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The 2015 Hemodialysis Adequacy Guideline Update from KDOQI is the next iteration of guidelines from the 2006 report. The document covers a number of important topics to guide clinicians in the management of patients with kidney disease. These include:

• When to initiate renal replacement therapy?
• Frequency of hemodialysis?
• How to manage volume and blood pressure in hemodialysis?
• Do high-flux or low-flux membranes affect outcomes?
• Does hemofiltration or hemodiafiltration affect outcome?

It is accompanied by a systematic review by Slinin et al entitled, “Timing of Dialysis Initiation, Duration and Frequency of Hemodialysis Sessions, and Membrane Flux: A Systematic Review for a KDOQI Clinical Practice Guideline.” Let’s take a look at each of these issues and review what the guidelines state.

The guidelines are graded for strength of recommendation as either

Level 1: Strong Recommendation (We Recommend)
Level 2: Conditional Recommendation/Suggestion (We Suggest)

Furthermore, the quality of evidence is graded from

A: High quality of evidence
B: Moderate quality of evidence
C: Low quality of evidence
D: Very low quality of evidence

Each of these 5 guidelines are summarized in Box 2.

1. Timing of Hemodialysis Initiation

• Education about different forms of renal replacement therapy (RRT) should be started once eGFR reaches <30 mL/min/1.73m² or the eminent need for RRT approaches. No change from 2006. No grade is given for this.
• The timing of therapy should be driven by signs and symptoms of uremia, evidence of protein-energy wasting, or metabolic abnormalities/volume overload refractory to medical management. The 2015 guideline removes any suggested eGFR (which was previously given as 15 mL/min/1.73m² in 2006). No grade given for this.

2. Frequent and Long Duration Hemodialysis (note: not in 2006 guideline)

In-center Frequent HD

• Suggest: Patients with ESRD should be offered in-center short frequent HD as an alternative to thrice weekly HD, with discussion of patient preference and risk/benefit. Not in 2006 guideline. Grade of 2C.
• Recommend: All patients need to be informed of risk of in-center frequent HD, including increase in vascular access complications and potential hypotension during HD. Not in 2006 guideline. Grade of 1C.

Home Long HD

• Consider home long HD for patients with ESRD who prefer this therapy for lifestyle considerations. Not in 2006 guideline. No grade given for this.
• Recommend: All patients need to be informed of risk of home long HD, including increase in vascular access complications, potential for increased caregiver burden and accelerated decline of residual kidney function. Not in 2006 guideline. Grade of 1C.

 Pregnancy

• During pregnancy, women with ESRD should receive long frequent HD either in center or at home. Not in 2006 guideline. No grade given for this.

3. Measurement of Dialysis: Urea Kinetics

• Recommend: Target single pool Kt/V of 1.4 and minimum Kt/V of 1.2 per HD session in thrice weekly HD. No change from 2006. Grade of 1B.
• Dose may be reduced in patients with significant residual kidney function provided residual kidney function is measured periodically. No change from 2006. No grade given for this.
• For schedules other than thrice weekly, suggest a target Kt/V of 2.3 volumes per week with minimum Kt/V of 2.1 using a method of calculation that includes ultrafiltration and residual kidney function. Not in 2006 guideline. No grade given for this.

4. Volume and Blood Pressure Control: Treatment Time and Ultrafiltration Rate

• Recommend: Patients with low residual kidney function (<2mL/min) undergoing thrice weekly dialysis need a minimum of 3 hours per treatment. No change from 2006. Grade of 1D.

– Consider longer session or extra session if large weight gains, high BP, high UF rates, metabolic complications, or inability to achieve dry weight. No change from 2006. No grade given for this.

• Recommend: Reduce dietary sodium intake and ensure adequate sodium/water removal with HD to manage HTN and volume. 2006 guidelines suggested restricting to no more than 5 g of sodium chloride (2.0 g or 85 mmol of sodium). The 2015 guideline removes exact amount. Grade of 1B.

– Prescribe a UF rate balancing risk of hemodynamic instability with benefit of volume removal. No change from 2006. No grade given for this.

5. New Hemodialysis Membranes for HD

• Recommend: biocompatible high flux or low flux HD membranes. No change from 2006. Grade of 1B

Overall, the 2015 HD Adequacy Guideline is move streamlined than the 2006 version, and covers topics such as frequent in-center, home HD, and pregnancy. These topics didn’t get much attention in 2006, and reflect a shift in practice. However, the literature review only rose to the level of garnering a “suggest” for frequent in-center and “no grade given” to home HD from the work group. However, it does represent a shift. Hopefully more research will emerge on these topics to bolster the guidelines. The other major change is the removal of an eGFR cutoff suggestion for initiating RRT, focusing more on signs and symptoms, a result of data from the IDEAL trial demonstrating no clinical benefit from the earlier initiation of HD. Overall, the document provides a comprehensive review of the topic but it is sobering to realize how little evidence we truly have.

Matthew Sparks, MD
AJKD Blog Advisory Board member