Editor’s Note: The National Kidney Foundation has begun the process of updating its guidelines that are part of the Kidney Disease Outcomes Quality Initiative (KDOQI). The first update completed is the guideline on hemodialysis adequacy. NN&I will offer these summaries as the guideline reviews are completed.

KDOQI guidelines are used by professionals around the world to prescribe hemodialysis to end-stage renal disease patients, and these guidelines continue to present evidence-based recommendations to aid clinicians in the treatment of particular diseases or groups of patients. This is the third update to the original KDOQI guidelines that were first published in 1997 and revised in 2000 and 2006. The update is meant to be referenced in combination with the 2006 update as some of the topics previously covered were not readdressed in this review. The 2015 recommendations are as follows:

Guideline 1: Timing of Hemodialysis Initiation

1.1 Patients who reach CKD stage 4 (GFR of 30 mL/min/1.73 m2), including those who have imminent need for maintenance dialysis at the time of initial assessment, should receive education about kidney failure and options for its treatment, including kidney transplantation, peritoneal dialysis, hemodialysis, in the home or in-center, and conservative treatment. Patients’ family members and caregivers also should be educated about treatment choices for kidney failure. (Not graded)

Read also: Revisions for KDOQI guidelines underway 

1.2 The decision to initiate maintenance dialysis in patients who choose to do so should be based primarily upon an assessment of signs and/or symptoms associated with uremia, evidence of protein-energy wasting, and the ability to safely manage metabolic abnormalities and/or volume overload with medical therapy rather than on a specific level of kidney function in the absence of such signs and symptoms. (Not graded)

Guideline 2: Frequent and Long Duration Hemodialysis

In-center Frequent HD

2.1 We suggest that patients with ESRD be offered in-center short frequent hemodialysis as an alternative to conventional in-center thrice-weekly hemodialysis after considering individual patient preferences, the potential quality of life and physiological benefits, and the risks of these therapies. (2C)

2.2 We recommend that patients considering in-center short frequent hemodialysis be informed about the risks of this therapy, including a possible increase in vascular access procedures (1B) and the potential for hypotension during dialysis. (1C)

2.3 Consider extended home hemodialysis (six to eight hours, three to six nights per week) for patients with ESRD who prefer this therapy for lifestyle considerations. (Not graded)

2.4 We recommend that patients considering home long frequent hemodialysis be informed about the risks of this therapy, including possible increase in vascular access complications, potential for increased caregiver burden, and accelerated decline in residual kidney function. (1C)

Read also: National Kidney Foundation Spring Clinical Meeting offers opportunities for APs, nurses 

Pregnancy

2.5 During pregnancy, women with ESRD should receive long frequent hemodialysis either in-center or at home, depending on convenience. (Not graded)

Guideline 3: Measurement of Dialysis: Urea Kinetics

3.1 We recommend a target single pool Kt/V (spKt/V) of 1.4 per hemodialysis session for patients treated thrice weekly, with a minimum delivered spKt/V of 1.2. (1B)

3.2 In patients with significant residual native kidney function (Kru), the dose of hemodialysis may be reduced provided Kru is measured periodically to avoid inadequate dialysis. (Not graded)

3.3 For hemodialysis schedules other than thrice weekly, we suggest a target standard Kt/V of 2.3 volumes per week with a minimum delivered dose of 2.1 using a method of calculation that includes the contributions of ultrafiltration and residual kidney function. (Not graded)

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

4.1 We recommend that patients with low residual kidney function (2 mL/min) undergoing thrice weekly hemodialysis be prescribed a bare minimum of 3 hours per session. (1D)

4.1.1 Consider additional hemodialysis sessions or longer hemodialysis treatment times for patients with large weight gains, high ultrafiltration rates, poorly controlled blood pressure, difficulty achieving dry weight, or poor metabolic control (such as hyperphosphatemia, metabolic acidosis, and/or hyperkalemia). (Not graded)

4.2 We recommend both reducing dietary sodium intake as well as adequate sodium/water removal with hemodialysis to manage hypertension, hypervolemia, and left ventricular hypertrophy. (1B)

4.2.1 Prescribe an ultrafiltration rate for each hemodialysis session that allows for an optimal balance among achieving euvolemia, adequate blood pressure control and solute clearance, while minimizing hemodynamic instability and intradialytic symptoms. (Not graded)

Guideline 5: New Hemodialysis Membranes

5.1 We recommend the use of biocompatible, either high or low flux hemodialysis membranes for intermittent hemodialysis. (1B)

A complete copy of the KDOQI revised guideline on adequacy is available at www.ajkd.com

Commentary

Compared with the 2006 update, this guideline puts greater emphasis on shared decision-making and patient-centered care. Much of the newer evidence reviewed for the update supports the previous guidelines, but the 2015 version presents a clearer picture of the lack of evidence for a one-size-fits-all approach to hemodialysis. Because of this, the updated guidelines call for flexibility in dialysis prescription and less emphasis on rigid minimum or maximum thresholds. There are also recommendations regarding high frequency hemodialysis in this update, including risks for certain patient populations, and the use of stdKt/V to measure frequent hemodialysis. This update puts more emphasis on controlling volume and blood pressure.

The guideline recommendations are based on a literature review carried out by the Minneapolis Veterans Affairs Center for Chronic Disease Outcomes Research at the University of Minnesota.1 MEDLINE (Ovid) was searched from 2000 to March 2014 for English language clinical trials and high quality observational studies in populations of all ages. Additional searches included articles found in reference lists in recent systematic reviews. The ClinicalTrials.gov database was also examined to identify recently completed studies in this area. One topic on which we have received questions is the lack of emphasis on short home hemodialysis and related technology. The evidence review team and workgroup did not analyze evidence concerning frequent home dialysis modalities with lower dialysate flow rates, given the lack of randomized clinical trials using these newer technologies. That said, the topic of home hemodialysis deserves further research, and with its increasing popularity, practitioners deserve guidance. This is something KDOQI will look into with future guideline and resource development.

Each recommendation is given two grades: a number representing the strength of the recommendation—how strongly the workgroup felt about it in consensus—either 1 (“we recommend” or 2 (“we suggest”); and a letter representing the quality of evidence available to make the recommendation (A-D; A is highest quality evidence). In some cases, there were topics on which the authors felt patients and clinicians would seek guidance, but there was not yet enough published research to make a recommendation based on evidence alone. In these cases the authors have made recommendations based on expertise, experience, and lower quality evidence. Such recommendations are marked as ‘ungraded’. For some questions, the workgroup did not find sufficient strength of evidence to recommend a range or absolute limit for all patients. In these cases, they address the options in the recommendation and present the available evidence in the subsequent rationale.

Clinical practice guidelines are not intended to be a mandate, but a tool to help physicians, patients, and caregivers make treatment decisions that are right for the individual. As with all guidelines, clinicians should be aware that circumstances may require straying from the published recommendations.

References

  1. Slinin Y, Greer N, Ishani A, et al. Timing of Dialysis Initiation, Duration and Frequency of Hemodialysis Sessions, and Membrane Flux: A Systematic Review for a KDOQI Clinical Practice Guideline. American Journal of Kidney Diseases. 2014; 66(5):823-836.

–– John Daugirdas MD, Thomas A. Depner MD, Jula Inrig MD, Rajnish Mehrotra MD, Michael V. Rocco MD, Rita Suri MD, and Daniel E. Weiner MD