Hemodialysis Prescription Guidelines for CKD Stage 5

Core Prescription Parameters

• The American Journal of Kidney Diseases recommends a standard hemodialysis prescription for a CKD stage 5 patient should include thrice-weekly sessions of 3.5-4 hours duration, targeting a minimum delivered spKt/V of 1.2 per session, using a high-flux dialyzer with appropriate blood and dialysate flow rates 1, 2
• The National Kidney Foundation suggests a schedule of 3 sessions per week (Monday-Wednesday-Friday or Tuesday-Thursday-Saturday) 3, 1
• The American Journal of Kidney Diseases recommends a duration of 3.5 to 4.5 hours per session 3, 2
• The guideline suggests a total weekly time of minimum 12 hours 1

Dialysis Adequacy Targets

• The National Kidney Foundation recommends a minimum delivered spKt/V of 1.2 per session 3, 2
• The American Journal of Kidney Diseases suggests a target delivered spKt/V of 1.4-1.5 to provide a safety margin 3

Dialyzer Specifications

• The American Journal of Kidney Diseases recommends using a high-flux dialyzer 1, 4
• The guideline suggests a surface area based on patient body surface area (typically 1.5-2.1 m² for adults) 1
• The American Journal of Kidney Diseases recommends using a biocompatible membrane to minimize inflammatory response 1

Blood and Dialysate Parameters

• The American Journal of Kidney Diseases recommends a blood flow rate (Qb) of 300-450 mL/min (adjust based on vascular access capability) 1
• The guideline suggests a dialysate flow rate (Qd) of 500-800 mL/min 1
• The American Journal of Kidney Diseases recommends higher flow rates to improve small-solute clearance 1

Ultrafiltration Management

• The American Journal of Kidney Diseases recommends establishing a target dry weight clinically based on blood pressure, edema assessment, and volume status 1, 2
• The guideline suggests keeping the ultrafiltration rate below 13 mL/kg/hour to minimize cardiovascular stress 1, 6
• The American Journal of Kidney Diseases recommends an interdialytic weight gain of ideally less than 5% of dry weight between sessions 1

Anticoagulation

• The American Journal of Kidney Diseases recommends a loading dose of 1000-2000 units IV bolus of heparin at the start of the session 1
• The guideline suggests a maintenance dose of 500-1500 units/hour continuous infusion of heparin 1
• The American Journal of Kidney Diseases recommends discontinuing heparin 30-60 minutes before the end of the session 1

Monitoring Requirements

• The American Journal of Kidney Diseases recommends monitoring blood pressure and heart rate every 30-60 minutes during each session 1
• The guideline suggests monitoring for symptoms of hypotension, cramping, or chest pain during each session 1
• The National Kidney Foundation recommends monthly laboratory monitoring of adequacy (spKt/V or URR ≥65%) 3, 1
• The American Journal of Kidney Diseases recommends monthly laboratory monitoring of serum phosphorus, targeting 3.5-5.5 mg/dL 5
• The guideline suggests monthly laboratory monitoring of serum calcium, targeting 8.4-9.5 mg/dL 5

Vascular Access

• The American Journal of Kidney Diseases recommends an arteriovenous fistula as the preferred vascular access 1
• The guideline suggests an arteriovenous graft or tunneled dialysis catheter as alternative options 1
• The American Journal of Kidney Diseases recommends a needle size of 15-16 gauge for fistula/graft 1

Special Considerations

• The American Journal of Kidney Diseases recommends preserving any remaining kidney function and reassessing adequacy as residual function declines 2
• The guideline suggests increasing session duration to 4.5-5 hours or considering more frequent dialysis (4-6 sessions per week) if the patient fails to achieve target Kt/V 1, 6, 3
• The American Journal of Kidney Diseases recommends avoiding excessive ultrafiltration rates (>13 mL/kg/hour) which increase cardiovascular stress and mortality 1, 6