연도별혈액투석청구현황 심평원혈액투석적정성평가설명회

연도별혈액투석청구현황 심평원혈액투석적정성평가설명회

건강보험심사평가원혈액투석적정성평가지표

투석환자의생존율 Dialysis Pts Survival, Korea & USRDS

혈액투석접근로관리 혈액투석접근로점검표 정적동정맥루내압비 희석식초음파혈류검사 (Transonic ) Duplex Doppler 초음파혈류검사 혈관조영술 (angiography)

혈액투석접근로점검표내용 (1) 환자명, 병록번호, 기저질환 1. 접근로종류 - 일반도관 (temporary dual lumen catheter) - 피하터널도관 (subcutaneous tunneled dual lumen catheter, Perm cath ) - 자가혈관동정맥루 (autologous vessel arteriovenous fistula, AVF) - 인조혈관동정맥루 (arteriovenous fistula with graft, AVG) 2. 도관경우접근혈관 - 우측내경정맥, 좌측내경정맥, 우측대퇴정맥, 우측대퇴정맥, 기타

혈액투석접근로점검표내용 (2) 3. 동정맥루위치, 연결혈관 - 좌전완 (left forearm), 좌상완 (left upper arm), - 우전완 (right forearm) 우상완 (right upper arm) - 기타혈관 (femoral etc.) - AVF : radio-cephalic, radio-basilic, brachio-cephalic, brachio-basilic, etc. - AVG : loop, straight, etc.

혈액투석접근로점검표내용 (3) 4. 임상추적검사기록항목 - 도관 : 출구부위발적, 멍, 혈종 (hematoma), 고정봉합, 기능평가 ( 혈액투석시혈류 250ml/min 시동맥압과정맥압 ) - 동정맥루 가. 시진 ( 視診 ) : 발적, 부종여부, 멍 (bruise), 동맥류 (aneurysm) 발생시크기 나. 촉진 ( 觸診 ) : 떨림 (thrill) 여부 : 약함, 중간, 강함 다. 청진 ( 聽診 ) : 잡음 (bruit: continuous or pulsating, low pitch or high pitch) 라. 천자간격 (cannulation distance) 5. 혈관성형술 (angioplasty) 혹은 Doppler 시술병력기록

혈액투석접근로점검표예 심평원혈액투석적정성평가설명회 << 혈관접근로임상기록예 >> 환자병록번호 : 123456 환자명 : O O O 기저질환 : 당뇨병성신증 2012/00/00 right int, jugular catheter inserted, perm cath 발적 (redn ess) 멍 (bruise) 고정 (fix s uture) arterial pressure at flow 250ml/mi n venous pressu re at flow 250 ml/min locking hep arin 2012/00/00 + ++ + - 100 + 50 5000unit x2 통증호소함... 2012/00/00 - - removed - 150 +80.... 2012/00/00 left forearm AVF : op date 2012/00/00 발적 (redn ess) 멍 (bruise) 떨림 (thrill ) 청진소견 (brui t I continuous o r pulsating) 청진소견 (bruit II low pitch or hig h pitch) 천자간격 (cann ulation distan ce) arterial pressure at flow 250ml/mi n venous pressu re at flow 250 ml/min needle gage 2012/00/00 - - ++ C L 8cm - 100 +80 16 약간의부종 2012/00/00 - ++ ++ C L 8cm - 120 +80 16 2012/00/00 - - + P H 8cm - 200 +60 16 지혈시혈종발생함. 천자시혈전확인됨 2012/00/00 AVF angioplasty, 영상의학과,

Seminars in Dialysis Vol 21, No 3 (May June) 2008 pp. 269 273

Seminars in Dialysis Vol 21, No 3 (May June) 2008 pp. 269 273

The Cohen s κ- value was used as a measurement of the level of agreement beyond chance between the diagnoses made by physical examination and angiography

Beathard GA: Seminars in Dialysis Vol 18, No 4 (July August) 2005, pp. 331 335

Causes of Early AVF failure Beathard GA: Seminars in Dialysis Vol 18, No 4 (July August) 2005, pp. 331 335

Evaluation protocol for early fistula failure Beathard GA: Seminars in Dialysis Vol 18, No 4 (July August) 2005, pp. 331 335

Evaluation protocol for early fistula failure (1) Step 1. Basic Information of Importance How long since it was created Where is it located What type of fistula is it Use history Has it been used? Have there been problems with use? Step 2. Examination of Anastomosis Feel for thrill (the buzz ) Indicator of flow Strong: good flow Weak: poor flow Systolic and diastolic: good flow Feel for pulse Indicator of downstream resistance Soft: low resistance, no stenosis Hard: high resistance, stenosis present Beathard GA: Seminars in Dialysis Vol 18, No 4 (July August) 2005, pp. 331 335

Evaluation protocol for early fistula failure (2) Step 3. Examination of the Body of the Fistula Over what extent is the fistula visible? Does it seem to disappear? What is fistula s diameter? Large enough to be readily cannulated? What is its depth? Is it there but too deep? Is fistula pulse palpable? Soft: normal Hyperpulsatile: downstream stenosis Check for accessory vein Is one present? Are multiple veins present? Step 4. Check Pulse Augmentation Strength of pulse without occlusion: outflow Strength of pulse with occlusion: inflow If pulse is normal: Augmentation is indicative of inflow If pulse is hyperpulsatile (indicative of stenosis): Degree of augmentation can be used to gauge degree of stenosis No augmentation indicates very severe stenosis Moderate augmentation indicates moderate stenosis Beathard GA: Seminars in Dialysis Vol 18, No 4 (July August) 2005, pp. 331 335

Evaluation protocol for early fistula failure (3) -Physical Examination of AVF- Accessory Vein Physical examination of accessory vein. When the fistula is occluded at point A, the thrill will disappear at the anastomosis (C). As the point of occlusion is moved upward past the accessory vein (D) to point B, the thrill will continue when the fistula is occluded because flow has an escape route. Pulse Augmentation Evaluation of pulse augmentation. The fistula is first completely occluded at point A. The change in pulse intensity (augmentation) is evaluated at point B. Beathard GA: Seminars in Dialysis Vol 18, No 4 (July August) 2005, pp. 331 335

Static Intra Access Pressure Evaluation - for Arterio-venous Graft : KDOQI

DIALYSIS PRESCRIPTION Vascular Access Dialyzer surface area & performance Dialysate & dialysate flow rate Blood Flow Rate Dialysis Dose (Duration & frequency) Dry Weight Anticoagulant Lab. Test Medication

Main Known Uremic Retention Solutes Small water soluble solutes Asymmetric dimethylarginine Benzylalcohol b-guanidinopropionic acid b-lipotropin Creatinine Cytidine Guanidine Guanidinoacetic acid Guanidinosuccinic acid Hypoxanthine Malondialdehyde Methylguanidine Myoinositol Orotic acid Orotidine Oxalate Pseudouridine Symmetric dimethylarginine Urea Uric acid Xanthine CMPF : carboxy-methyl-propyl-furanpropionic acid. Protein-bound solutes 3-Deoxyglucosone CMPF Fructoselysine Glyoxal Hippuric acid Homocysteine Hydroquinone Indole-3-acetic acid Indoxyl sulfate Kinurenine Kynurenic acid Methylglyoxal N-carboxymethyllysine P-cresol Pentosidine Phenol P-OH hippuric acid Quinolinic acid Spermidine Spermine Middle molecules Adrenomedullin Atrial natriuretic peptide b2-microglobulin b-endorphin Cholecystokinin Clara cell protein Complement factor D Cystatin C Degranulation inhibiting protein I Delta-sleep-inducing peptide Endothelin Hyaluronic acid Interleukin 1b Interleukin 6 Kappa-Ig light chain Lambda-Ig light chain Leptin Methionine-enkepahlin Neuropeptide Y Parathyroid hormone Retinol binding protein Tumor necrosis factor alpha

Size of Uremic Toxins 심평원혈액투석적정성평가설명회 Small Molecules : BUN, creatinine clinically monitoring indicators Original Middle Molecule Hypothesis : 300-2,000 daltons Recent Concept of Middle Molecule : 500-60,000daltons -European Uremic Toxin Work Group (EUTox group) in 2003

Uremic Toxicity Summary 심평원혈액투석적정성평가설명회 Water balance: pulmonary edema, peripheral edema, neck vein engorgement Electrolyte: hyperkalemia, hyperphosphatemia, hypocalcemia, hyponatremia Acid-base balance: metabolic acidosis (normal anion gap and/or high anion gap) Long-term Exposure to Uremic Toxins (small molecules, middle molecules, AGE, light chains ) Endothelial Cell Damage Atherosclerosis & hypertension CVA or Cardiac Diseases Dysfunction of Immune system Infection Miscellaneous Disease Renal osteodystrophy Uremic dermatopathy Uremic pph.neuropathy Uremic malnutrition Uremic encephalopathy amyloidosis Death

Properties of an Ideal Clearance Marker 심평원혈액투석적정성평가설명회 Is easily measured; Accumulates in uremia; Is easily removed by the dialyzer. BUN!! Intracellular / Plasma solute Equilibration (suspended uremic human erythrocytes)

BUN in Maintenance Hemodialysis Pre BUN Pre BUN 2 Reduction By Dialysis BUN Post BUN Post BUN 2 Increased by Urea Generation 월화수목금토일월화

UREA REDUCTION RATE (URR) C 0 - C URR = (x 100,%) C 0 C 0 : Pre-dialysis urea concentration C : Post-dialysis urea concentration

Blood Volume Change During Dialysis Final Volume = Initial Volume - Ultrafiltration + Refilling 심평원혈액투석적정성평가설명회

DIALYSIS DOSE - UREA KINETIC MODELS - Fixed Volume Single Pool Model Variable Volume Single Pool Model Variable Volume Double Pool Model

FRACTIONAL CLEARANCE OF UREA K: dialyzer urea clearance (ml/min) t: time on dialysis (min) V: volume of urea distribution (Body water) M : 60% of body wt. F: 55% of body wt. Or (Watson formula) M: V = 2.447-0.09516A + 0.1074 H + 0.3362 W F: V = - 2.097 + 0.1069 H + 0.2466 W V: volume (L), A: age, H: height (cm), W: weight (kg)

Measuring Clearance During Single Dialysis - Single Pool Model - d(cv urea )/dt = G - KC K : dialyzer clearance, V: volume of solute distribution G: Generation if G=0, dv = 0 (dc/c 0 )/dt = - k = - K/V C = C 0 e -Kt/V Kt/V= - ln (C 0 /C)

Measured Kt/V (Daugirdas equation,1993) spkt/v urea = - ln (( R )-0.008Xt)+((4-3.5 X R )X ΔBW/BW) Post HD BUN R= Pre HD BUN t : dialysis hours

Post Dialysis Urea Rebound ] Post dialysis Urea Rebound

Urea Redistribution During & Post Dialysis

Measuring Clearance During Dialysis 심평원혈액투석적정성평가설명회 - Double Pool Model - Organ 1 Organ 2 e Organ 3 Extracellular Water (V e ) ; V e X C e K c X C e K c X C i Intracellular Water (V i ) ; V i X C i e

Single-pool vs Double-pool Urea Model 심평원혈액투석적정성평가설명회 ] Post dialysis Urea Rebound

Equilibrated Kt/V (ekt/v) 심평원혈액투석적정성평가설명회 - Prediction of Equilibrating Rate by simple equation - The equilibrated postdialysis BUN can be calculated from an extrapolation of the rebound curve, correcting for urea generation during the rebound period. The resulting BUN is the basis for ekt/vurea, which can be estimated from spkt/vurea using simple Equations.

Methods for Calculating ekt/v (Equilibrated Kt/V) 심평원혈액투석적정성평가설명회 Daugirdas (from HEMO study) AV access spkt/v - 0.6spKt/V + 0.03 spkt/v - 36 spkt/v + 0.03 spkt/v(1-0.6/t) + 0.03 spkt/v(1-36/t) + 0.03 Venous access spkt/v - 0.47K/V + 0.02 spkt/v - 28 spkt/v + 0.02 spkt/v(1-0.47/t) + 0.02 spkt/v(1-28/t) + 0.02 Tattersall only to AV access spkt/v(t/(t+35) (spkt/v is a fraction per hr : spkt/v= spkt/v/(hr on HD) (Kt/V is a fraction per minutes : spkt/v = spkt/v/(min on HD) (t in hr) (t in min) (K/V is a fraction per hr) (t in min)

Kt/V with REMAINED RENAL FUNCTION KT/V = Kt/V + 5.5 Kr/V (twice a week dialysis) KT/V = Kt/V + 9.5 Kr/V (thrice a week dialysis) Kr: residual urea clearance -- Calculation of Residual Renal Function V x U Kr = t x (U1+U2)/2 V: urine volume in interdialytic period, U: urine urea nitrogen, t: interdialytic time in min, U1: postdialysis BUN on first dialysis of the week, U2: predialysis BUN on second dialysis

PROTEIN CATABOLIC RATE (PCR) PCR= 0.22 + or PCR = 0.22 + 0.036 x id rise BUN (mg/dl)x 24 id interval (hours) 0.1 x id rise urea (mmol) x 24 id interval (hours) npcr (normalized PCR) = PCR (gm/day) / standard BWt(kg)

GUIDELINES OF ADEQUATE DIALYSIS Kt/V: 1.2-1.4 for thrice a wk dialysis 1.5-1.8 for twice a wk dialysis TAC urea : < 50 mg/dl Predialysis BUN < 80 mg/dl PCR: 1.0-1.4 g/kg/day HIGH PROBABILITY OF DIALYSIS FAILURE Kt/V < 0.8 PCR < 0.8 g/kg/day

투석적절도그래프 ( 주 3 회환자용 ) 심평원혈액투석적정성평가설명회

DISCREPANCY IN DIALYSIS DELIVERY Dialysis Specific Inaccurate Dialyzer Clearance Incorrect Blood Flow Incorrect Dialysis Time (interruption) Dialyzer clotting Patient Specific Access Dysfunction Poor needle position V urea Inaccuracy Sampling Error Predialysis sample diluted with saline Predialysis sample after dialysis start Postdialysis sample before end of dialysis or >5 min after end of dialysis

KDOQI Hemodialysis Adequacy 2006 : Am J Kid Dis Vol 48, No 1, Suppl 1 (July), 2006. I. Clinical Practice Guidelines For Hemodialysis Adequacy Guideline 1. Initiation Of Dialysis Guideline 2. Methods For Measuring And Expressing The Hemodialysis Dose Guideline 3. Methods For Postdialysis Blood Sampling Guideline 4. Minimallyadequate Hemodialysis Guideline 5. Control Of Volume And Blood Pressure Guideline 6. Preservation Of Residual Kidney Function Guideline 7. Quality Improvement Programs Guideline 8. Pediatric Hemodialysis Prescription And Adequacy II. Clinical Practice Recommendations For Hemodialysis Adequacy Clinical Practice Recommendations For Guideline 1. Initiation Of Dialysis Clinical Practice Recommendations For Guideline 2. Methods For Measuring ~ Clinical Practice Recommendations For Guideline 4. Minimallyadequate ~ Clinical Practice Recommendations For Guideline 5. Control Of Volume ~ III. Research Recommendations

GUIDELINE 2. Methods For Measuring & Expressing HD Dose 2.1 The delivered dose of HD should be measured at regular intervals no less than monthly. (A) 2.2 The frequency of treatments should be included in the expression of dose. (A) 2.3 The dose of HD should be expressed as (K urea X Td)/V urea (abbreviated as Kt/V), where K urea is the effective (delivered) dialyzer urea clearance in milliliters per minute integrated over the entire dialysis, Td is the time in minutes measured from beginning to end of dialysis, and V urea is the patient s volume of urea distribution in milliliters. (B)

GUIDELINE 2. Methods For Measuring & Expressing HD Dose 2.4 The preferred method for measurement of the delivered dose is formal urea kinetic modeling. Other methods may be used provided they give similar results and do not significantly overestimate the modeled dose. (A) 2.5 Methods described in Appendix can be used to add the continuous component of residual urea clearance to the intermittent dialysis spkt/v to compute an adjusted intermittent Kt/V. Laboratories reporting adjusted session Kt/V values should clearly identify such measurements by a different name (eg, adjusted Kt/V or total Kt/V). (B)

Impact of Ultrafiltration on Delivered Dose of HD Impact of ultrafiltration on delivered dose of HD measured by using spkt/v and URR. The curves are derived from formal single-pool modeling of urea kinetics assuming a 3-hour dialysis, no RKF, and a volume of urea distribution that is 58% of BW. Wt refers to net ultrafiltration losses as a fraction of final BW.

Preferred Measures of the Delivered Dose (in Order of Preference) For 2 or 3 dialysis treatments per wk - Single pool Kt/V urea determined by: Urea kinetic modeling Simplified multivariable equation - Equilibrated Kt/V (ekt/v) - Bloodless measurements of dialyzer clearance using ionic conductance or dialysate urea monitoring - URR - Double pool Kt/V urea by formal kinetic modeling (used only for research purposes) - Solute removal index (SRI) from dialysate collections For more frequent dialysis: a continuous equivalent of kidney clearance - Standard Kt/V urea - Normalized Kt/V urea

GUIDELINE 3. METHODS FOR POSTDIALYSIS BLOOD SAMPLING 심평원혈액투석적정성평가설명회 3.1 Both samples (predialysis and postdialysis) should be drawn during the same treatment session. (A) 3.2 The risk of underestimating predialysis BUN level because of saline dilution or by sampling the blood after treatment has begun should be avoided. (A) 3.3 The risk of underestimating the postdialysis BUN level because of access recirculation (AR) should be avoided by first slowing the blood flow through the dialyzer to a rate at which AR is expected to be minimal (100 ml/min) for a period long enough to ensure that unrecirculated blood has advanced to below the sampling port (usually 15 seconds). (A) 3.4 An alternative method is to stop the dialysate flow for a period long enough to increase the dialysate outlet BUN level close to that of the blood inlet BUN level (3 minutes) before obtaining the postdialysis sample. (A)

Timing the Postdialysis BUN sample Timing the postdialysis BUN sample. Sampling at point B, taking precautions to avoid errors attributed to access recirculation (Access recirc.) and urea rebound, will ensure accuracy and consistency of Kt/V urea measurements. CP recirc. = cardiopulmonary recirculation.

Predialysis Blood Drawing Procedure A. When using an AV fistula or graft Obtain blood specimen from arterial needle (no saline or heparin, before connecting to tubing) B. When using a venous catheter Withdrawn 5ml of locked heparin fluid from arterial port, use new syringe for blood sample

Postdialysis Blood Drawing Procedure * Slow-Blood-Flow Method A. Drawing from blood line sampling port - Set lowest UFR (TMP) & dialysate or off. - Blood flow down to 100mL/min for 15 sec, obtain sample. B. Drawing from arterial needle tubing - Set lowest UFR (TMP) & dialysate or off. - Blood flow down to 100mL/min for 15 sec, then stop the blood pump. - Clamp the arterial tubing, disconnect & obtain sample from arterial needle tubing. * Stop-Dialysate-Flow Method - Turn off dialysate flow & lowest UFR (TMP) or off. - Wait 3 min. (Do not reduce blood flow rate) - Obtain sample from sampling port or arterial needling tubing. (continue the pump speed or sudden stop)

GUIDELINE 4. MINIMALLYADEQUATE HEMODIALYSIS 심평원혈액투석적정성평가설명회 4.1 Minimally adequate dose: The minimally adequate dose of HD given 3 times per week to patients with Kr less than 2 ml/min/1.73 m 2 should be an spkt/v (excluding RKF) of 1.2 per dialysis. For treatment times less than 5 hours, an alternative minimum dose is a URR of 65%. (A) 4.2 Target dose: The target dose for HD given 3 times per week with Kr less than 2 ml/min/1.73 m2 should be an spkt/v of 1.4 per dialysis not including RKF, or URR of 70%. (A) 4.3 In patients with residual urea clearance (Kr) greater than or equal to 2 ml/min/1.73 m 2, the minimum session spkt/v can be reduced. In such patients, the target spkt/v should be at least 15% greater than the minimum dose. (B) 4.4 Missed and shortened treatments: Efforts should be made to monitor and minimize the occurrence of missed or shortened treatments. (B)

ERA-EDTA Best Practice Guidelines 2002 (I) Nephrol Dial Transplant Vol. 17 supplement 7, July 2002 Guideline II.1.1 A. Urea is the most suitable marker for the uraemic toxins in the range of the low MW solutes. (Evidence level: B) Guideline II.1.2 A. HD dose should be expressed in terms of equilibrated Kt/V (ekt/v) with the rate equation based on the regional blood flow two-pool urea kinetic model : ekt/v=spkt/v (0.6XspKt/V/T)+0.03 (with an arteriovenous access) ekt/v=spkt/v-(0.47xspkt/v/t)+0.02 (with a venovenous access, i.e. absence of cardiopulmonary recirculation).

ERA-EDTA Best Practice Guidelines 2002 (II) Nephrol Dial Transplant Vol. 17 supplement 7, July 2002 ~ Guideline II.1.2 C. The value for the single-pool Kt/V (spkt/v) should be derived from the formal single-pool variable volume urea kinetic model (spukm) [42]. As an alternative, the natural logarithm equation provides the most accurate estimate of spkt/v : spkt/v=-ln (Ct/Co 0.008XT) + (4-3.5XCt/Co)XdBW/BW where: K=dialyzer clearance (ml/min); V=urea distribution volume (ml); t, T=treatment time (in minutes and hours, respectively); Co, Ct=start and end-session urea (or BUN) concentration; dbw=intradialytic weight loss (kg); BW=end-session body weight (kg). D. Sampling Ct 30 min after the end of the session and applying the spkt/v equation gives the ekt/v value.

ERA-EDTA Best Practice Guidelines 2002 (III) Nephrol Dial Transplant Vol. 17 supplement 7, July 2002 Guideline II.1.3 A. Based on the available evidence the minimum prescribed HD dose per session for a thrice-weekly schedule should be: urea ekt/v>=1.20 (sp Kt/V~1.4). Twice-weekly schedules are not recommended. (Evidence level: B)

1176 THE NEW ENGLAND JOURNAL OF MEDICINE Nov. 12, 1981 EFFECT OF THE HEMODIALYSIS PRESCRIPTION ON PATIENT MORBIDITY Report from the National Cooperative Dialysis Study* E.G. Lowrie, M.D., N.M. Laird, Ph.D., T. F. Parker, M.D., and J.A. Sargent, Ph.D. Abstract This report summarizes morbidity in 151 patients in a coopertive trial ~ The data indicate that the occurrence of morbid events is affected by the dialysis prescription. Increased morbidity appears to accompany prescriptions associated with a relatively high BUN. Conversely, morbidity may be decreased by prescriptions associated with more efficient removal of urea if the dietary intake of protein and other nutrients is adequate. (N Engl J Med. 1981; 305: 1176-81.)

HEMO Study (I) 심평원혈액투석적정성평가설명회 N Engl J Med 2002;347:2010-9 Conclusions : Patients undergoing hemodialysis thrice weekly appear to have no major benefit from a higher dialysis dose than that recommended by current U.S. guidelines or from the use of a high-flux membrane. (N Engl J Med 2002;347:2010-9.)

HEMO Study (II) 심평원혈액투석적정성평가설명회 Figure 1. Survival Curves for the Treatment Groups. After adjustment for the base-line factors, mortality in the high-dose group was 4 percent lower (95 percent confidence interval, -10 to 16; P=0.53) than that in the standard-dose group (Panel A), and mortality in the high-flux group was 8 percent lower (95 percent confidence interval, -5 to 19; P=0.23) than that in the low-flux group (Panel B).

Points for Clinical Applications (I) UREA REDUCTION RATE (URR) URR = C 0 - C C 0 (x 100,%) Measured Kt/V (Daugirdas equation,1993) C 0 : Pre-dialysis urea concentration C : Post-dialysis urea concentration spkt/v urea = - ln (( R )-0.008Xt)+((4-3.5 X R )X ΔBW/BW) Post HD BUN R= Pre HD BUN t : dialysis hours Equilibrated Kt/V (ekt/v) - AV access spkt/v - 0.6spKt/V + 0.03 - Venous access spkt/v - 0.47K/V + 0.02 (spkt/v is a fraction per hr : spkt/v= spkt/v/(hr on HD) (K/V is a fraction per hr)

Points for Clinical Applications (II) PROTEIN CATABOLIC RATE (PCR) PCR= 0.22 + 0.036 x id rise BUN (mg/dl)x 24 id interval (hours) npcr (normalized PCR) = PCR (gm/day) / standard BWt(kg) GUIDELINES OF ADEQUATE DIALYSIS Kt/V: 1.2-1.4 for thrice a wk dialysis 1.5-1.8 for twice a wk dialysis Predialysis BUN < 80 mg/dl PCR: 1.0-1.4 g/kg/day HIGH PROBABILITY OF DIALYSIS FAILURE Kt/V < 0.8 PCR < 0.8 g/kg/day

Points for Clinical Applications (III) KDOQI Guideline ADEQUATE HEMODIALYSIS - Kr less than 2 ml/min/1.73 m 2 Minimal dose: spkt/v > 1.2 per dialysis, URR > 65%, 3 times per week Target dose : spkt/v = 1.4 per dialysis, URR = 70%. 3 times per week - Residual urea clearance (Kr) > 2 ml/min/1.73 m 2 Target spkt/v should be at least 15% greater than the minimum dose ERA-EDTA Best Practice Guidelines 2002 (III) Minimum prescribed HD dose per session for a thrice-weekly schedule should be: urea ekt/v>=1.20 (sp Kt/V~1.4). Twice-weekly schedules are not recommended.