How do I set the initial dialyzer prescription for a new patient?

Start with: body surface area (BSA)-appropriate dialyzer surface area (typically 1.5-2.0 m² for adults), high-flux membrane, Qb 300 mL/min (adjusted up based on access), Qd 500 mL/min, 4 hours 3x/week. Adjust based on first-month Kt/V, laboratory trends, and patient tolerance.

When should I consider sodium modeling?

Sodium modeling is indicated for patients with recurrent intradialytic hypotension despite appropriate dry weight and UF rate. Contraindicated in patients with high interdialytic sodium intake, as it increases thirst and interdialytic weight gain. The stepped approach (145→135 mEq/L across session) is preferred over linear for more predictable BP support.

What is the evidence for high-flux dialyzers?

The HEMO study (Cheung et al., NEJM 2003) showed that high-flux dialysis reduced cardiovascular mortality by 37% in patients with >3.7 years of dialysis vintage and by 13% in all patients overall. High-flux membranes also reduce β2-microglobulin levels (associated with dialysis-related amyloidosis) and have better middle molecule clearance.

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Template Worksheet

Hemodialysis Prescription Worksheet & Order Set

Structured hemodialysis prescription template covering all prescription elements per KDOQI guidelines: modality selection, dialyzer choice, blood/dialysate flow rates, anticoagulation, UF profiling, dialysate composition, and frequency/duration.

What's Inside

Patient Information & History

8 items

Patient demographics, primary diagnosis, comorbidities (DM, HTN, CHF), CKD etiology, allergies, and recent procedures (access creation, transplant evaluation).

Modality & Frequency Selection

5 items

Conventional HD (3x/week, 4 hrs), extended HD (3x/week, 5-6 hrs), short daily HD (5-6x/week, 2-3 hrs), nocturnal HD (3x/week, 6-8 hrs), or SLED (8-12 hrs).

Dialyzer & Target Parameters

7 items

Dialyzer type (high-flux vs low-flux), surface area based on BSA, KoA, blood flow rate target (Qb 300-400 mL/min), dialysate flow rate (Qd 500-800 mL/min), target Kt/V ≥1.2 per session.

Dialysate Prescription

6 items

Sodium (136-145 mEq/L), potassium (0-4 mEq/L based on serum K+), calcium (2.5-3.5 mEq/L), bicarbonate (30-40 mEq/L), and temperature (35-37°C, cooler for hypotension-prone).

Anticoagulation

7 items

Unfractionated heparin (bolus + infusion, typical: 2000U bolus + 1000U/hr), LMWH (enoxaparin 0.5-1.0 mg/kg), citrate (for CRRT or HIT patients), or no anticoagulation (for coagulopathy risk).

UF & Dry Weight Management

6 items

Prescribed UF goal (interdialytic weight gain + saline/rinseback), maximum UF rate (<10 mL/kg/hr to minimize hypotension risk), target dry weight, and UF profiling instructions.

Preview

Prescription Elements (Sample)

Dialyzer selection: High-flux polysulfone/polyethersulfone (PES) recommended for all patients due to superior middle molecule clearance (ESRD patients accumulate β2-microglobulin, removed more effectively by high-flux membranes per HEMO study, Cheung et al., 2003, NEJM)
Blood flow rate: Initiate dialysis at Qb 200 mL/min for first 15 minutes, then increase incrementally by 50 mL/min every 5-10 minutes to target 350-400 mL/min depending on access quality and patient tolerance (higher Qb = better clearance, diminishing returns >400 mL/min)
Dialysate sodium: standard 138 mEq/L; use sodium modeling (step-down from 145 to 135 mEq/L) for hypotension-prone patients; avoid low sodium (<135 mEq/L) due to hypotension and cramping risk
Heparin protocol: 2000U IV bolus at start of dialysis, then 1000U/hr continuous infusion; stop infusion 30-60 min before end of session (if no anticoagulation risk). Target ACT (activated clotting time) 180-220 seconds (1.5-2x baseline)
UF profiling: Linear UF recommended for most patients; step UF for patients with large interdialytic weight gain (remove majority in first 2 hours); intermittent UF for hypotension-prone — UF on for 30 min, off for 15 min, cycle throughout session
Dry weight assessment: Previous session minimum weight (within last 6 sessions) — adjust if patient has: BP trend (↑ with fluid overload or ↓ with excessive UF), cramping in later hours of dialysis, or shortness of breath before next session

Measurable Impact

Prescription parameters

≥1.2

Kt/V target per session

<10

Max UF rate (mL/kg/hr)

KDOQI

Adequacy guidelines aligned

Based on Published Standards

KDOQI Clinical Practice Guidelines for Hemodialysis Adequacy (2015 Update)

HEMO Study — Cheung et al. (NEJM, 2003) — Membrane Flux and Dialysis Dose

NKF-KDOQI Guidelines for Cardiovascular Disease in Dialysis Patients (2005)

KDOQI Clinical Practice Guidelines for Vascular Access (2019 Update) — Access Flow for Prescription

European Renal Best Practice (ERBP) — Guideline for Dialysis Prescription

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What's Inside

Patient Information & History

8 items

Patient demographics, primary diagnosis, comorbidities (DM, HTN, CHF), CKD etiology, allergies, and recent procedures (access creation, transplant evaluation).

Modality & Frequency Selection

5 items

Conventional HD (3x/week, 4 hrs), extended HD (3x/week, 5-6 hrs), short daily HD (5-6x/week, 2-3 hrs), nocturnal HD (3x/week, 6-8 hrs), or SLED (8-12 hrs).

Dialyzer & Target Parameters

7 items

Dialyzer type (high-flux vs low-flux), surface area based on BSA, KoA, blood flow rate target (Qb 300-400 mL/min), dialysate flow rate (Qd 500-800 mL/min), target Kt/V ≥1.2 per session.

Dialysate Prescription

6 items

Sodium (136-145 mEq/L), potassium (0-4 mEq/L based on serum K+), calcium (2.5-3.5 mEq/L), bicarbonate (30-40 mEq/L), and temperature (35-37°C, cooler for hypotension-prone).

Anticoagulation

7 items

Unfractionated heparin (bolus + infusion, typical: 2000U bolus + 1000U/hr), LMWH (enoxaparin 0.5-1.0 mg/kg), citrate (for CRRT or HIT patients), or no anticoagulation (for coagulopathy risk).

UF & Dry Weight Management

6 items

Prescribed UF goal (interdialytic weight gain + saline/rinseback), maximum UF rate (<10 mL/kg/hr to minimize hypotension risk), target dry weight, and UF profiling instructions.

Preview

Prescription Elements (Sample)

Dialyzer selection: High-flux polysulfone/polyethersulfone (PES) recommended for all patients due to superior middle molecule clearance (ESRD patients accumulate β2-microglobulin, removed more effectively by high-flux membranes per HEMO study, Cheung et al., 2003, NEJM)
Blood flow rate: Initiate dialysis at Qb 200 mL/min for first 15 minutes, then increase incrementally by 50 mL/min every 5-10 minutes to target 350-400 mL/min depending on access quality and patient tolerance (higher Qb = better clearance, diminishing returns >400 mL/min)
Dialysate sodium: standard 138 mEq/L; use sodium modeling (step-down from 145 to 135 mEq/L) for hypotension-prone patients; avoid low sodium (<135 mEq/L) due to hypotension and cramping risk
Heparin protocol: 2000U IV bolus at start of dialysis, then 1000U/hr continuous infusion; stop infusion 30-60 min before end of session (if no anticoagulation risk). Target ACT (activated clotting time) 180-220 seconds (1.5-2x baseline)
UF profiling: Linear UF recommended for most patients; step UF for patients with large interdialytic weight gain (remove majority in first 2 hours); intermittent UF for hypotension-prone — UF on for 30 min, off for 15 min, cycle throughout session
Dry weight assessment: Previous session minimum weight (within last 6 sessions) — adjust if patient has: BP trend (↑ with fluid overload or ↓ with excessive UF), cramping in later hours of dialysis, or shortness of breath before next session

Measurable Impact

Prescription parameters

≥1.2

Kt/V target per session

<10

Max UF rate (mL/kg/hr)

KDOQI

Adequacy guidelines aligned

Based on Published Standards

KDOQI Clinical Practice Guidelines for Hemodialysis Adequacy (2015 Update)

HEMO Study — Cheung et al. (NEJM, 2003) — Membrane Flux and Dialysis Dose

NKF-KDOQI Guidelines for Cardiovascular Disease in Dialysis Patients (2005)

KDOQI Clinical Practice Guidelines for Vascular Access (2019 Update) — Access Flow for Prescription

European Renal Best Practice (ERBP) — Guideline for Dialysis Prescription