Dialysis Adequacy

Over just a 60-year period, hemodialysis has become a routine medical procedure offered at over 7000 outpatient locations and in patients’ homes in the United States with a remarkable ability to prevent death from uremia in patients with chronic kidney disease—which would be a surprise to many of the early innovators. Yet the promise of restoring normal symptomatology has not been borne out. Over the last 40 years, intensive research has tried to define best hemodialysis practices and the measurement and assurance of the optimal solute clearance associated with improved outcomes. For better or worse, professional societies and the governmental regulatory agencies have chosen urea as the uremic solute to measure the “adequacy” of a hemodialysis treatment. This chapter will review the history of measuring hemodialysis efficacy, current standards and practice, and alternative clinical metrics that may help improve hemodialysis care. The conclusions the reader should draw from this chapter are that dialysis adequacy has still not been perfected and the current measures are not well suited to the home dialysis patient who performs more than thrice-weekly hemodialysis.