HEMODIALYSIS ADEQUACYHEMODIALYSIS ADEQUACY

Laurie Vinci RN, BSN, CNNLaurie Vinci RN, BSN, CNN

September 17, 2011September 17, 2011

OBJECTIVESOBJECTIVES

Identify adequacy of dialysis and it’s Identify adequacy of dialysis and it’s

componentscomponents Discuss K-DOQI Guidelines for Discuss K-DOQI Guidelines for

hemodialysis adequacy hemodialysis adequacy Discuss nursing interventions to achieveDiscuss nursing interventions to achieve

adequate dialysisadequate dialysis

Definition: Hemodialysis AdequacyDefinition: Hemodialysis Adequacy

The delivered dose of hemodialysis that will The delivered dose of hemodialysis that will optimize the survival and well-being of the optimize the survival and well-being of the patientpatient

Numerous studies have demonstrated a Numerous studies have demonstrated a correlation between the delivered dose of correlation between the delivered dose of hemodialysis and patient mortality and hemodialysis and patient mortality and morbiditymorbidity

Components of Hemodialysis Components of Hemodialysis AdequacyAdequacy

Delivered dose of hemodialysis (HD) should be Delivered dose of hemodialysis (HD) should be measured at regular intervals no less than monthlymeasured at regular intervals no less than monthly

Two components of HD adequacy:Two components of HD adequacy:

1) Urea Kinetic Modeling (Kt/V)1) Urea Kinetic Modeling (Kt/V)

2) Urea Reduction Ratio (URR) 2) Urea Reduction Ratio (URR)

NKF-KDOQI, 2006, CPG 2 NKF-KDOQI, 2006, CPG 2

Kt/V (Dose of Dialysis)Kt/V (Dose of Dialysis)

K = Urea clearance through dialysisK = Urea clearance through dialysis

t = Time of dialysis in minutest = Time of dialysis in minutes

V = Volume of urea in proportion to V = Volume of urea in proportion to

volume of body watervolume of body water

Urea Reduction Ratio (URR)Urea Reduction Ratio (URR)

Difference between pre and post BUNDifference between pre and post BUN Statistically significant predictor of mortalityStatistically significant predictor of mortality

URR = URR = PRE BUN- POST BUNPRE BUN- POST BUN X 100 X 100

PRE BUNPRE BUN

Methods for Dialysis BUN Methods for Dialysis BUN Blood SamplingBlood Sampling

Pre/Post dialysis blood samples must be from Pre/Post dialysis blood samples must be from same sessionsame session

Avoid dilution of pre BUN sample (with Avoid dilution of pre BUN sample (with heparin/saline)heparin/saline)

NKF-KDOQI, 2006, CPG 3NKF-KDOQI, 2006, CPG 3

SLOW FLOW/STOP PUMPSLOW FLOW/STOP PUMPMETHODMETHOD

AT COMPLETION OF DIALYSISAT COMPLETION OF DIALYSIS::

1) Turn dialysate flow off, decrease UFR to 50 ml/min, lowest TMP 1) Turn dialysate flow off, decrease UFR to 50 ml/min, lowest TMP or offor off

2) Decrease BFR to 100 ml/min for 15 seconds2) Decrease BFR to 100 ml/min for 15 seconds

A) A) Slow FlowSlow Flow: After 15 seconds, leaving blood pump at 100 : After 15 seconds, leaving blood pump at 100 ml/min, draw BUN sample from port on arterial line. Stop blood pump ml/min, draw BUN sample from port on arterial line. Stop blood pump and terminate treatment per unit protocol.and terminate treatment per unit protocol.

OROR

B) B) Stop PumpStop Pump: After 15 seconds, stop pump, clamp arterial and : After 15 seconds, stop pump, clamp arterial and venous blood lines, draw BUN sample from arterial needle tubing, then venous blood lines, draw BUN sample from arterial needle tubing, then terminate treatment per unit protocolterminate treatment per unit protocol

Minimally adequate HDMinimally adequate HD HD treatment 3 x weekHD treatment 3 x week Kt/V 1.2 or URR 65%Kt/V 1.2 or URR 65%

Target dose of HDTarget dose of HD Kt/V 1.3 or URR 70%Kt/V 1.3 or URR 70%

NKF-KDOQI, 2006, CPG 4 NKF-KDOQI, 2006, CPG 4

Dose of dialysis should not be based solely Dose of dialysis should not be based solely on the URR and/or Kt/V. Other factors on the URR and/or Kt/V. Other factors need to be included:need to be included:

1) Potassium removal1) Potassium removal

2) Correction of acidosis2) Correction of acidosis

3) Sufficient protein/caloric intake to prevent 3) Sufficient protein/caloric intake to prevent

malnutritionmalnutrition

4) Longer time for fluid removal4) Longer time for fluid removal

Control of Volume and Blood Control of Volume and Blood PressurePressure

Blood pressure control improves patient outcomesBlood pressure control improves patient outcomes UFUF should be optimized with a goal to render the should be optimized with a goal to render the patient euvolemic and normotensivepatient euvolemic and normotensive Restrict Na intake to 2 gms/24 hrsRestrict Na intake to 2 gms/24 hrs Increasing positive Na+ balance by “Na profiling” or Increasing positive Na+ balance by “Na profiling” or using a high dialysate Na+ concentration should be using a high dialysate Na+ concentration should be avoidedavoided

NKF-KDOQI, 2006, CPG 5 NKF-KDOQI, 2006, CPG 5

Strategies to Minimize Strategies to Minimize Hypotensive SymptomsHypotensive Symptoms

Avoid excessive UFAvoid excessive UF Slow the UF rateSlow the UF rate Perform isolated UF (SUF)Perform isolated UF (SUF) Manipulate Na levels (modeling)Manipulate Na levels (modeling) Decrease dialysate temperature from 37C to 34-35C Decrease dialysate temperature from 37C to 34-35C

(need MD order)(need MD order) Administer midodrine pre dialysis (MD order)Administer midodrine pre dialysis (MD order) Manage HemoglobinManage Hemoglobin Optimize patient behavior through educationOptimize patient behavior through education

Interventions: Evaluate elements of HD Interventions: Evaluate elements of HD treatments that may compromise urea treatments that may compromise urea

clearanceclearance AssessAssess for access recirculationfor access recirculation Verify flow of blood through the access (especially if Verify flow of blood through the access (especially if

loop graft)loop graft) Inadequate blood flow from the access resulting in Inadequate blood flow from the access resulting in

decreased blood flowsdecreased blood flows Dialyzer blood leak on day Kt/V and/or BUN drawnDialyzer blood leak on day Kt/V and/or BUN drawn Inefficient dialyzerInefficient dialyzer DFR set too lowDFR set too low Inadequate coagulationInadequate coagulation Inadequate dialyzer reprocessingInadequate dialyzer reprocessing

Review Treatment Documentation on day of Review Treatment Documentation on day of Kt/V and URRKt/V and URR

Review prescribed treatment vs. actual Review prescribed treatment vs. actual treatment parameterstreatment parameters

Review Blood Flow Rate and Dialysate Flow Review Blood Flow Rate and Dialysate Flow RateRate

Assess for Lab and Blood Assess for Lab and Blood Sampling ErrorsSampling Errors

Lab errorsLab errors Dilution of pre BUN with N/S or heparinDilution of pre BUN with N/S or heparin Drawing pre BUN after HD initiatedDrawing pre BUN after HD initiated Drawing post BUN before HD completed or Drawing post BUN before HD completed or

drawing sample late (>3 mins. after drawing sample late (>3 mins. after completion)completion)

Blood lines or needles reversedBlood lines or needles reversed

Assess Reductions in Treatment Assess Reductions in Treatment TimesTimes

Treatment Week Month YearTreatment Week Month Year 5 Minutes 15 Minutes 65 Minutes 780 Minutes5 Minutes 15 Minutes 65 Minutes 780 Minutes (1.08 Hours) (13 Hours/0.54 Days)(1.08 Hours) (13 Hours/0.54 Days)

10 Minutes 30 Minutes 130 Minutes 1,560 Minutes10 Minutes 30 Minutes 130 Minutes 1,560 Minutes (2.17 Hours) (26 Hours/1.08 Days)(2.17 Hours) (26 Hours/1.08 Days)

15 Minutes 45 Minutes 195 Minutes 2,340 Minutes15 Minutes 45 Minutes 195 Minutes 2,340 Minutes (3.25 Hours) (39 Hours/1.63 Days)(3.25 Hours) (39 Hours/1.63 Days)

20 Minutes 60 Minutes 260 Minutes 3,120 Minutes20 Minutes 60 Minutes 260 Minutes 3,120 Minutes (1 Hour) (4.33 Hours) (52 Hours/2.17 Days)(1 Hour) (4.33 Hours) (52 Hours/2.17 Days)

25 Minutes 75 Minutes 325 Minutes 3,900 Minutes25 Minutes 75 Minutes 325 Minutes 3,900 Minutes (1.25 Hours) (5.42 Hours) (65 Hours/2.71 Days)(1.25 Hours) (5.42 Hours) (65 Hours/2.71 Days)

30 Minutes 90 Minutes 390 Minutes 4,680 Minutes30 Minutes 90 Minutes 390 Minutes 4,680 Minutes (1.5 Hours) (6.5 Hours) (78 Hours/3.25 Days)(1.5 Hours) (6.5 Hours) (78 Hours/3.25 Days)