Dialysis adequacy

CHECK LIST
1.INTRODUCTION
2.WHAT IS ADEQUACY AND CLEARANCE
3.PARAMETERS TO LOOK FOR
4.FACTORS THAT AFFECT ADEQUACY
5.CASE ILLUSTRATION
PARAMETERS TO LOOK
FOR
SYMPTOMS ALONE
insufficient.
combination of dialysis plus eprex can
eliminate most uraemic symptoms
eventhough patient may be underdialysed.
Low predialysis BUN alone-
-well nourished who is adequately dialysed
-reduce protein intake which is a reflect of
inadequate dialysis
PARAMETERS TO LOOK FOR
PCR-protein catabolic rate.
PCR >1g/kg/d and TAC of urea <18mmol/l
associated with low morbidity.
target PCR 1-1.2 g/kg/d
PCR vary directly with KT/V.
3 measurement are required to obtain PCR
value with an error of < 10%.
 KT/V
Dialysate clearance of urea (k from
manufacture –in ml/min)
Multiply by duration of dialysis treatment (T
in min)
Divided by volume of distribution of urea (V)
 KT/V-how frequent ?
Once per month.
More freq for unstable patients.
In one study of 50 stable patients,the kt/v
had to be measured at least 3 times to
obtain a reliable and constant value
because of variation in the value of
urea,UF volume and urea clearance.
 FACTORS WHICH
INFLUENCED THE DIALYSIS
ADEQUACY
 KT/V
A STUDY OF 146 PATIENTS-low KT/V were due
to:
40%-lower than prescribed blood flow or time of
dialysis,largely from inadequate needle
placement and patient iniated time constraint.
25%-from significant access recirculation.
35%-no cause identified.subsequent kt/v rapidly
returned to normal without intervention.
* Unrecognized cause-increase body mass,needle
size.
 Low KT/V-what to do ?
1.Check fistula integrity
recirculation-dialysis deliver less than that
prescribed.
suspect if inadequate reduction in post
dialysis BUN (should be <40% of
predialysis).
high degree of access recirculation indicate
the presence of access stenosis.
 Low KT/V
Needle placement
placing needle to close together will
increase reentry of dialysed blood into
arterial needle.
needle should point in opposite direction.
Fistulography should be perfrmed if
recirculation >10%.
Recirculation should be assess every 3
months.
 Low KT/V
2.TREATMENT DURATION
-late arriving
-late initiation
-early termination
-blood leak
-needle difficulties
-excess triggering of machine alarm
 Low KT/V
3.METHOD OF OBTAINING BUN
SAMPLE.
technical error resulting in incorrectly low
predialysis BUN or high post dialysis BUN
may result in low KT/V.
*SAMPLING OF POST DIALYSIS BUN
slow blood pump to 50ml/min and then
obtained the blood sample 15 sec later.
 Low KT/V
4-MACHINE/PATIENT
-inadequate calibration
-low blood flow
-episode of hypotension
-overestimate of dialyzer clearance
CONCLUSION-ROLE OF
PARAMEDICS