Patient Well-Being and Health
Clinical Evaluation Nutrition Haemoglobin Blood Pressure Preservation of Residual Renal Function Vascular Access Routine Blood Tests Bone Disease Rehabilitation and Emotional Support Clinical Evaluation Every patient on dialysis should have a clinical evaluation performed by a doctor regularly. Within treatment centres supervised by a nephrologist, chronic haemodialysis patients must be seen duri
Preservation of Residual Renal Function
Rehabilitation and Emotional Support
Clinical Evaluation
Every patient on dialysis should have a clinical evaluation performed by a doctor regularly. Within treatment centres supervised by a nephrologist, chronic haemodialysis patients must be seen during routine rounds conducted at least once per week. In addition a consultation in rooms is recommended for a full clinical assessment at the initiation of renal replacement therapy and thereafter at least 2-3 times per year.
Treatment centres with no on-site nephrologist should refer patients for regular consultations with a nephrologist at least once a month. Dialysis records, laboratory tests and transplant related issues should be addressed during such consultations. The nephrologist must be available for telephonic consultations required for dialysis unit staff to provide adequate therapy, guide vascular access and transplant centre referrals.
Note 1:
Particular attention should be paid to cardiovascular risk factors as cardiovascular disease is the main cause of mortality. Interventions aimed at reducing risks should be instituted including cessation of cigarette smoking, addressing dyslipidaemia (per KDOQI guidelines), and optimizing blood pressure control.
Note 2:
This patient contact session should also be used to detect any social problems, nutritional deficiencies and inform the patient of his/her suitability or otherwise for renal transplantation, and establish his/her readiness for transplantation.
Nutrition
Basic nutritional requirements
Energy 35 kcal/kg/d, protein 1.2 g/kg/day, <30% total calories from fat and <10% from saturated fat.
Phosphate, sodium, potassium according to patient needs and residual renal function.
Interdialytic weight gain <5% of dry weight.
Supplementation of water soluble vitamins.
Note 1:
Poverty may preclude the implementation of dietary modification. Assistance should be given to patients as far as possible.
Note 2:
A dietitian should be involved in the care of these patients and the diet individualized as far as possible.
Monitoring
Global clinical assessment, including assessment of average dry body weight at monthly visits. Follow-up patient interviews and assessment of food intake by the dietician if needed. Laboratory tests in stable patients should be performed according to the protocol in section g. Anthropometry or bioimpedance should be performed only if indicated.
Haemoglobin
Patients on chronic dialysis should ideally have haemoglobin levels of 10-12 g/dl.
Note 1:
Hb should be checked monthly and a full blood count done every 3 months.
Note 2:
If the haemoglobin is below target levels, then first exclude other causes of anaemia that are not due to lack of erythropoietin (EPO) by:
- Clinical assessment
- Standard investigations (additional tests may be needed):
- FBC with reticulocyte count
- Serum ferritin and transferrin saturation
Supplement with iron if transferrin saturation <20% or serum ferritin <200 ng/ml:
- Administer iv iron 20 mg test dose, then 100 mg/week x 8-10 weeks and reassess
- Maintenance (iv) iron is usually needed (100-400 mg/ month)
- Monitor iron status regularly (monthly until target levels are stable for 2 months then 3-monthly)
- Maintain transferrin saturation 20-50% and serum ferritin 200-500 ng/ml.
Note 3:
TSAT and ferritin may be inaccurate in states of inflammation or malnutrition.
Note 4:
If the patient has adequate iron stores, administer an erythrocyte stimulating agent (ESA).
Use short- or long-acting ESAs according to label; monitor Hb regularly until stable on target. Titrate the dose of EPO by adjusting the dose or frequency of injection. If large doses of ESA are required, then evaluate for EPO resistance:
- Missed ESA doses
- Inflammation (e.g. occult infection)
- Inadequate dialysis
- Hyperparathyroidism
- Trace metal (particularly aluminium) overload
- Poor water quality
- Occult haemolysis
- Recheck for other causes of anaemia again
Note 5:
The management of anaemia should not occur in isolation but take into consideration factors such as the nutrition of the patient and the adequacy of dialysis.
Note 6:
Blood transfusions should be avoided as far as possible and reserved for symptomatic anaemia unresponsive to EPO, for acute haemodynamic instability and in preparation for surgery that cannot safely be postponed. Written consent is required for each transfusion. Use leukocyte depleted blood products for transplant candidates.
Blood Pressure
Target blood pressure for CVD risk reduction in CKD should be <140/90 mm Hg.
Note 1:
Antihypertensive agents should be prescribed as follows:
- Diuretics should be included in most patients, except those who are anuric
- Choose additional agents based on CVD-specific indications to achieve therapeutic and preventive targets and to avoid side-effects and interactions
- The antihypertensive regimen should be simplified as much as possible
- Long-acting (once-daily agents) should be used when possible, and taken at the same time each day
- Patients with intradialytic hypotension should take their medications post dialysis.
Note 2:
Counsel patients on sodium and fluid restriction, and the use of diuretics in those with residual renal function. Daily dietary sodium intake should be restricted to no more than 5 g of salt (sodium chloride), equivalent to <2 g/day of sodium.
Note 3:
Ultrafiltration should be optimized to render the patient euvolemic and normotensive. Increasing positive sodium balance by “sodium profiling” or using a high dialysate sodium concentration should be avoided.
Preservation of Residual Renal Function
Several actions and precautions are recommended to preserve residual renal function (RRF), which is a strong predictor of mortality for dialysis patients:
- Angiotensin-converting enzyme (ACE) inhibitors and/ or angiotensin receptor blockers (ARBs) are the agents of choice in patients with significant RRF who need antihypertensive medication. Monitor for hyperkalaemia and use with caution in vasculopaths
- Avoid potential nephrotoxins, especially aminoglycoside antibiotics, contrast agents, and NSAIDs (including Cox-2 inhibitors)
- Avoid aggressive lowering of blood pressure and/or volume depletion
- Prerenal and postrenal causes of decreases in RRF should be considered in the appropriate clinical setting.
Vascular Access
An arteriovenous fistula (AVF) is the vascular access of choice in haemodialysis patients and should be fashioned timeously (GFR <25 ml/min) to ensure maturity (1-4 months later) when required.
Note 1:
The order of placement of AVF is at the wrist and then the elbow starting with the non-dominant arm. The advantages of fistulae include excellent patency once established, improved flow overtime, and a lower incidence of stenosis, infection and vascular steal phenomenon.
Note 2:
If it is not possible to establish a fistula, access may be established using an arteriovenous graft of synthetic material (preferably PTFE).
Note 3:
Cuffed tunnelled central venous catheters should be discouraged as a permanent vascular access.
Note 4:
The initial cannulation of a native AVF must be performed by an experienced person.
Note 5:
Patients with AVF must adopt good personal hygiene habits; clean technique should be used before cannulation (see European Best Practice Guidelines).
Note 6:
The placement of subclavian vein catheters for acute dialysis should be avoided as should venepuncture of antecubital fossa veins, in patients who are potential candidates for haemodialysis.
Note 7:
The AVF should be monitored by regular physical examination, and surveillance for stenosis can be done by monitoring static dialysis venous pressure, by duplex ultrasound and by assessing for recirculation.
Routine Blood Tests
Costs were carefully considered in drafting the protocol. Blood results should be checked on all patients on chronic dialysis as per the table on page 11 and the predialysis serum targets to be aimed for are as follows:
- Potassium 4.0-5.5 mmol/l
- Phosphate 0.8-1.4 mmol/l
- Calcium 2.05-2.45 mmol/l
- iPTH = 2-9 times the upper limit of the normal range
- Albumin >35 g/l (minimum), optimal >40 g/l
Bone Disease
Phosphate binders
The use of phosphate binders is indicated to control the serum phosphorus level towards the normal range. The binder must be taken at meal time (either just before or during the meal) for optimal phosphate binding. The dose can be adjusted according to the phosphorus “load” in the meal (e.g., 2 before breakfast, 1 before a light lunch, 3 before the main meal, usually at night).
Non calcium containing phosphate binders should be used when serum phosphate is elevated and:
- Calcium levels are above target
- iPTH levels are below twice the normal range
- Vascular calcification is present.
Note 1:
The use of aluminium hydroxide should be very limited.
Note 2:
Calcimimetics should be considered for suppression of PTH in the presence of hypercalcaemia.
Note 3:
We recommend the use of low calcium dialysate (1.25-1.5 mmol/l) and dietary calcium restriction in patients prone to hypercalcaemia.
Note 4:
Vit D3 levels may be measured at the initiation of dialysis
Note 5:
Vitamin D preparations or analogues should be prescribed under the following conditions:
- Target phosphorus level achieved but calcium low or low normal range
- iPTH higher than 2 to 9 times normal
- Vitamin D can be given 3 times a week (with dialysis) to reduce the risk of hypercalcaemia
- Vitamin D preparations are contraindicated in the presence of serum calcium above target ranges, and high serum phosphate levels (needs individualised assessment).
Note 6:
Parathyroidectomy should only be considered when the iPTH is higher than target and it has failed to respond to medical therapy.
Note 7, Cautionary:
Adynamic bone disease is a potential complication of all measures that over-suppress iPTH (including aggressive use of vitamin D, chronic positive calcium balance, or parathyroidectomy).
Rehabilitation and Emotional Support
The emotional and social/economic support of patients is integral to the holistic approach of the care given to patients on dialysis. In order to provide this care, it is recommended that each treatment centre has access to a social worker and/or psychologist.
Paget G, Naicker S, et al. Guideline for the optimal care of patients on chronic dialysis in South Africa. South African Renal Society; 2015.