Hemodialysis Adequacy

Publication Date: November 1, 2015
Last Updated: March 14, 2022

Recommendation Statements

Timing of Hemodialysis Initiation

Patients who reach CKD stage 4 (GFR < 30 mL/min/1.73 m2), including those who have imminent need for maintenance dialysis at the time of initial assessment, should receive education about kidney failure and options for its treatment, including kidney transplantation, PD, HD in the home or in-center, and conservative treatment. Patients' family members and caregivers also should be educated about treatment choices for kidney failure. (Not Graded)
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The decision to initiate maintenance dialysis in patients who choose to do so should be based primarily upon an assessment of signs and/or symptoms associated with uremia, evidence of protein-energy wasting, and the ability to safely manage metabolic abnormalities and/or volume overload with medical therapy rather than on a specific level of kidney function in the absence of such signs and symptoms. (Not Graded)
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Frequent and Long Duration Hemodialysis

In-center Frequent HD

We suggest that patients with end-stage kidney disease be offered in-center short frequent hemodialysis as an alternative to conventional in-center thrice weekly hemodialysis after considering individual patient preferences, the potential quality of life and physiological benefits, and the risks of these therapies. (Level 2 (Conditional Recommendation /Suggestion)
 “We suggest”, C: Low)
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We recommend that patients considering in-center short frequent hemodialysis be informed about the risks of this therapy, including a possible increase in vascular access procedures (1B) and the potential for hypotension during dialysis. (Level 1 (Strong Recommendation):  
“We recommend”, C: Low)
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Home Long HD

Consider home long hemodialysis (6-8 hours, 3 to 6 nights per week) for patients with end-stage kidney disease who prefer this therapy for lifestyle considerations. (Not Graded)
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We recommend that patients considering home long frequent hemodialysis be informed about the risks of this therapy, including possible increase in vascular access complications, potential for increased caregiver burden, and accelerated decline in residual kidney function. (Level 1 (Strong Recommendation):  
“We recommend”, C: Low)
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Pregnancy

During pregnancy, women with end-stage kidney disease should receive long frequent hemodialysis either in-center or at home, depending on convenience. (Not Graded)
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Measurement of Dialysis: Urea Kinetics

We recommend a target single pool Kt/V (spKt/V) of 1.4 per hemodialysis session for patients treated thrice weekly, with a minimum delivered spKt/V of 1.2. (Level 1 (Strong Recommendation):  
“We recommend”, B: Moderate)
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In patients with significant residual native kidney function (Kru), the dose of hemodialysis may be reduced provided Kru is measured periodically to avoid inadequate dialysis. (Not Graded)
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For hemodialysis schedules other than thrice weekly, we suggest a target standard Kt/V of 2.3 volumes per week with a minimum delivered dose of 2.1 using a method of calculation that includes the contributions of ultrafiltration and residual kidney function. (Not Graded)
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Volume and Blood Pressure Control: Treatment Time and Ultrafiltration Rate

We recommend that patients with low residual kidney function (< 2 mL/min) undergoing thrice weekly hemodialysis be prescribed a bare minimum of 3 hours per session. (Level 1 (Strong Recommendation):  
“We recommend”, D: Very low)
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Consider additional hemodialysis sessions or longer hemodialysis treatment times for patients with large weight gains, high ultrafiltration rates, poorly controlled blood pressure, difficulty achieving dry weight, or poor metabolic control (such as hyperphosphatemia, metabolic acidosis, and/or hyperkalemia). (Not Graded)
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We recommend both reducing dietary sodium intake as well as adequate sodium/water removal with hemodialysis to manage hypertension, hypervolemia, and left ventricular hypertrophy. (Level 1 (Strong Recommendation):  
“We recommend”, B: Moderate)
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Prescribe an ultrafiltration rate for each hemodialysis session that allows for an optimal balance among achieving euvolemia, adequate blood pressure control and solute clearance, while minimizing hemodynamic instability and intradialytic symptoms. (Not Graded)
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New Hemodialysis Membranes

We recommend the use of biocompatible, either high or low flux hemodialysis membranes for intermittent hemodialysis. (Level 1 (Strong Recommendation):  
“We recommend”, B: Moderate)
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Recommendation Grading

Overview

Title

Hemodialysis Adequacy

Authoring Organization

National Kidney Foundation

Publication Month/Year

November 1, 2015

Last Updated Month/Year

January 11, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

It is intended to assist practitioners caring for patients in preparation for and during hemodialysis.

Target Patient Population

Patients on hemodialysis

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Home health, Hospital, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Management

Diseases/Conditions (MeSH)

D015924 - Blood Pressure Monitors, D006436 - Hemodialysis Units, Hospital, D006437 - Hemodialysis, Home, D006464 - Hemoperfusion, D017583 - Hemodiafiltration, D015312 - Hemodialysis Solutions, D001810 - Blood Volume

Keywords

Chronic Hemodialysis, hemodialy, hemoperfusion

Source Citation

DOI:https://doi.org/10.1053/j.ajkd.2015.07.015
Am J Kidney Dis. 2015;66(5):884-930.

Supplemental Methodology Resources

Systematic Review Document