1st scenario

Mr X, 50 year old male with past medical history of hypertension, diabetes, end stage renal disease on home hemodialysis for last 3 months. Reports drinking increased fluid throughout the day.

Vitals: PR 82/min, BP 160/100 mmHg
Wt 100 kg, Ht 160 cm
Exam pertinent for 2+ lower extremity edema

Labs:
Na 138 meq/L, K 4.8 meq/L, Cl 104 meq/L, CO2 24meq/L, BUN 56 mg/dl, Cr 6.4 mg/dl

How to tailor HHD prescription in this situation?

Know frequency of dialysis session per week and calculate sp Kt/V. Lets assume he wants to do 6 times a week.
  • (With permission from copyright holder.)
  • spKt/V 0.5

    Calculate minimum hours needed to achieve desired ultrafiltration (UF) if weekly total fluid gain is 18L.
    • In one week, total fluid gain is 18L
      If doing 6 days dialysis, everyday fluid removal should be 18/6 = 3 L
      Taking max UFR 8 ml/kg/hr = 8 x 100 = 800 ml/hr
      Number of hours needed = Fluid removal per session (ml)/UFR (ml/hr) = 3000/800= 3.75 hrs ~ 3 hr 45 mins

    Calculate dialysate volume. (assuming FF 40%, BFR 300ml/hr)
    Hint: for this you need Flow fraction, BFR, TBW

    Calculate time needed for each session for adequate clearance.

    Hint: you need Dialysate volume, Dialysate flow rate (DFR)

    • Dialysate volume is 25L, FF 0.4, BFR 300 ml/hr, DFR (ml/min)= FF x BFR (ml/min) = 0.4 x 300 = 120 ml/min
      Time needed for adequate clearance (min) = Dialysate volume (ml)/DFR (ml/min)
      = 25,000/120 = 208 min = 3 hr 28 min

    Prescription is ready
    • Frequency: 6 times a week
    • FF 0.4
    • BFR 300 ml/min
    • DFR 120 ml/min
    • Dialysate volume= 25L
    • Minimum time for each session for adequate clearance and volume control = 3 hr 45 min

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