Individualizing the Dialysate in the Hemodialysis Patient

Abstract

In most outpatient centers the dialysate is prepared centrally such that the composition of the dialysate is the same for all patients. When delivered in this manner most patients tolerate the procedure well. However, there are patients who tolerate the procedure poorly, which has prompted a great deal of research focused on individualizing the composition of the dialysate in order to improve patient tolerability. Prescribing a patient-specific dialysate will become increasingly important as the age of and number of comorbid conditions increase in the dialysis population. Patients with end-stage renal disease (ESRD) depend on dialysis to maintain fluid and electrolyte balance. Hemodialysis allows for solutes to diffuse between blood and dialysate such that, over the course of the procedure, plasma composition is restored toward normal values. The makeup of the dialysate is of paramount importance in accomplishing this goal. In most out-patient settings patients receive hemodialysis using dialysate prepared in bulk and delivered via a central delivery system so that the composition of the dialysate is the same for all patients. While most patients tolerate the procedure when administered in this fashion, many patients suffer from hemodynamic instability or symptoms of dialysis disequilibrium. One strategy to improve the clinical tolerance to dialysis is to adjust the dialysate composition according to the individual characteristics of the patient. This article reviews recent developments on how the dialysate can be manipulated in order to improve patient tolerance. Individualizing the dialysate composition is likely to gain increasing importance given the advancing age and increasing number of comorbid conditions found in ESRD patients.

Renal replacement therapy review

“…103,104 Hence, individualization of dialysate composition may improve individual patient outcomes and is recommended for on-line dialysate production. 103,105,106 Commercial fluid compositions for CRRT also vary the amount of potassium, glucose and calcium but with less flexibility of choice, however, as compared to on-line fluid production. 107 Calcium and bicarbonate content becomes important for patients on regional citrate anticoagulation (see section on anticoagulation), as calcium in dialysate counteracts the effects of citrate at the membrane and alkalosis may develop due to citrate metabolism and increased bicarbonate load.…”

Acute Complications of Hemodialysis

“…Such modeling is particularly made for patients with intradialytic hypotension, cramps or severe uremia or for those whose hemodynamics is not stable. However, modeling will not be appropriate for patients with hypernatremia or intradialytic hypertension (Palmer, 2001). Finally, preparation of individual HD prescriptions should be remembered in adjusting the Na balance.…”

Concentração de cálcio no dialisato e hipercalcemia na DRC

“…No entanto, parece claro que o tratamento adequado da Cad é um fator importante e deveria ser considerado parte do tratamento dos distúrbios do metabolismo mineral e ósseo da DRC. 4 Na realidade, desde a década de 1960, época em que a HD foi introduzida como terapia de substituição da função renal, as recomendações da Cad foram principalmente baseadas em opinião de especialistas e de acordo com a situação clínica de cada época, mais do que em evidências. Na década de 1960, as maiores preocupações eram controlar os níveis séricos de P e de Ca com o objetivo de prevenir doença óssea e calcificação metastática em pacientes mantidos em diáli-se regular.…”