JapaneseSociety forDialysisTherapyClinicalGuideline for “Maintenance Hemodialysis: Hemodialysis Prescriptions” (2015)

The Japanese Society for Dialysis Therapy (JSDT) has published Clinical Guidelines for Maintenance Hemodialysis: Hemodialysis Prescription. These evidence-based guidelines focus on the characteristics of the dialysis performed in Japan. The number of elderly patients undergoing long-term hemodialysis (HD) is higher in Japan than in other countries. The purpose of the guidelines is to provide recommendation for long-term, stable HD. The main body of the guidelines shows the current recommended minimal standards for HD performed in Japan (i.e. HD at a blood flow rate of at least 200 mL/min using an ultrapure dialysis fluid with a flow rate of at least 500 mL/min and a high-performance membrane (HPM) dialyzer, three times per week for at least 4 h). Although most of the guidelines are evidence based, the recommendations for stably maintaining the condition of patients undergoing long-term HD are presented as opinions. Nevertheless, according to a report by the JSDT Renal Data Registry (JRDR), a considerable number of dialysis facilities have not followed the recommended minimal standards. We hope that at least the minimal standards recommended in the guidelines will be adopted by all dialysis facilities. The guidelines consist of three parts. The main part of the guidelines is in Chapters 1–4, Chapters 1–4, Chapters 1–4, Chapters 1–4 and presents the basics of HD prescriptions, such as the removal of solutes (substances of low-to-middle molecular weight), control of body fluid, and evaluation of treatment effect. The patients targeted in these prescriptions are HD outpatients in a stable condition; inpatients and patients with severe complications are excluded. In Chapter 5, blood purification methods that lack sufficient supportive evidence but may be effective to improve the prognosis of HD patients are explained. Therefore, the evidence level and advisability of these methods are not shown in Chapter 5. Chapter 6 presents the guidelines for pediatric HD. The number of pediatric HD patients is small and sufficient evidence to formulate guidelines is not available in Japan. Therefore, the evidence level and advisability of HD in pediatric patients are not shown in Chapter 6. Although survival rates related to dialysis therapy in Japan are the highest worldwide 1, there are still many ongoing discussions on whether or not Japan should have a specific dialysis prescription guideline to achieve standardization. This high HD efficacy rate is based on the comparison between Japan and other countries; there are still differences in survival rate among facilities in Japan. In addition, the current quality level of HD may vary in the future, depending on the changes in economic and social conditions. Therefore, we believe that this is the appropriate time to establish guidelines, because dialysis treatment has matured technologically, and a certain level of quality of HD has been attained. Evidence levels and strengths of recommendations are defined and presented in combination, based on an evidence grading system adapted from the Kidney Disease Improving Global Outcomes position paper 2 and JSDT modification 3, 4. As shown in Table 1, the strength of the recommendation is graded as either 1 (“strong”: i.e. “we recommend” you do it, for positive recommendations, and “we recommend” you do not do it, for negative recommendations) or 2 (“weak”: “we suggest” you do it, or “we suggest” you do not do it). For the final category, “No grade” (“it is reasonable”), there is insufficient evidence available to give a grade; however, these ungraded statements are based on a consensus of expert opinion, and the expectation is that consideration should be given to follow the statement. Dialysis dose is expressed by the single-pool Kt/V for urea (spKt/V). (1B) Measurement of the dialysis dose is done at least once a month. Recommended delivered dialysis dose by spKt/V is the following: The minimal adequate dose is 1.2. (1B) The target dose is 1.4 or higher. (2B) The recommended minimal dialysis time is 4 h or longer. (1B) *These recommendations are for patients with maintenance HD three times per week for less than 6 h. Among small solutes, urea (molecular weight, 60), a final product of protein metabolism impaired by uremia, is a clinically useful marker 5, 6. Urea is water-soluble and diffuses across the cell membrane almost freely. A simple mathematical kinetic model, termed the single-pool model (also known as the one-compartment model), can be applied to urea, because urea is assumed to be uniformly distributed in the body fluid 7. In addition, the National Cooperative Dialysis Study (NCDS) conducted in the USA demonstrated that time averaged concentration of blood urea nitrogen (TACBUN) and protein catabolic rate (PCR, a nutrition index) are important factors related to the prognosis of dialysis patients, including complications and death 8. 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