Tests that measure effectiveness of dialysis

[TheSpleen]

Can anyone point me to a website (or maybe previous posts - I didn't find one) That discusses what tests measure how effective dialysis is?
Prior to dialysis, we were mostly looking at Creatinine levels/GFR to see how Candice's kidneys were doing.
Now that she's started dialysis, what should we be looking at?

[okarol]

Jenna's Kt/V was what we kept an eye on with in-center hemo. Not sure about PD.
I found this:

Tests to measure the effectiveness of dialysis
From Healthwise

Dialysis removes urea and other waste products from the blood. To find out how well dialysis is working, you will have blood tests that look at the level of urea in your blood. Usually, these tests are done once a month, at the beginning of your session and again at the end. In general, two measures indicate how well dialysis is working: urea reduction ratio (URR) and Kt/V.
Urea reduction ratio

One way to measure how well hemodialysis is removing urea from the body is to measure blood urea nitrogen (BUN) level. The BUN is measured before and after your treatment session. Then, the two numbers are compared to see how much the urea level in the blood has decreased. This difference is called the urea reduction ratio (URR), and it is usually expressed as a percentage. An adequate dose of hemodialysis should result in an average URR of 65%.1
Kt/V

Another way to measure the effectiveness of hemodialysis is to compare the amount of fluid that is cleared of urea during each dialysis session with the amount of fluid that exists in the body. This is called the Kt/V.

    * Kt represents the amount of fluid that is cleared of urea during each dialysis session. It is measured in milliliters per minute (mL/min).
    * V represents the volume of water a person's body contains.

The Kt/V is the most accurate measure of hemodialysis because it also measures the amount of urea removed with excess fluid and takes into consideration other factors, such as weight loss during dialysis. An adequate dose of hemodialysis should result in an average Kt/V of 1.2.1
What to think about

    * An adequate dose of dialysis can usually be delivered in 3 to 5 hours.
    * Inadequate doses of hemodialysis (hemodialysis URR percentages that average below 65% or Kt/V values below 1.2) increase the risk of complications and death.2

References
Citations

   1. Depner TA, et al. (2006). Clinical Practice Guidelines for Hemodialysis Adequacy. New York: National Kidney Foundation. Available online: www.kidney.org/professionals/KDOQI/guidelines.cfm.
   2. Owen WF (1998). Status of hemodialysis adequacy in the United States: Does it account for improved patient survival? American Journal of Kidney Diseases, 32(6, Suppl 4): S39–S43.

Credits
Author   Jeannette Curtis
Editor   Susan Van Houten, RN, BSN, MBA
Associate Editor   Pat Truman, MATC
Primary Medical Reviewer   E. Gregory Thompson, MD
- Internal Medicine
Specialist Medical Reviewer   D.C. Mendelssohn, MD, FRCPC
- Nephrology
Last Updated   November 13, 2007
Author:    Jeannette Curtis   Last Updated: November 13, 2007
Medical Review:    E. Gregory Thompson, MD - Internal Medicine
D.C. Mendelssohn, MD, FRCPC - Nephrology

http://health.msn.com/health-topics/articlepage.aspx?cp-documentid=100057795

[Meinuk]

Medicare is the primary use for Kt/v and it is a flawed equation (see references below).  This number is important because it is how a dialysis unit reports its outcomes.  (some private companies give bonuses for good numbers in units.  Kt/V is financially motivated and NOT a good medical indicator).  There are a few threads on this, but for now when you are dialyzing in center, KT/v and overall creatinine and BUN are the unit's indicies.

A good resource for understanding kidney/dialysis lab tests is module 7 at Kidney School  http://www.kidneyschool.org/splash/toc.shtml?gclid=CM_n--6IppcCFQFvGgodjwEX-w

I just have to throw in my 2 cents that when you do a higher dosage of hemodialysis (at home or nocturnal) Kt/V simply does not reflect how you feel.

Once you have started any form of dialysis, although you may have some residual kidney function and still urinate- GFR is negligible.  You should be monitoring how she feels - are they taking off too much fluid and causing nausea or lightheadedness?  Are they taking off too little and is she feeling boated and achy? 

Also, phosphorus  - is she itchy?

Remember - in center dialysis is MINIMUM dialysis.  You need to be vigilant with fluid intake and dietary restrictions.  In Center nocturnal allows for more dialysis and fewer restrictions, PD has less restriction and can be done at home, as is Home Hemo via NxStage less restrictions, more energy, more dialysis, and then there is the gold standard of dialysis extended at home - which studies have shown rivals a deceased donor transplant.

Of course, then there is transplant where, if all goes well, you have no restrictions (aside from grapefruit, sushi and raw meat and raw sprouts etc)

Back to indicators - for the first month, Candice should just adjust to how her body is adjusting to dialsis.  The unit will provide you with monthly labs.  (ask for real labs - not the dialysis for dummies sheets woth stickers, soon enough, you'll be able to correlate her hemoglobin and hemotocrit and all of the other lab values as an indicator of how efficient dialysis is.

My advice - push for the best possible therapy - don't settle.  Dialysis should not make a person miserable - it should make them feel better.  If you aren't feeling better, something is wrong.

Best,

Anna

From Paper citing Kt/V:  http://www.nature.com/ki/journal/v58/n76s/full/4491951a.html

The duration, frequency, and intensity of more frequent dialysis reported have varied a great deal. Levels of spKt/V prescribed each treatment have varied from 0.3 to 1.7, treatment time from 1.5 to 8 hours, and frequency of four to six times per week. The clinical reports all indicate improved outcome irrespective of the level of Kt/V, which has led some to conclude that Kt/V is a badly flawed parameter to define adequacy of the dialysis prescription

[boxman55]

My suggestion is to have the Nepth explain what all the lab results mean. They take them once a month right about now. They drew mine today. anyway then you will know and can stay on top of it...Boxman

[G-Ma]

My new center RAI takes labs once a week to keep on top of everything and I am feeling better than I did in center before and using NxStage...that just wore me out.  I told the nurses today I want to bottle this good feeling so I can store it and sip from it as needed going forward and the techs and nurses here are fantastic.  They come out to the waiting room and let us know if there are problems, we can ring the doorbell if we want and don't get condemned for it.  We can talk back and forth on dialysis without being told to be quiet and the techs and nurses visit with us.  My numbers are very good.  Hope this lasts awhile.  As Meinuk and Boxman said....Keep on top of everything, you are helping yourself if you do.
Ann

[TheSpleen]

In case anyone's interested, talked to the doc on Friday and he said the main thing's he's looking at (in our case, at least) are:
No swelling in her legs, good blood pressure, removing at least 1 liter of liquid per day, phosphorous less than 5.5 and Kt/v >1.7 (we havn't done this test, yet).

[nursewratchet]

KT\V of at least 1.4; AND\OR, depending on your clinic, URR of at least 70.  URR is Urea Reduction Rate. 

[Sunny]

Good insight on dialysis expectations.