1. HEMODIALYSIS ADEQUACY HEMODIALYSIS ADEQUACY Laurie Vinci RN, BSN, CNN Laurie Vinci RN, BSN, CNN September 17, 2011 September 17, 2011

2. OBJECTIVES OBJECTIVES Identify adequacy of dialysis and it’s Identify adequacy of dialysis and it’s components components Discuss K-DOQI Guidelines for Discuss K-DOQI Guidelines for hemodialysis adequacy hemodialysis adequacy Discuss nursing interventions to achieve Discuss nursing interventions to achieve adequate dialysis adequate dialysis

3. Definition: Hemodialysis Adequacy The delivered dose of hemodialysis that will optimize the survival and well-being of the patient The delivered dose of hemodialysis that will optimize the survival and well-being of the patient Numerous studies have demonstrated a correlation between the delivered dose of hemodialysis and patient mortality and morbidity Numerous studies have demonstrated a correlation between the delivered dose of hemodialysis and patient mortality and morbidity

4. Components of Hemodialysis Adequacy  Delivered dose of hemodialysis (HD) should be measured at regular intervals no less than monthly  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

5. Kt/V (Dose of Dialysis) Kt/V (Dose of Dialysis) K = Urea clearance through dialysis K = Urea clearance through dialysis t = Time of dialysis in minutes t = Time of dialysis in minutes V = Volume of urea in proportion to V = Volume of urea in proportion to volume of body water volume of body water

6. Urea Reduction Ratio (URR)  Difference between pre and post BUN  Statistically significant predictor of mortality URR = PRE BUN- POST BUN X 100 URR = PRE BUN- POST BUN X 100 PRE BUN PRE BUN

7. Methods for Dialysis BUN Blood Sampling Pre/Post dialysis blood samples must be from same session Pre/Post dialysis blood samples must be from same session Avoid dilution of pre BUN sample (with heparin/saline) Avoid dilution of pre BUN sample (with heparin/saline) NKF-KDOQI, 2006, CPG 3 NKF-KDOQI, 2006, CPG 3

8. SLOW FLOW/STOP PUMP METHOD AT COMPLETION OF DIALYSIS: AT COMPLETION OF DIALYSIS: 1) Turn dialysate flow off, decrease UFR to 50 ml/min, lowest TMP or off 1) Turn dialysate flow off, decrease UFR to 50 ml/min, lowest TMP or off 2) Decrease BFR to 100 ml/min for 15 seconds 2) Decrease BFR to 100 ml/min for 15 seconds A) Slow Flow: After 15 seconds, leaving blood pump at 100 ml/min, draw BUN sample from port on arterial line. Stop blood pump and terminate treatment per unit protocol. A) Slow Flow: After 15 seconds, leaving blood pump at 100 ml/min, draw BUN sample from port on arterial line. Stop blood pump and terminate treatment per unit protocol. OR OR B) Stop Pump: After 15 seconds, stop pump, clamp arterial and venous blood lines, draw BUN sample from arterial needle tubing, then terminate treatment per unit protocol B) Stop Pump: After 15 seconds, stop pump, clamp arterial and venous blood lines, draw BUN sample from arterial needle tubing, then terminate treatment per unit protocol

9. Minimally adequate HD Minimally adequate HD  HD treatment 3 x week  Kt/V 1.2 or URR 65% Target dose of HD Target dose of HD  Kt/V 1.3 or URR 70%  NKF-KDOQI, 2006, CPG 4

10. Dose of dialysis should not be based solely on the URR and/or Kt/V. Other factors need to be included: Dose of dialysis should not be based solely on the URR and/or Kt/V. Other factors need to be included: 1) Potassium removal 1) Potassium removal 2) Correction of acidosis 2) Correction of acidosis 3) Sufficient protein/caloric intake to prevent 3) Sufficient protein/caloric intake to prevent malnutrition malnutrition 4) Longer time for fluid removal 4) Longer time for fluid removal

11. Control of Volume and Blood Pressure Blood pressure control improves patient outcomes  UF should be optimized with a goal to render the patient euvolemic and normotensive  Restrict Na intake to 2 gms/24 hrs  Increasing positive Na+ balance by “Na profiling” or using a high dialysate Na+ concentration should be avoided NKF-KDOQI, 2006, CPG 5 NKF-KDOQI, 2006, CPG 5

12. Strategies to Minimize Hypotensive Symptoms Avoid excessive UF Avoid excessive UF Slow the UF rate Slow 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 (need MD order) Decrease dialysate temperature from 37C to 34-35C (need MD order) Administer midodrine pre dialysis (MD order) Administer midodrine pre dialysis (MD order) Manage Hemoglobin Manage Hemoglobin Optimize patient behavior through education Optimize patient behavior through education

13. Interventions: Evaluate elements of HD treatments that may compromise urea clearance Assess for access recirculation Assess for access recirculation Verify flow of blood through the access (especially if loop graft) Verify flow of blood through the access (especially if loop graft) Inadequate blood flow from the access resulting in decreased blood flows Inadequate blood flow from the access resulting in decreased blood flows Dialyzer blood leak on day Kt/V and/or BUN drawn Dialyzer blood leak on day Kt/V and/or BUN drawn Inefficient dialyzer Inefficient dialyzer DFR set too low DFR set too low Inadequate coagulation Inadequate coagulation Inadequate dialyzer reprocessing Inadequate dialyzer reprocessing

14. Review Treatment Documentation on day of Kt/V and URR Review Treatment Documentation on day of Kt/V and URR Review prescribed treatment vs. actual treatment parameters Review prescribed treatment vs. actual treatment parameters Review Blood Flow Rate and Dialysate Flow Rate Review Blood Flow Rate and Dialysate Flow Rate

15. Assess for Lab and Blood Sampling Errors Lab errors Lab errors Dilution of pre BUN with N/S or heparin Dilution of pre BUN with N/S or heparin Drawing pre BUN after HD initiated Drawing pre BUN after HD initiated Drawing post BUN before HD completed or drawing sample late (>3 mins. after completion) Drawing post BUN before HD completed or drawing sample late (>3 mins. after completion) Blood lines or needles reversed Blood lines or needles reversed

16. Assess Reductions in Treatment Times Assess Reductions in Treatment Times Treatment Week Month Year Treatment Week Month Year 5 Minutes 15 Minutes 65 Minutes 780 Minutes 5 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 Minutes 10 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 Minutes 15 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 Minutes 20 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 Minutes 25 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 Minutes 30 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)