Is Adequate Dialysis good enough or will we aim for Optimum Dialysis?

As Dialysis Patients, when we get our Dialysis sessions, we might often wonder if we got a good session? Did we get our money's worth? Was it worth being tied to a machine for hours? Was it worth all the trouble?

Medical Professionals have tried to answer that question for many years now.

The accepted measure of the quality of a dialysis session is Kt/V. This measure has been used to measure the adequacy of a Dialysis Session for years now. Doctors consider Kt/V values over 1.2 adequate.

There is one problem with this measure though. It only represents the clearance of Urea. Nothing else. Now, urea is a small molecule. If the clearance of urea is adequate, we can assume that molecules of the size of urea are being removed adequately as well. Molecules containing sodium and potassium, for example, would fall in this category. 

However, this does not tell us anything about other toxins that are larger. The blood contains excess toxins of different sizes. Just because the dialysis session has removed urea, we cannot say how well larger toxins have been removed.

Doctors have come up with various workarounds for this.

Some people have suggested that a simple product of the number of hours per session multiplied by the number of sessions per week squared would give a better measure of good dialysis. So, if you're getting 4 hours per session and getting three sessions a week, the product would be 36. If you got 8 hours per session and 5 sessions a week, the product would be 200.

This, however, did not consider the type of dialyser used or even the dialysis parameters like blood flow rate or dialysate flow rate that are used which impact the effectiveness of the dialysis session.

Dr. John Agar, a reputed nephrologist from Australia, suggested that the best way to measure the quality of dialysis was to look at the comprehensive impact it has on the patient. He formulated the Good Dialysis Index, which was a multi-dimensional index of the impact dialysis had on the patient. It was a 20-point questionnaire that was divided into four sections:

  • Patient Directed Questions: these measured the patient's Quality of Life 
  • Process Directed Questions: these measured the actual dialysis dose delivered and intra-dialytic complications
  • Laboratory Directed Questions: these looked at blood tests
  • Chart Directed Questions: these looked at the Medications the patient is on
A look at the specific questions may strike us as being too ambitious. For instance, it asks for more than 7 sessions every two weeks and over 18 hours of dialysis every week. It also suggests that patients should not be on any anti-hypertensive or phosphate binding medications.

While not everyone can get a 20 out of 20 in this Good Dialysis Index, we can at least aspire to or work towards that, isn't it?

The Indian situation is very different. Yes. Since most of us pay for our treatment out of pocket, we cannot compare ourselves with those in countries where all medical treatment expenses are borne by the Government.

However, we should definitely try to improve the quality of our dialysis treatments so that we get the best out of every session. We need to follow our doctor's advice as much as possible to ensure that our dialysis treatment works for us and gives us the life we desire. We should at least know how good our dialysis is and try to find out what we can do to improve it. We need to be proactive about our health and realise there is a lot we can do to feel better.


Anonymous said…
totally agree! that is why new concert Artifical Kidney "HD+HP", HD to remove small urea, while HP is the method to remove large uremic toxin, protein bound toxin.