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Renal Association Clinical Practice Guideline on Haemodialysis

Renal Association Clinical Practice Guideline on Haemodialysis

Renal Association has released new  Clinical Practice Guideline on Haemodialysis that has been published in BMC Nephrology.

These guidelines are an update of a previous version written in 2009. It aims to provide guidance on how to look after patients and how to run dialysis units, and provides standards which units should in general aim to achieve.

Following are the major recommendations:

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1. Dialysis dose in thrice weekly dialysis schedules

  • We recommend eKt/V as the most clinically valid small-solute measure of dialysis dose, and recommend monitoring of dialysis dose on a monthly basis for the majority of centre-based dialysis patients. [1B]
  • We recommend targeting dialysis dose to achieve consistently a minimum eKt/V of 1.2 for thrice weekly patients, in the absence of a measured contribution from residual function. [1B]
  • We recommend a minimum of 12 hours per week for the majority of thrice weekly patients with minimal residual function. [1B]

2. Non-standard schedules (Guidelines 2.1 – 2.4)

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Augmented schedules

  • We suggest offering an augmented schedule to patients who are unable to achieve adequacy targets or fluid control on a standard thrice weekly schedule. [2B]
  • We suggest that relative contraindications to augmented schedules should be considered, such as significant residual function or problematic fistula access. [2C]

Incremental schedules

  • We suggest that lower haemodialysis dose targets may be optimal in patients with significant residual renal function. [2D]
  • We recommend that residual renal function should be quantified intermittently in patients on incremental dialysis schedules. [1D]

Conservative schedules

  • We suggest that lower haemodialysis dose targets may be optimal when quality of life is the primary goal of treatment, rather than longevity. [2D]

Paediatric schedules

  • In children and adolescents we recommend an approach to the assessment of dialysis adequacy which goes beyond biochemical targets, incorporating clinical goals such as growth, bone health, cardiac function and quality of life. [1C]
  • We recommend targeting dialysis dose to achieve a minimum eKt/V of 1.2 for thrice weekly patients, or a standardized Kt/V of 2.2 for those on augmented schedules. [1C]
  • We suggest an augmented schedule for children on predominantly liquid nutrition, and those with ventricular systolic dysfunction. [2D]
  • We recommend a blood flow rate of 5-7ml/kg/min for the majority of patients, using consumables appropriate to body size, with extracorporeal volume less than 10% of the patient’s blood volume. [1C]

Schedules during pregnancy

  • We recommend counselling women of reproductive age who are receiving or anticipating dialysis, so that they are aware of the interactions between renal replacement therapies and pregnancy which may impact on family planning and modality decisions. [1D]
  • For dialysis patients wishing to continue their pregnancy, we recommend changing as early as possible to an individualised, augmented haemodialysis schedule. For those with minimal residual function this should be at least 20 hours per week, delivered over at least 6 sessions. [1B]
  • We recommend an individualised dialysate prescription appropriate to the dialysis schedule and biochemistry results, anticipating the frequent need for a high potassium / low bicarbonate dialysate, supplemented with phosphate. [1C]
  • We suggest an individualised fluid management protocol, with low ultrafiltration rates and regular clinical assessment, anticipating the typical change in weight during pregnancy. [2C]

3. Membrane flux and haemodiafiltration

  • We recommend that patients with minimal residual function should be treated with high-flux dialysers. [1B]
  • We suggest that haemodiafiltration may be considered as a treatment for intra-dialytic hypotension refractory to other measures, and for dialysis patients with favourable prognosis who are unable or unlikely to be transplanted. [2B]

4. Fluid in haemodialysis 

Fluid assessment and management in adults

  • We recommend assessment of fluid status when prompted by clinical circumstances, and on a quarterly basis for stable patients. [1C]
  • We suggest a multidisciplinary approach to fluid assessment, with patient involvement and the adoption of patient-friendly terminology such as “target weight”, “fluid gain” and “over-hydration”. [2D]
  • We recommend clinical assessment of fluid status on a monthly basis for the majority of patients. [1C]
  • We suggest supplementing clinical assessment of fluid status with a validated objective measurement, such as bioimpedance, at regular intervals, when clinical assessment is unclear, and following an intercurrent illness. [2C]
  • We recommend a dialysate temperature not greater than 36’C if standardised. [1C]
  • We recommend avoiding excessive ultrafiltration rates by addressing fluid gains, accepting staged achievement of target weight, or using an augmented schedule, as necessary. [1B]
  • We recommend prompt nursing intervention to restore haemodynamic stability in symptomatic/severe intradialytic hypotension, with such interventions leading to clinical review. [1C]

Paediatric fluid considerations

  • In growing children we recommend clinical assessment of fluid status and target weight, and dietetic assessment, at least monthly. [1C]
  • We suggest supplementing clinical assessment with a validated objective measure of fluid status such as bioimpedance, on a monthly basis or more frequently during periods of rapid growth or illness. [2C]
  • We recommend regular assessment of ultrafiltration tolerance, using extended times to avoid excessive ultrafiltration rates. [1D]

5. Dialysate

Selection of dialysate potassium

  • We recommend an optimal pre-dialysis serum potassium in the range 4.0–6.0mmol/L, remembering to consider measurement errors (e.g. due to haemolysis) when interpreting levels. [1B]
  • We suggest choosing dialysate potassium between 1.0 and 3.0mmol/L for the majority of patients, using an individualised approach, in general using the highest dialysate potassium that is sufficient to control pre-dialysis hyperkalemia. [2C]
  • We suggest a combined approach to managing hyperkalaemia, which may include decreasing dialysate potassium and/or other measures, including dietary advice, medication review and increased dialysis frequency. [2D]

Selection of dialysate buffer

  • We recommend optimal pre-dialysis serum bicarbonate in the range 18.0-26.0mmo/L, remembering to consider measurement errors (e.g. due to exposure to air) when interpreting levels. [1C]
  • We suggest the term ‘dialysate buffer’ rather than ‘dialysate bicarbonate’ to avoid confusion arising from differences in manufacturers’ terminology. [2C]
  • We suggest choosing a dialysate buffer below or equal to 37.0mEq/L for the majority of patients, using a standardized or individualized approach. [2C]
  • We suggest a combined approach to abnormal pre-dialysis serum bicarbonate, which may include increasing dialysis dose, oral bicarbonate, nutritional support, or individualizing dialysate buffer. [2D]

Supplementation of dialysate with phosphate

  • We suggest considering supplementation of the dialysate with phosphate in patients on augmented dialysis schedules. [2D]

Paediatric dialysate considerations

  • We recommend individualization of dialysate electrolyte concentrations, including potassium, buffer and calcium. [1C]
  • We suggest an individualized dialysate temperature, between core temperature and 0.5°C below, with monitoring of intradialytic core temperature for neonates and smaller children. [2D]

6. Anticoagulation

  • We recommend that patients without increased bleeding risk should be given unfractionated or low-molecular-weight heparin during dialysis to reduce clotting of the extracorporeal system. [1A]
  • We recommend that systemic anticoagulation should be omitted or minimised in patients with increased bleeding risk. [1C]
  • We recommend that patients with heparin allergies should be prescribed a non-heparin form of anticoagulation. [1A]

7. Adverse events during dialysis

Routine blood loss

  • We suggest that during washback, dialysis lines and dialyser are observed to ensure residual blood loss is kept to a minimum. [2C]

Disconnection haemorrhage

  • We recommend maintaining awareness of the risk of disconnection, the limitations of pressure alarms, and importance of direct observation, through a program of education, including patients and carers. [1D]
  • We suggest regular assessment of individual risk, so that high risk patients can have enhanced monitoring, which could include specific devices. [2B]

Immune reactions during dialysis

  • We recommend that dialysis staff should be aware of the features and management of dialysis reactions, and should have access to a range of dialyser types. [1C]

8. Patient experience of dialysis

Home haemodialysis

  • We recommend that home haemodialysis should be available in all units as part of a comprehensive renal replacement therapy programme. [1A]
  • We suggest training patients and/or care partners to achieve a defined set of competencies, using an individualised approach to training method and speed. [2D]
  • We suggest units form a contract with patients outlining responsibilities, including an agreement to dialyse as per prescription and trained technique, and including a policy for re-imbursement of directly arising patient costs. [2D]
  • We suggest supporting patients with a specific team including nephrologists, technicians, and nurses, with rapid access to dialysis in-centre when required. [2C]
  • We suggest an agreed individualised prescription for home haemodialysis, taking into account lifestyle goals, with the same dose and time target considerations as centre-based patients. [2C]
  • We recommend enhanced safety measures for patients who dialyse alone or overnight, and an enhanced risk assessment for patients with blood-borne viruses. [1C]

Shared haemodialysis care

  • We suggest that all centre-based haemodialysis patients should have opportunity and encouragement to learn aspects of their dialysis treatment, and take an active role in their care. [2D]

Intradialytic exercise

  • We recommend that intradialytic exercise should be available in all units, as a treatment for enhancing physical functioning, in patients without contraindications. [1B]
  • We suggest that intradialytic exercise be considered as a method of enhancing quality of life. [2C]
  • We suggest that exercise regimes be devised by appropriately trained staff. [2C]

Dialysis experience for children and adolescents

  • We recommend that haemodialysis for children and adolescents should be delivered in a dedicated paediatric dialysis centre or at home, with the involvement of a paediatric multidisciplinary team. [1C]
  • We recommend that adolescents should commence an active transition programme by 14 years, or at the time of presentation in those already over 14. [1D]

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Source: BMC Nephrology

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