Hemodialysis Prescription for Acute Kidney Injury with Obstructive Ureteral Calculus

Indications for Hemodialysis

The decision to initiate emergent hemodialysis depends on the presence of life-threatening complications, such as severe hyperkalemia with ECG changes, severe metabolic acidosis, pulmonary edema, uremic complications, or severe symptomatic dysnatremia, according to the American College of Physicians 1
Severe hyperkalemia with ECG changes, such as peaked T waves, widened QRS, bradycardia, or asystole, is an absolute indication for emergent hemodialysis 1
Severe metabolic acidosis with impaired respiratory compensation is an absolute indication for emergent hemodialysis 1
Pulmonary edema unresponsive to diuretics is an absolute indication for emergent hemodialysis 1
Uremic complications, such as encephalopathy, pericarditis, or bleeding, are absolute indications for emergent hemodialysis 1
Severe symptomatic dysnatremia resistant to medical management is an absolute indication for emergent hemodialysis 1

For hemodynamically stable patients, intermittent hemodialysis is recommended, which provides faster correction of severe hyperkalemia, according to the American Society of Nephrology 1, 2
For hemodynamically unstable patients requiring vasopressors, continuous renal replacement therapy (CRRT) with CVVHDF or CVVH is recommended 3, 2
The blood flow rate for intermittent hemodialysis should be 300-400 mL/min, according to the National Kidney Foundation 3
The dialysate flow rate for intermittent hemodialysis should be 500-800 mL/min, according to the National Kidney Foundation 3
The target Kt/V for intermittent hemodialysis should be 3.9 per week, typically 1.2-1.4 per session for 3 sessions weekly, according to the American College of Physicians 1
The dialysate composition for intermittent hemodialysis should be bicarbonate-based, according to the American Society of Nephrology 3, 1
The potassium bath for intermittent hemodialysis should be 0-1 mEq/L if severe hyperkalemia, and 2 mEq/L for maintenance, according to the American College of Physicians 1
The calcium bath for intermittent hemodialysis should be 2.5 mEq/L, according to the National Kidney Foundation 3
The ultrafiltration rate for intermittent hemodialysis should be limited to <13 mL/kg/hour to avoid intradialytic hypotension and further renal injury, according to the Kidney Disease: Improving Global Outcomes (KDIGO) foundation 4, 5

The modality for CRRT should be CVVHDF, according to the American Society of Nephrology 3, 2
The effluent dose for CRRT should be 20-25 mL/kg/hour, according to the American College of Physicians 3, 1, 2
The replacement fluid for CRRT should be bicarbonate-based, according to the National Kidney Foundation 3, 1
Anticoagulation for CRRT should be regional citrate anticoagulation if no contraindications, according to the American Society of Nephrology 1, 2

Uncuffed non-tunneled dialysis catheter should be used, according to the American College of Physicians 1, 2
The preferred sites for vascular access are the right internal jugular vein, femoral vein, left internal jugular vein, and subclavian vein (last choice due to stenosis risk), according to the National Kidney Foundation 2
Ultrasound guidance should always be used for insertion, according to the American Society of Nephrology 2

Hourly vital signs and assessment for hypotension should be performed, according to the Kidney Disease: Improving Global Outcomes (KDIGO) foundation 4
Electrolytes and acid-base status should be monitored every 2-4 hours initially, according to the American College of Physicians 3, 2
Pre- and post-dialysis weights should be monitored, according to the Kidney Disease: Improving Global Outcomes (KDIGO) foundation 4
Urine output monitoring should be performed if any residual function, according to the Kidney Disease: Improving Global Outcomes (KDIGO) foundation 4, 5

If dialysis continues beyond 14 days, renal recovery should be assessed weekly with pre-dialysis creatinine and residual kidney function measurements, according to the American Society of Nephrology 3