Conserving Water and Dialysate During Inpatient Dialysis Sessions

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Background: Assessing hemodialysis adequacy for inpatients remains poorly understood. The applicability of outpatient targets such as the urea reduction ratio (URR) to inpatients has not been systematically studied, yet is a marker measured in our hospital. Furthermore, the average baseline dialysate flow rate employed in our institution exceeds the rate that is sufficient to achieve adequate dialysis per guidelines. Patients receiving hemodialysis have their URR measured when our nurses anticipate they will remain longer than 3 sessions. Our current practice is to prescribe a standard dialysate flow rate of 700ml/min for all established patients. We aimed to improve the quality of our inpatient dialysis unit by educating providers about the conservation benefits of dialysate flow rates that can be employed without any decrement to the adequacy of dialysis treatments. Methods: We educated prescribing providers of the minimal impact of a Qd exceeding 1.5 times the Qb on measured URR, and proposed that a new universal standard of 600ml/min be implemented. Providers maintained the ability to prescribe any dialysate flow rate they felt appropriate for the patient. Measurements of URR continued as per standard dialysis practice. Data from one month prior to and after the education intervention were reviewed. Results: In the one month preceding the intervention, 49 dialysis sessions had a measured URR, and there were 44 sessions in the month immediately after. The average pre-BUN, post-BUN, blood flow rate and treatment time were not statistically different. The prescribed average dialysate flow rate was 686ml/min pre-intervention and 620ml/min post-intervention (p = 0.000002). Despite this, there was no statistically significant difference in measured URR (p = 0.19). The average used dialysate volume per session decreased from 138L to 130L (p = 0.04). Conclusions: Decreasing the standard dialysate flow rate for acute inpatients had no impact on measured URR. While this confers modest dialysate concentrate and water savings per patient, the net effect of multiple daily sessions over a prolonged period of time offers important conservation benefits to any dialysis unit.

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