Adequacy of twice weekly hemodialysis in finish stage renal illness sufferers at a tertiary care dialysis centre

Results from the Dialysis Outcomes and Practice Patterns Study
December 25, 2020 0 Comments

Indian J Nephrol. 2015 Nov-Dec; 25(6): 329–333.


Hemodialysis has improved the morbidity and mortality related to finish stage renal illness. In India, hemodialysis prescription is empiric, which ends up in problems associated to under-dialysis. Therefore, adequacy of hemodialysis in Indian setting was analyzed on this research. A complete of fifty sufferers on twice per week hemodialysis have been assessed for 1 month. The variety of classes assembly requirements laid out by Kidney Illnesses Final result High quality Initiatives (KDOQI) pointers have been calculated. They have been divided into two teams: one in whom dialysis was monitored and session size enhanced to fulfill the minimal customary Kt/V of two and second management group; the place Kt/V was not monitored. Hemoglobin (Hb) ranges, albumin ranges, imply arterial strain and World Well being Group (WHO) high quality of life (QoL) rating have been in contrast within the two teams after 6 months. Solely 28% of hemodialysis classes have been ample as per KDOQI pointers. There was vital enchancment in Hb ranges (1.47 vs. 0.15 g/dl), imply arterial strain ranges (15.2 vs. 3.16 mm Hg), serum albumin ranges (0.82 vs. 0.11 g/dl) and WHO QoL rating (17.2 vs. 2.24) in research group as in comparison with management group. Customary Kt/V can be utilized as an necessary device to change twice weekly dialysis classes to offer higher QoL to the sufferers. Nonetheless, research with bigger pattern dimension are required to conclusively show our outcomes.

Key phrases: Finish stage renal illness, hemodialysis adequacy, hemodialysis frequency


Power kidney illness (CKD) is a devastating illness with profound bodily morbidity related to monetary, social and emotional stress on the person. The definition of CKD relies on the presence of kidney harm (i.e., albuminuria) or decreased kidney operate (i.e., glomerular filtration price <60 mL/min/ 1.73 m2) for 3 months or extra. The time period “end- stage renal illness” (ESRD) typically refers to CKD handled with both dialysis or transplantation. The age-adjusted incidence price of ESRD in India has been estimated to be 229/million inhabitants.[1] Diabetes is the primary explanation for kidney failure in most international locations, accounting for 40% or extra of latest sufferers.[2] Prevalence appears to be rising significantly in older people, and partly due to an rising prevalence of diabetes and hypertension.[3] Prices for dialysis and transplantation are rising alongside prices for different power illnesses.[4]

Hemodialysis is the mainstay remedy which is obtainable for ESRD sufferers who can not bear renal transplantation. The principle function of hemodialysis is the supply of enough and protected affected person therapy, which contributes to the higher bodily situation of the affected person and it prevents additional issues and problems which can be resulting from uremia. In India, often hemodialysis prescription is empiric, which can result in underneath dialysis and associated problems.[5] The delivered Kt/V decided by single-pool urea kinetic modeling continues to be most popular as essentially the most exact and correct measure of dialysis. A central concern within the administration of sufferers present process upkeep hemodialysis is the evaluation of the adequacy of dialysis.

The delivered dose of HD for sufferers with established renal failure has elevated over the past decade.[6] Regardless of its dramatic success at saving lives, hemodialysis stays removed from excellent remedy. Greater than 20% of hemodialysis sufferers die annually.[7] As well as, morbidity stays excessive, with frequent problems of coronary heart illness, hypertension, anemia, bone illness, poor diet, irritation, melancholy, and impaired cognitive and bodily operate. In developed international locations often hemodialysis is completed thrice per week. Nonetheless in India most sufferers are given HD twice per week. Solely 20% of sufferers are dialyzed 3 instances per week. The dialysis prescription is empirical, with Kt/V < 1 in essentially the most of sufferers.[8] Though it's well-known that rising the frequency of dialysis improves the standard of life (QoL), it's not an choice resulting from strain from too many sufferers and insufficient hemodialysis machines.

Whereas optimum ranges stay to be established, doses of dialysis represented by Kt/V measurements <1.20 are broadly thought of insufficient.[9] Beneath this degree, every 0.10 lower in Kt/V is estimated to extend the relative threat of dying by 7%.[10] The standardized Kt/V is a technique to measure the clearance effectivity of HD of variable frequency, gradual steady renal alternative therapies, residual renal operate (RRF) and all conditions involving using clearance from varied strategies.[11] The serum albumin focus, which is used routinely as a marker of nutritive standing, is the results of the synthesis, catabolism and quantity re-distribution, in addition to trans capillary change loss.[12] World Well being Group (WHO) QoL BREF rating offers a measurement of functioning and well-being quite than of illnesses and problems, therefore is extra complete and appropriate with the WHO's idea of well being.[13] This rating can act as an end result measure to match administration methods.[14]

Hemodialysis Adequacy Scientific Follow Tips 2006 recommends spKt/V of two (minimal spKt/V akin to a standardized Kt/V of approximate 2.0/week). For twice per week hemodialysis: If RRF (Kr) >2 mL/min/1.73 m2 the minimal spKt/V needs to be 2. If Kr < 2 mL/min/1.73 m2 then twice per week hemodialysis is just not often really helpful. These spKt/V values must be thought of as minimal values, not goal values.

This research is aimed to evaluate the adequacy of hemodialysis offered at Tertiary Care Middle in addition to to find out whether or not adjusting solely the period of dialysis based mostly on standardized Kt/V measurement improves the QoL of sufferers.

Supplies and Strategies

Fifty sufferers on upkeep hemodialysis at a Tertiary Care Middle have been studied for adequacy of hemodialysis.

Exclusion standards

  • Sufferers with acute sickness not associated to CKD requiring hospitalization in final 1 month

  • Sufferers on thrice per week hemodialysis

  • Sufferers on steady ambulatory peritoneal dialysis.


First part of the research (assessing adequacy of dialysis). Baseline knowledge together with primary illness, period of hemodialysis, peak, weight, pulse and blood strain was recorded. The pre and postdialysis blood urea nitrogen, postdialysis weight and ultrafiltrate quantity of fifty sufferers was recorded weekly for 1 month.

We used the gradual blood circulation sampling method[15] for submit hemodialysis samples. The spKt/V and eqKt/V was estimated from the pre and postdialysis blood urea nitrogen, postdialysis weight and ultrafiltrate quantity utilizing the Davita net based mostly calculator at For every week, customary Kt/V was calculated from the spKt/V, common session size, variety of classes of dialysis per week utilizing the HDCN net calculator at The variety of classes assembly requirements laid out for adequacy of dialysis as per kidney illnesses end result high quality initiatives (KDOQI) pointers and frequent hemodialysis community was calculated. Within the second part of the research, the 50 sufferers have been randomized into the research group A and management group B after knowledgeable consent by pc generated randomization. At baseline medical parameters, hemoglobin (Hb), serum albumin and the questionnaire based mostly WHO QoL rating have been recorded in all sufferers. Thereafter, within the 25 sufferers in research group A, standardized Kt/V was measured weekly. The size of the dialysis was extended if required, to fulfill a goal of two for standardized Kt/V. Within the management group, no monitoring of Kt/V was completed. After 6 months once more medical parameters, Hb, serum albumin and the QoL questionnaire together with the measures of adequacy of hemodialysis have been recorded.

Statistical evaluation was carried out between the 2 teams utilizing Mann–Whitney take a look at for variations in Hb ranges, albumin ranges, medical parameters and WHO QoL scores. First part was cross-sectional descriptive research and the second was randomized case–management research. Research was completed at a Tertiary Care Dialysis Middle. Moral approval was obtained by moral committee. Sufferers’ written knowledgeable consent was taken in a language that they perceive.



In our research, 56% (n = 28) of the research inhabitants was male and 44% (n = 22) was feminine. The typical age of enrolled sufferers was 56.02 ± 9.89 years (vary: 29–65 years). The most typical primary illness was diabetic nephropathy; seen in 34% (n = 17) of sufferers [].

Desk 1

Frequency of primary illness in research inhabitants (n=50)

An external file that holds a picture, illustration, etc.
Object name is IJN-25-329-g001.jpg

Imply arterial strain of our sufferers (n = 50) was 117.16 ± 10.79 mm Hg (Vary: 146–90 mm Hg). Imply Hb degree of the research inhabitants was 8.15 ± 1.49 g/dl (Vary: 12.0–6.4 g/dl). The typical albumin ranges of our sufferers (n = 50) was 3.28 ± 0.46 g/dl (Vary: 5.5–2.4 g/dl). 82% (n = 41) sufferers had serum albumin ranges <3.5 g/dl. Imply QoL rating was 80.78 ± 14.76 (Vary: 110–51).

The variety of classes assembly requirements laid out for adequacy of dialysis

Completely 400 classes have been analyzed. As per KDOQI pointers, (minimal standardized Kt/V –2.0, single pool Kt/V −2.0) 112 classes have been discovered to be insufficient. The typical standardized Kt/V was 1.4 [].

An external file that holds a picture, illustration, etc.
Object name is IJN-25-329-g002.jpg

Frequency of ample dialysis classes (spKt/V > 1.2); whole classes = 400; insufficient classes = 288 (72%) and ample dialysis classes = 112 (28%)

Baseline comparability of each teams with respect to parameters

Each the research teams have been roughly matched for age, intercourse, imply arterial strain, Hb, albumin and WHO QoL rating [].

An external file that holds a picture, illustration, etc.
Object name is IJN-25-329-g003.jpg

Baseline comparability of each teams; group A (n = 25). The dialysis classes monitored and modified as per Kt/V; group B (n = 25) continued on standard 4 h dialysis classes twice per week

Distinction between research and management group at 6 months follow-up

The typical hemodialysis period in research group (group A) was 318.22 ± 34.11 (vary: 240–360) min. In group B, the typical period was 240 ± 30 min [].

An external file that holds a picture, illustration, etc.
Object name is IJN-25-329-g004.jpg

Bar diagram depicting change in all parameters. Important enchancment in group A (dialysis classes monitored and modified as per Kt/V) as in comparison with group B (continued on standard 4 h dialysis classes twice per week)

The typical fall of imply arterial strain in group A was 15.2 ± 7.96 (vary: 33.0 to −2.0) mm Hg, whereas in group B it was 3.16 ± 6.84 (vary: 28.0 to −7.0) mm Hg. The distinction was statistically vital with Mann–Whitney take a look at (P < 0.05). The rise in Hb in group A was 1.47 ± 1.06 (vary 3.2–0.1) g/dl as in comparison with 0.15 ± 0.65 (vary: +2.0 to − 1.0) g/dl in group B, which was statistically vital with Mann–Whitney take a look at. The rise in serum albumin was 0.82 ± 0.51 (vary: 2.0–0.1) g/dl in group A as in comparison with 0.11 ± 0.39 (vary +1.0 to − 0.5) g/dl in group B (P < 0.05). The typical rise in WHO- QoL rating was 17.2 ± 11.35 (vary: +40 to + 2) in group A as in comparison with 2.24 ± 8.53 (vary: +22 to −12) in group B (P < 0.05). There was a big enchancment in all parameters in research group as in comparison with the management group [].

Desk 2

Distinction between end result between two research teams

An external file that holds a picture, illustration, etc.
Object name is IJN-25-329-g005.jpg


On the finish of part I, in our research it was discovered that 34% of sufferers had diabetic nephropathy as primary illness. 16% had hypertensive nephropathy, 16% had power interstitial nephritis, and 14% had power glomerulonephritis. Roughly comparable outcomes have been seen in different research from India reminiscent of research by Rajapurkar et al.[16] in 2012. In our research, 84% (n = 42) of sufferers had Hb ranges of <10 g/dl. In our research, the typical Hb at onset of the research was 8.1 g/dl. In a research in USA by Reddan et al.[17] in 2003 on sufferers on thrice per week hemodialysis the typical Hb was 11.1 g/dl. Decrease Hb ranges; seen in our research will be attributed to comparative decrease dietary standing, twice per week dialysis, insufficient dialysis and poor compliance with medicine. It was came upon that solely 28% of hemodialysis classes have been minimally ample as per KDOQI requirements. The typical standardized Kt/V was 1.4. This isn’t a shocking discovering as poor assets and extreme sufferers per dialysis machine can regularly result in insufficient dialysis. Moreover comparable outcomes have been reported from different facilities in India (Rao et al. 1998). Research from neighboring international locations have additionally offered comparable outcomes – Nepal-17%[18] and Pakistan –31%.[19] In part II of the research; monitoring of research group (group A) and thereafter enhancing dialysis size to take care of standardized Kt/V of two resulted in marked statistically vital enchancment in medical parameters, albumin and QoL. In our research imply arterial strain fall in research group was 15.2 mm Hg as in comparison with 3.16 mm Hg within the management group which was statistically vital. Serum albumin has been historically thought of as a marker of dietary standing in sufferers on common hemodialysis. Serum albumin has a robust correlation with mortality in sufferers on hemodialysis.[20] Nonetheless latest knowledge means that it’s also a marker of irritation and power sickness.[21] In our research, we came upon that there was statistically vital rise in serum albumin in research group as in comparison with the management group. The typical rise in serum albumin in research group was 0.47 g/dl as in comparison with 0.15 g/dl with P < 0.05. Anemia not solely leads to poor QoL in sufferers present process hemodialysis, however it's also a predictor of mortality. In our research, we came upon that there was vital rise in Hb ranges in sufferers of research group (1.47 g/dl) as in comparison with management group (0.15 g/dl) with P < 0.05 and Z rating of 4.52. We came upon that there was a big enchancment in WHO QoL rating in research group (17.2) as in comparison with the management group (2.24) with P < 0.05 and Z rating of 4.34. The advance was largely seen in domains of - Bodily and psychological. Different two domains – social and environmental remained unaffected.

The research additionally had a number of necessary limitations. Chance of observer bias exists as blinding was not possible. Additionally, this research has been completed on a small pattern dimension (n = 50) which limits the extrapolation to the overall inhabitants. Therefore randomized management research with a bigger pattern dimension could be required to verify our findings. Actual residual kidney operate was not assessed on the onset of the research. It performs a serious contribution in whole solute clearance, particularly in eradicating center, in addition to small solute proteins.[22] One in all RRF’s main advantages is the optimization of fluid steadiness, blood strain management, decreased left ventricular hypertrophy and discount of heart problems. Additionally totally different variables reminiscent of medicine, transfusions, social circumstances, intermittent sickness, diet, and so on. weren’t analyzed. Nonetheless, since each teams have been randomized by pc generated randomization impact of those variables on research end result was probably minimal.

Nonetheless rising period of hemodialysis even for few sufferers is just not a simple process. The issue in rising dialysis time and/or frequency is essentially resulting from limitations to adoption of those different modalities quite than real disadvantages. The principle barrier is the truth that no randomized managed trial has but demonstrated the medical benefit of those methods over standard hemodialysis. Convincing sufferers to extend their session time and/or frequency is just not simple, particularly in India as sufferers usually dwell removed from dialysis facilities and need to spend more money from their meager financial assets. Affected person training and monetary assist is essential to result in understanding and acceptance of extended or extra frequent dialysis classes.

In abstract, Customary Kt/V can be utilized as an necessary device to change dialysis classes to offer higher QoL to the sufferers who’re on twice per week hemodialysis. This device is very helpful in India the place sufferers dwell comparatively distant from dialysis facilities and need to spend appreciable cash to even journey to those facilities. Nonetheless, research with bigger pattern dimension are required to conclusively show our outcomes.


Supply of Help: Nil

Battle of Curiosity: None declared.


1. Singh AK, Farag YM, Mittal BV, Subramanian KK, Reddy SR, Acharya VN, et al. Epidemiology and threat components of power kidney illness in India – Outcomes from the SEEK (screening and early analysis of kidney illness) research. BMC Nephrol. 2013;14:114. [PMC free article] [PubMed] [Google Scholar]
2. Kepler J. 2010 Annual Information Report: Atlas of Power Kidney Illness and Finish-Stage Renal Illness in america. Vol. 2. Atlas of ESRD; 2010. Worldwide comparisons. United States Renal Information System. [Google Scholar]
3. Coresh J, Selvin E, Stevens LA, Manzi J, Kusek JW, Eggers P, et al. Prevalence of power kidney illness in america. JAMA. 2007;298:2038–47. [PubMed] [Google Scholar]
4. Yach D, Hawkes C, Gould CL, Hofman KJ. The worldwide burden of power illnesses: Overcoming impediments to prevention and management. JAMA. 2004;291:2616–22. [PubMed] [Google Scholar]
5. Rao M, Juneja R, Jacob CK. Emperical prescription hemodialysis – Is there room for enchancment. Indian J Nephrol. 1998;8:12–6. [Google Scholar]
6. Casula A, Webb L, Feest T. UK Renal Registry thirteenth Annual Report (December 2010): Chapter 8: Adequacy of haemodialysis in UK grownup sufferers in 2009: Nationwide and centre-specific analyses. Nephron Clin Pract. 2011;119(Suppl 2):c141–7. [PubMed] [Google Scholar]
7. US Renal Information System. USRDS 2005 Annual Information Report: Atlas of Finish-Stage Renal Illness in america, Bethesda, Nationwide Institutes of Well being, Nationwide Institute of Diabetes and Digestive and Kidney Illnesses. 2005 [Google Scholar]
8. Rao M, Juneja R, Shirly RB, Jacob CK. Haemodialysis for end-stage renal illness in Southern India – A perspective from a tertiary referral care centre. Nephrol Dial Transplant. 1998;13:2494–500. [PubMed] [Google Scholar]
9. NKF-DOQI medical follow pointers for hemodialysis adequacy. Nationwide Kidney Basis. Am J Kidney Dis. 1997;30(3 Suppl 2):S15–66. [PubMed] [Google Scholar]
10. Held PJ, Port FK, Wolfe RA, Stannard DC, Carroll CE, Daugirdas JT, et al. The dose of hemodialysis and affected person mortality. Kidney Int. 1996;50:550–6. [PubMed] [Google Scholar]
11. Diaz-Buxo JA, Loredo JP. Customary Kt/V: Comparability of calculation strategies. Artif Organs. 2006;30:178–85. [PubMed] [Google Scholar]
12. Younger DO, Lund RJ, Haynatzki G, Dunlay RW. Prevalence of the metabolic syndrome in an incident dialysis inhabitants. Hemodial Int. 2007;11:86–95. [PubMed] [Google Scholar]
13. Nameless High quality of life and medical trials [Editorial] Lancet. 1995;346:1–2. [PubMed] [Google Scholar]
14. McClellan WM, Anson C, Birkeli Ok, Tuttle E. Useful standing and high quality of life: Predictors of early mortality amongst sufferers getting into therapy for finish stage renal illness. J Clin Epidemiol. 1991;44:83–9. [PubMed] [Google Scholar]
15. NKF-Ok/DOQI Scientific Follow Tips for Hemodialysis Adequacy: Replace 2000. Am J Kidney Dis. 2001;37(Suppl 1):S7–64. [PubMed] [Google Scholar]
16. Rajapurkar MM, John GT, Kirpalani AL, Abraham G, Agarwal SK, Almeida AF, et al. What can we find out about power kidney illness in India:First report of the Indian CKD registry. BMC Nephrol. 2012;13:10. [PMC free article] [PubMed] [Google Scholar]
17. Reddan DN, Frankenfield DL, Klassen PS, Coladonato JA, Szczech L, Johnson CA, et al. Regional variability in anaemia administration and haemoglobin within the US. Nephrol Dial Transplant. 2003;18:147–52. [PubMed] [Google Scholar]
18. Manandhar DN, Chhetri PK, Tiwari R, Lamichhane S. Analysis of dialysis adequacy in sufferers underneath hemodialysis and effectiveness of dialysers reuses. Nepal Med Coll J. 2009;11:107–10. [PubMed] [Google Scholar]
19. Anees M, Ahmed AM, Rizwan SM. Analysis of dietary standing of sufferers on haemodialysis. J Coll Physicians Surg Pak. 2004;14:665–9. [PubMed] [Google Scholar]
20. Owen WF, Jr, Lew NL, Liu Y, Lowrie EG, Lazarus JM. The urea discount ratio and serum albumin focus as predictors of mortality in sufferers present process hemodialysis. N Engl J Med. 1993;329:1001–6. [PubMed] [Google Scholar]
21. Friedman AN, Fadem SZ. Reassessment of albumin as a dietary marker in kidney illness. J Am Soc Nephrol. 2010;21:223–30. [PubMed] [Google Scholar]
22. Fry AC, Singh DK, Chandna SM, Farrington Ok. Relative significance of residual renal operate and convection in figuring out beta-2-microglobulin ranges in high-flux haemodialysis and on-line haemodiafiltration. Blood Purif. 2007;25:295–302. [PubMed] [Google Scholar]

Articles from Indian Journal of Nephrology are offered right here courtesy of Wolters Kluwer — Medknow Publications

Leave a Reply

Your email address will not be published. Required fields are marked *