq/L : acceptable for patients with normal or slightly reduced preHD serum sodium Adjusted if there is marked preHD hypernatremia or hyponatremia Hyponatremia : preHD serum sodium >130 meq/L - To achieve a post HD serum sodium of 140 meq/L, set dialysis sodium concentration to 140 + (140 preHD serum Na+ value) Example: preHD serum Na+ 130 meq/L 140 + (140 130) 140 + (10) = 150 meq/L Dialysate sodium Hyponatremia : preHD serum sodium <130 meq/L

- Note duration of hyponatremia, if chronic: dangerous to achieve normonatremia quickly - for severe chronic hyponatremia: Set dialysate sodium concentration no higher than 15-20 meq/L above the preHD serum Na+ level - correction of hyponatremia during multiple dialysis treatments performed over several days Hypernatremia - dangerous to correct by hemodialyzing against a low sodium dialysate - If the dialysate sodium level is > 3 5 meq/L lower than the preHD serum Na+: 3 complications: 1. Hypotension 2. muscle cramps 3. cerebral edema exacerbates dialysis dysequilibrium syndrome. - dialyze patient with a dialysate sodium level close (within 2 meq/L) to that of the serum Na+ - correct hypernatremia by slow administration of slightly hyponatric fluids

Dialysate Potassium concentration 0 4 meq/L preHD serum K+ < 4 meq/L - dialysate potassium level should be 4 meq/L or higher. preHD serum K+ >5.5 meq/L - dialysate potassium level of 2.0 meq/L is appropriate; should be raised to 2.5 3.0 meq/L for patients at risk for arrhythmia or in those on digitalis. preHD serum K+ >7.0 meq/L - dialysate potassium level below 2.0 meq/L; monitor serum K+ hourly

Dialysate Calcium concentration 2.5 3.5 meq/L - dialysate calcium levels < 3.0 meq/L : predisposes to hypotension preHD hypocalcemia further lowering with correction of acidosis during HD: routine use of 2.5 meq/L calcium is inappropriate. Acute hypercalcemia minimize overly rapid decrease in serum calcium: tentany or seizure; requires frequent measurement and physical examination during HD

Dialysate Magnesium concentration 0.5 0.75 meq/L / usual 0.75 1.5 meq/L Magnesium vasodilator ; Blood pressure is better maintained with dialysate Mg of 0.75 meq/L

Dialysate Dextrose concentration 100 200 mg/L

- reduces risk of hypoglycemia; lower incidence of dialysis-related side effects

Dialysate phosphate concentration (none) - normally absent from the dialysate - patients have elevated serum phosphate levels - large surface area dialyzer + longer dialysis session - increase the amount of phosphate removal during dialysis - Hypophosphatemia - aggravated by dialysis against a zero phosphate bath - respiratory muscle weakness - alterations in hemoglobin oxygen affinity - respiratory arrest - adding phosphorus to bicarbonate-containing dialysis solution: final dialysate should be 1.3 mmol/L (4 mg/dl); Phosphorus cannot be added to citrate containing dialysis solutions: Ca-Mg-PO4 solubility problems

DIALYSATE FLOW RATE For acute dialysis: usually 500 mL/min For maintenance dialysis: - standard: 500 mL/min - when BFR is high (e.g. >400 mL/min) increasing DFR to 800 mL/min will increase dialyzer clearance by about 10%

DIALYSIS SOLUTION TEMPERATURE - usually 35-37oC - lower range should be used in hypotension-prone patients

FLUID REMOVAL ORDERS Guidelines:

1. Fluid removal plan during dialysis should take into account the 0.2L that the patient will receive at the end of the treatment and other fluid ingested or administered during the hemodialysis session 2. During the initial dialysis length should be limited to 2 hours. If a large amount of fluid (i.e. 4L) must be removed: impractical and dangerous DO isolated ultrafiltration OR dialyze patient for 4-5 hours at a reduced BFR; remove the fluid at 1 L/hour. (Note: BFR <200 ml/min: risk of dialyzer clotting) 3. Best to remove fluid at a constant rate throughout the dialysis treatment. Chronic dialysis (Maintenance Dialysis) Concept of dry weight: Dry weight the postdialysis weight at which all or most excess body fluid has been removed. If dry weight is set too high: patient will remain in a fluid-overload state at the end of the dialysis session. If dry weight is set too low: patient may suffer from frequent hypotension during the latter part of the dialysis session. Patient often experience malaise, a washed-out feeling, cramps and dizziness after dialysis. - determined on a trial-and-error basis - changes periodically and should be reevaluated at least every 2 weeks

ANTICOAGULATION ORDERS (Separate Topic) Heparin: Routine heparinization Regional heparinization Tight heparinization Low molecular weight heparin Heparin-free dialysis

HEMODIALYSIS TREATMENT A. Rinsing and priming the dialyzer - thorough rinsing: reduces incidence or severity of anaphylactic dialyzer reactions

B. Obtaining vascular access 1. Percutaneous venous cannula - clot or residual heparin is first aspirated - check patency of catheter lumen 2. Arteriovenous (AV) fistula i. ii. iii. Tips regarding needle placement: In a patient with poorly distended venous limb - apply tourniquet; removed during dialysis; presence of tourniquet during dialysis will encourage recirculation. Use 16-gauge or 15-gauge needle Prepare needle insertion site with povidone-iodine for a full 10 minutes

Needle placement: Arterial needle - inserted first - at least 3 cm away from the site of AV anastomosis - inserted bevel up at 45-degree angle pointing toward the anastomosis Venous needle - inserted bevel up at 45-degree angle pointing toward the heart - insertion point at least 3 5 cm proximal to the arterial needle 3. Arteriovenous (AV) graft - guidelines for placing needles same as for AVF - use of tourniquet is never necessary C. Initiating dialysis - BFR is initially set at 50 mL/min, then 100 mL/min until the entire blood circuit fills with blood - Priming fluid is the dialyzer and tubing can either be given to the patient or disposed of to drain. In unstable patients: priming fluid is usually administered to the patient to help maintain the blood volume. - after the circuit is filled with blood and proper blood levels in the venous drip chamber are ensured BFR should be increased promptly to the desired level. - pressure levels of the arterial and venous pressure monitors are noted; pressure limits are set - initiate dialysis solution flow

D. Patient monitoring and complications - patients blood pressure should be monitored as often as necessary, but at least every 15 minutes (acute dialysis) - watch out for complications: separate topic

E. Termination of dialysis - blood in the extracorporeal circuit can be returned using either SALINE or AIR

SALINE: - patient usually receives 100-200 mL of saline during the rinse-back procedure AIR: - blood pump is first shut off - arterial blood line is clamped close to the patient - arterial blood line is the disconnected just distal to the clamping; opening it to air - blood pump is restarted at a reduced rate (20-50 ml/min) - air is allowed to displace the blood in the dialyzer - when air reaches the venous air trap or when air bubbles are first seen in the venous blood line venous line is clamped - blood pump is shut off and the return procedure is terminitaed - increases risk of air embolism F. Postdialysis evaluation 1. Weight loss - weigh patient after dialysis - compare postHD weight with the preHD weight - not uncommon for the weight loss to be greater or lesser than that anticipated. Sources of errors: a. Use of TMP that failed to account that the in vivo Kuf may be markedly less than the published in vitro value

b. Reduction in the dialyzer water permeability because of coating of the membrane with protein or clot c. Difficulty in maintaining the desired TMP during dialysis due to changes in venous resistance d. Use of a dialyzer that is highly permeable to water e. Failure to take into account fluid administered to the patient during hemodialysis. Errors a-d minimized by use of a dialysis machine with ultrafiltration controller

END OF TOPIC.