Prescribing Hemodialysis or Hemodiafiltration: When One Size Does Not Fit All the Proposal of a Personalized Approach Based on Comorbidity and Nutritional Status

Abstract

There is no simple way to prescribe hemodialysis. Changes in the dialysis population, improvements in dialysis techniques, and different attitudes towards the initiation of dialysis have influenced treatment goals and, consequently, dialysis prescription. However, in clinical practice prescription of dialysis still often follows a “one size fits all” rule, and there is no agreed distinction between treatment goals for the younger, lower-risk population, and for older, high comorbidity patients. In the younger dialysis population, efficiency is our main goal, as assessed by the demonstrated close relationship between depuration (tested by kinetic adequacy) and survival. In the ageing dialysis population, tolerance is probably a better objective: “good dialysis” should allow the patient to attain a stable metabolic balance with minimal dialysis-related morbidity. We would like therefore to open the discussion on a personalized approach to dialysis prescription, focused on efficiency in younger patients and on tolerance in older ones, based on life expectancy, comorbidity, residual kidney function, and nutritional status, with particular attention placed on elderly, high-comorbidity populations, such as the ones presently treated in most European centers. Prescription of dialysis includes reaching decisions on the following elements: dialysis modality (hemodialysis (HD) or hemodiafiltration (HDF)); type of membrane (permeability, surface); and the frequency and duration of sessions. Blood and dialysate flow, anticoagulation, and reinfusion (in HDF) are also briefly discussed. The approach described in this concept paper was developed considering the following items: nutritional markers and integrated scores (albumin, pre-albumin, cholesterol; body size, Body Mass Index (BMI), Malnutrition Inflammation Score (MIS), and Subjective Global Assessment (SGA)); life expectancy (age, comorbidity (Charlson Index), and dialysis vintage); kinetic goals (Kt/V, normalized protein catabolic rate (n-PCR), calcium phosphate, parathyroid hormone (PTH), beta-2 microglobulin); technical aspects including vascular access (fistula versus catheter, degree of functionality); residual kidney function and weight gain; and dialysis tolerance (intradialytic hypotension, post-dialysis fatigue, and subjective evaluation of the effect of dialysis on quality of life). In the era of personalized medicine, we hope the approach described in this concept paper, which requires validation but has the merit of providing innovation, may be a first step towards raising attention on this issue and will be of help in guiding dialysis choices that exploit the extraordinary potential of the present dialysis “menu”.

Design of Mobile Hemodialysis Apparatus for Acute Renal Failure Patient's Self-Help and Treatment Adherence

“…Giorgina Barbara Piccoli et. al have explained about which hemodialysis process should have higher efficiency in younger and older patients [9]. The authors have shown priority in nutrition level.…”

Intradialytic Nutrition and Hemodialysis Prescriptions: A Personalized Stepwise Approach

“…However, the risk of depletion of important nutrients during dialysis sessions with highly permeable membranes cannot be ruled out, and, while the advantages of better depuration are clear in young, well-nourished patients, it is still far from certain that high flow hemodiafiltration produces advantages for malnourished patients [26][27][28][29][30][31][32][33].…”

“…Moreover, dialysis prescription varies widely, and very different treatments may be gathered under the same name; information on the dialysis schedule is often incomplete, thus making comparisons and implementing strategies can be challenging [29][30][31].…”

“…Yet, they have a severely reduced muscle mass, and this reduction is correlated with survival [81,[84][85][86][87]. However, it is not unusual to find that these thin, fragile patients have very high dialysis efficiency, often linked to their low BMI and volume distribution, whose dialysis prescription should probably be decreased rather than increased [29,30]. These cases, particularly the Japanese school, suggest modulating dialysis efficiency to avoid loss of precious nutrients.…”

Green nephrology and eco-dialysis: a position statement by the Italian Society of Nephrology

“…The modest gain in efficiency (usually estimated as less than 20%) is in fact attainable only in patients with concomitant high blood flow, and even in such cases the clinical advantage may be dubious [66][67][68][69][70][71]. At present the balance may point towards a lower dialysate flow in elderly patients with low metabolic needs, where optimal dialysis is probably a compromise between depuration and depletion [72,73].…”