Hemodialysis patients receiving a greater Kt dose than recommended have reduced mortality and hospitalization risk

Achieving an adequate dialysis dose is one of the key goals for dialysis treatments. Here we assessed whether patients receiving the current cleared plasma volume (Kt), individualized for body surface area per recommendations, had improved survival and reduced hospitalizations at 2 years of follow-up. Additionally, we assessed whether patients receiving a greater dose gained more benefit. This prospective, observational, multicenter study included 6129 patients in 65 Fresenius Medical Care Spanish facilities. Patients were classified monthly into 1 of 10 risk groups based on the difference between achieved and target Kt. Patient groups with a more negative relationship were significantly older with a higher percentage of diabetes mellitus and catheter access. Treatment dialysis time, effective blood flow, and percentage of on-line hemodiafiltration were significantly higher in groups with a higher dose. The mortality risk profile showed a progressive increase when achieved minus target Kt became more negative but was significantly lower in the group with 1 to 3 L clearance above target Kt and in groups with greater increases above target Kt. Additionally, hospitalization risk appeared significantly reduced in groups receiving 9 L or more above the minimum target. Thus, prescribing an additional 3 L or more above the minimum Kt dose could potentially reduce mortality risk, and 9 L or more reduce hospitalization risk. As such, future prospective studies are required to confirm these dose effect findings. Achieving an adequate dialysis dose is one of the key goals for dialysis treatments. Here we assessed whether patients receiving the current cleared plasma volume (Kt), individualized for body surface area per recommendations, had improved survival and reduced hospitalizations at 2 years of follow-up. Additionally, we assessed whether patients receiving a greater dose gained more benefit. This prospective, observational, multicenter study included 6129 patients in 65 Fresenius Medical Care Spanish facilities. Patients were classified monthly into 1 of 10 risk groups based on the difference between achieved and target Kt. Patient groups with a more negative relationship were significantly older with a higher percentage of diabetes mellitus and catheter access. Treatment dialysis time, effective blood flow, and percentage of on-line hemodiafiltration were significantly higher in groups with a higher dose. The mortality risk profile showed a progressive increase when achieved minus target Kt became more negative but was significantly lower in the group with 1 to 3 L clearance above target Kt and in groups with greater increases above target Kt. Additionally, hospitalization risk appeared significantly reduced in groups receiving 9 L or more above the minimum target. Thus, prescribing an additional 3 L or more above the minimum Kt dose could potentially reduce mortality risk, and 9 L or more reduce hospitalization risk. As such, future prospective studies are required to confirm these dose effect findings. Adequate dialysis dose is one of the most important goals in hemodialysis (HD) treatment and should be appropriately prescribed. Achieving a minimum dialysis dose is the responsibility of nephrologists and represents an area open to improvement. Because age, gender, and comorbidity cannot be changed, dialysis parameters should be adjusted to ensure that the patient receives the optimal treatment. Several clinical practice guidelines1NKF-DOQI Clinical Practice Guideline for hemodialysis adequacy: 2015 update.Am J Kidney Dis. 2015; 66: 884-930Abstract Full Text Full Text PDF PubMed Scopus (613) Google Scholar, 2European Best Practice Guidelines for Haemodialysis. Nephrol Dial Transplant 2002;17(Suppl 7):17–21.Google Scholar, 3The Canadian Society of Nephrology: Clinical practice guidelines the delivery of haemodialysis.J Am Soc Nephrol. 1999; 10: S306-S310PubMed Google Scholar, 4Greenwood R, Tomson C, Hoenich N. Haemodialysis – clinical standards and targets. In: The Renal Association, Royal College of Physicians of London, eds. Treatment of Adult and Children with Renal Failure. Standards and Audit Measure. Third edition, Chapter 3. London: The Lavenham Press Ltd; 2002:19–35.Google Scholar, 5Maduell F. García M. Alcázar R. Dosificación y adecuación del tratamiento dialítico. Guías SEN: Guías de Centros de hemodiálisis.Nefrología. 2006; 26: 15-21PubMed Google Scholar have recommended a minimum Kt/V or urea reduction ratio (URR) as methods for monitoring dialysis dose. Because the urea kinetic method requires pre- and post-dialysis urea determinations, monitoring is performed monthly, bimonthly, or quarterly, and the result of this 3% to 7% of total sessions is extrapolated to the totality of the treatments. Given the relevance of dialysis dose to survival and that multiple factors can influence dialytic efficacy in each session, it seems reasonable to incorporate biosensors to quantify the dose in each session and in real time. Most monitors have incorporated ionic dialysance (ID), which allows calculation of dialysis dose in all sessions, without involving any additional workload, analytical determinations, or cost.6Peticlerc T. Bene B. Jacobs C. et al.Non-invasive monitoring of effective dialysis dose delivered to the haemodialysis patient.Nephrol Dial Transplant. 1995; 10: 212-216PubMed Google Scholar Consequently, many dialysis units have already abandoned urea determinations. In 1999, Lowrie et al.7Lowrie E.G. Chertow G.M. Lew N.L. et al.The urea {clearance x dialysis time} product (Kt) as an outcome-based measure of hemodialysis dose.Kidney Int. 1999; 56: 729-737Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar proposed Kt as a method of monitoring dialysis dose and mortality. These authors observed a J-shaped survival curve when they distributed the patients into quintiles from the smallest to the highest URR, while the curve descended with Kt for the same patients.8Chertow G.M. Owen W.F. Lazarus J.M. et al.Exploring the reverse J-shaped curve between urea reduction ratio and mortality.Kidney Int. 1999; 56: 1872-1878Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar In 2005, the minimum Kt dose was individualized according to body surface area (BSA)9Lowrie E.G. Li Z. Ofsthun N.J. Lazarus J.M. The online measurement of hemodialysis dose (Kt): Clinical outcome as a function of body surface area.Kidney Int. 2005; 68: 1344-1354Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar and validated in a further study.10Lowrie E.G. Li Z. Ofsthun N.J. Lazarus J.M. Evaluating a new method to judge dialysis treatment using online measurements of ionic clearance.Kidney Int. 2006; 70: 211-217Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar Since 2006, the Guidelines of the Spanish Society of Nephrology5Maduell F. García M. Alcázar R. Dosificación y adecuación del tratamiento dialítico. Guías SEN: Guías de Centros de hemodiálisis.Nefrología. 2006; 26: 15-21PubMed Google Scholar have proposed that dialysis centers with dialysis machines that have ionic dialysance use Kt to monitor dialysis dose. The Optimizing Results in Dialysis research initiative began in 2010 with the aim of improving HD patient outcomes by elucidating patient characteristics and practice of care in Spain.11Aljama P. ORD Work and Initiative Group (“Optimising Results in Dialysis”).Nefrología. 2012; Google Scholar In a study by this F. 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Thus, adjusted and risk profile that an adequate dialysis dose as by Kt individualized for improved the in HD dialysis dose are based on analytical pre- and post-dialysis urea determinations. and Spanish guidelines1NKF-DOQI Clinical Practice Guideline for hemodialysis adequacy: 2015 update.Am J Kidney Dis. 2015; 66: 884-930Abstract Full Text Full Text PDF PubMed Scopus (613) Google Scholar, 2European Best Practice Guidelines for Haemodialysis. Nephrol Dial Transplant 2002;17(Suppl 7):17–21.Google Scholar, 3The Canadian Society of Nephrology: Clinical practice guidelines the delivery of haemodialysis.J Am Soc Nephrol. 1999; 10: S306-S310PubMed Google Scholar, 4Greenwood R, Tomson C, Hoenich N. Haemodialysis – clinical standards and targets. In: The Renal Association, Royal College of Physicians of London, eds. Treatment of Adult and Children with Renal Failure. Standards and Audit Measure. Third edition, Chapter 3. London: The Lavenham Press Ltd; 2002:19–35.Google Scholar, 5Maduell F. García M. Alcázar R. Dosificación y adecuación del tratamiento dialítico. Guías SEN: Guías de Centros de hemodiálisis.Nefrología. 2006; 26: 15-21PubMed Google Scholar a minimum Kt/V of a of Kt/V of and a of to ensure that these minimum are urea measurements are monthly, bimonthly, or to the dialysis the from this 3% to 7% of the total sessions be extrapolated to that in all Because multiple factors can influence dialytic efficacy in each HD session, have to quantify the dose by the patient in each session and in real time. Most monitors have incorporated which allows the dialysis dose to be in all sessions, without involving additional workload, analytical determinations, or cost.6Peticlerc T. Bene B. Jacobs C. et al.Non-invasive monitoring of effective dialysis dose delivered to the haemodialysis patient.Nephrol Dial Transplant. 1995; 10: 212-216PubMed Google Scholar Consequently, many dialysis units have already abandoned urea determinations. 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