KDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 Update

doi:10.1053/j.ajkd.2015.07.015

American Journal of Kidney Diseases

Volume 66, Issue 5, November 2015, Pages 884-930

https://doi.org/10.1053/j.ajkd.2015.07.015 Get rights and content

Abstract

The National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for all stages of chronic kidney disease (CKD) and related complications since 1997. The 2015 update of the KDOQI Clinical Practice Guideline for Hemodialysis Adequacy is intended to assist practitioners caring for patients in preparation for and during hemodialysis. The literature reviewed for this update includes clinical trials and observational studies published between 2000 and March 2014. New topics include high-frequency hemodialysis and risks; prescription flexibility in initiation timing, frequency, duration, and ultrafiltration rate; and more emphasis on volume and blood pressure control. Appraisal of the quality of the evidence and the strength of recommendations followed the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Limitations of the evidence are discussed and specific suggestions are provided for future research.

Section snippets

Work Group Membership

Work Group Chairs
John T. Daugirdas, MD University of Illinois College of Medicine Chicago, IL	Thomas A. Depner, MD University of California, Davis Sacramento, CA

Work Group Members
Jula Inrig, MD, MHS Duke University Medical Center Yorba Linda, CA Rajnish Mehrotra, MD University of Washington Division of Nephrology, Harborview Medical Center Seattle, WA Michael V. Rocco, MD, MSCE Wake Forest School of Medicine Winston Salem, NC Rita S. Suri, MD, MSc, FRCPC University of Montreal Montreal, Quebec Daniel E. Weiner,

KDOQI Leadership

Michael Rocco, MD, MSCE

KDOQI Chair

Holly Kramer, MD

Vice Chair, Research

Michael J. Choi, MD

Vice Chair, Education

Milagros Samaniego-Picota, MD

Vice Chair, Policy

Paul J. Scheel, MD, MBA

Vice Chair, Policy

KDOQI Guideline Development Staff

Kerry Willis, PhD, Chief Scientific Officer

Jessica Joseph, MBA, Vice President, Scientific Activities

Laura Brereton, MSc, KDOQI Project Director

Section I: use of the clinical practice guideline

This Clinical Practice Guideline document is based upon the best information available as of June 2015. It is designed to provide information and assist decision making. It is not intended to define a standard of care, and should not be construed as one, nor should it be interpreted as prescribing an exclusive course of management. Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and

Contents
Figures 889
Abbreviations and Acronyms 890
Current CKD Nomenclature Used by KDOQI 891
Executive Summary 892
- Gathering the Evidence 892
  - Initiating HD 892
  - Frequency and Duration of Dialysis 892
  - Membranes and Hemodiafiltration Versus HD 893
  - Small-Solute Clearance 893
  - Adverse Effects of Dialysis 893
  - Limitations of “Adequacy” 893
- Structure of the Work Group 893
- Methods 893
  - ERT Study Selection and Outcomes of Interest 894
- Guideline Statements 895
Guideline 1: Timing of Hemodialysis Initiation 896
- Rationale for Guideline 1.1

Tables

Table 1.
Grade for Strength of Recommendation 895
Table 2.
Summary Data From Observational Studies That Assessed the Association Between Serum Creatinine–Based Estimates of Kidney Function at the Time of Initiation of Dialysis and Risk for Death 899
Table 3.
Summary Data From Observational Studies That Assessed the Association Between Measured Kidney Function at the Time of Initiation of Dialysis and Risk for Death 900
Table 4.
Commonly Used Validated GFR Estimating Equations in Adults 900
Table 5.
Clinical Settings Affecting Creatinine Generation

Figures

Figure 1.
Systematic errors from 2 commonly used linear formulas based on percent reduction in urea concentration. 909
Figure 2.
Data from the Netherlands Cooperative Study showing a marked increase in risk of death in patients with no residual native kidney function. 910
Figure 3.
Delivered dialysis doses in the HEMO Study. 912

Abbreviations and Acronyms

ACTIVE	Advanced Cognitive Training for Independent and Vital Elderly
AV	Arteriovenous
avCpre	Average predialysis blood urea nitrogen
BP	Blood pressure
BSA	Body surface area
BUN	Blood urea nitrogen
CANUSA	Canadian-USA Study on Adequacy of Peritoneal Dialysis
CI	Confidence interval
Ci	Dialysate inlet conductivities
CKD	Chronic kidney disease
CKD-EPI	Chronic Kidney Disease Epidemiology Collaboration
CL_cr	Creatinine clearance
Co	Dialysate outlet conductivities
CV	Cardiovascular
D	Dialysance
DRIP	Dry Weight Reduction Intervention

Current CKD Nomenclature Used by KDOQI

CKD Categories	Definition
CKD	CKD of any stage (1-5), with or without a kidney transplant, including both non–dialysis-dependent CKD (CKD 1-5ND) and dialysis-dependent CKD (CKD 5D)
CKD ND	Non–dialysis-dependent CKD of any stage (1-5), with or without a kidney transplant (ie, CKD excluding CKD 5D)
CKD T	Non–dialysis-dependent CKD of any stage (1-5) with a kidney transplant

Specific CKD Stages	Empty Cell
CKD 1, 2, 3, 4	Specific stages of CKD, CKD ND, or CKD T
CKD 3-4, etc	Range of specific stages (eg, both CKD 3 and

Executive Summary

When hemodialysis (HD) was introduced as an effective workable treatment in 1943,¹ the outlook for patients with advancing kidney failure suddenly changed from anticipation of impending death to indefinite survival. Since then, implementation of dialysis has advanced from an intensive bedside therapy to a more streamlined treatment, sometimes self-administered in the patient’s home, using modern technology that has simplified dialysis treatment by reducing the time and effort required by the

Guideline 1: Timing of Hemodialysis Initiation

1.1
Patients who reach CKD stage 4 (GFR < 30 mL/min/1.73 m²), including those who have imminent need for maintenance dialysis at the time of initial assessment, should receive education about kidney failure and options for its treatment, including kidney transplantation, PD, HD in the home or in-center, and conservative treatment. Patients' family members and caregivers also should be educated about treatment choices for kidney failure. (Not Graded)
1.2
The decision to initiate maintenance dialysis in

Guideline 2: Frequent and Long Duration Hemodialysis

In-center Frequent HD

2.1
We suggest that patients with end-stage kidney disease be offered in-center short frequent hemodialysis as an alternative to conventional in-center thrice weekly hemodialysis after considering individual patient preferences, the potential quality of life and physiological benefits, and the risks of these therapies. (2C)
2.2
We recommend that patients considering in-center short frequent hemodialysis be informed about the risks of this therapy, including a possible increase in vascular access

Guideline 3: Measurement of Dialysis---Urea Kinetics

3.1
We recommend a target single pool Kt/V (spKt/V) of 1.4 per hemodialysis session for patients treated thrice weekly, with a minimum delivered spKt/V of 1.2. (1B)
3.2
In patients with significant residual native kidney function (Kru), the dose of hemodialysis may be reduced provided Kru is measured periodically to avoid inadequate dialysis. (Not Graded)
3.3
For hemodialysis schedules other than thrice weekly, we suggest a target standard Kt/V of 2.3 volumes per week with a minimum delivered dose of 2.1

Guideline 4: Volume and Blood Pressure Control---Treatment Time And Ultrafiltration Rate

4.1
We recommend that patients with low residual kidney function (< 2 mL/min) undergoing thrice weekly hemodialysis be prescribed a bare minimum of 3 hours per session. (1D)
- 4.1.1
  Consider additional hemodialysis sessions or longer hemodialysis treatment times for patients with large weight gains, high ultrafiltration rates, poorly controlled blood pressure, difficulty achieving dry weight, or poor metabolic control (such as hyperphosphatemia, metabolic acidosis, and/or hyperkalemia). (Not Graded)
4.2
We

Guideline 5: Hemodialysis Membranes

5.1
We recommend the use of biocompatible, either high or low flux hemodialysis membranes for intermittent hemodialysis. (1B)

Acknowledgements

Some of the recommendations included in this Update were published originally in the American Journal of Kidney Diseases in 2006 and were reproduced with permission from the NKF. The Work Group thanks Drs Jeff Berns, Beth Piraino, Peter McCullough, and Chet Fox for careful review of this manuscript and Kerry Willis, Emily Howell, Jessica Joseph, and Laura Brereton from the NKF for help coordinating the work of the group and preparing the manuscript. We are indebted to the ERT from the

Hemodialysis Adequacy: 2015 Update Work Group

John Daugirdas, MD (Chair), is a nephrologist and Clinical Professor of Medicine at the University of Illinois at Chicago. Dr Daugirdas has received the Chicago Top Doctor Award for multiple years. Research includes participation in 4 NIH/NIDDK-sponsored studies, the HEMO Trial, FHN trials, the TiMe Trial, and in the design of the Chronic Renal Insufficiency Cohort (CRIC) Trial. Dr Daugirdas is currently studying how much dialysis to prescribe using various schedules, as well as factors

References (225)

M.V. Rocco et al.
The effects of frequent nocturnal home hemodialysis: the Frequent Hemodialysis Network Nocturnal Trial
Kidney Int
(2011)
J.T. Daugirdas et al.
Effect of frequent hemodialysis on residual kidney function
Kidney Int
(2013)
Y. Slinin et al.
Timing of dialysis initiation, duration and frequency of hemodialysis sessions, and membrane flux: a systematic review for a KDOQI clinical practice guideline
Am J Kidney Dis
(2015)
K. Uhlig et al.
Grading evidence and recommendations for clinical practice guidelines in nephrology. A position statement from Kidney Disease: Improving Global Outcomes (KDIGO)
Kidney Int
(2006)
L.A. Inker et al.
KDOQI US commentary on the 2012 KDIGO clinical practice guideline for the evaluation and management of CKD
Am J Kidney Dis
(2014)
S.D. Bieber et al.
Comparative outcomes between continuous ambulatory and automated peritoneal dialysis: a narrative review
Am J Kidney Dis
(2014)
Y.-W. Chiu et al.
An update on the comparisons of mortality outcomes of hemodialysis and peritoneal dialysis patients
Semin Nephrol
(2011)
J.O. Schell et al.
Discussions of the kidney disease trajectory by elderly patients and nephrologists: a qualitative study
Am J Kidney Dis
(2012)
A. Levin et al.
Variability and risk factors for kidney disease progression and death following attainment of stage 4 CKD in a referred cohort
Am J Kidney Dis
(2008)
L. Li et al.
Longitudinal progression trajectory of GFR among patients with CKD
Am J Kidney Dis
(2012)

A.M. O'Hare et al.

Trajectories of kidney function decline in the 2 years before initiation of long-term dialysis

Am J Kidney Dis

(2012)

A.M. O'Hare et al.

When to refer patients with chronic kidney disease for vascular access surgery: should age be a consideration?

Kidney Int

(2007)

G.M. Devins et al.

Predialysis psychoeducational intervention and coping styles influence time to dialysis in chronic kidney disease

Am J Kidney Dis

(2003)

B.J. Manns et al.

The impact of education on chronic kidney disease patients' plans to initiate dialysis with self-care dialysis: a randomized trial

Kidney Int

(2005)

E. Lacson et al.

Effects of a nationwide predialysis educational program on modality choice, vascular access, and patient outcomes

Am J Kidney Dis

(2011)

S.E. Liebman et al.

Differences between dialysis modality selection and initiation

Am J Kidney Dis

(2012)

R. Mehrotra et al.

Patient education and access of ESRD patients to renal replacement therapies beyond in-center hemodialysis

Kidney Int

(2005)

H.N. Young et al.

The rationale, implementation, and effect of the Medicare CKD education benefit

Am J Kidney Dis

(2011)

K. Zuber et al.

Kidney disease education one year after the Medicare Improvement of Patients and Providers Act: a survey of US nephrology practices

Am J Kidney Dis

(2012)

S.M. Wilson et al.

The IMPACT (Incident Management of Patients, Actions Centered on Treatment) Program: a quality improvement approach for caring for patients initiating long-term hemodialysis

Am J Kidney Dis

(2012)

R. Arramreddy et al.

Urgent-start peritoneal dialysis: a chance for a new beginning

Am J Kidney Dis

(2014)

A. Ghaffari

Urgent-start peritoneal dialysis: a quality improvement report

Am J Kidney Dis

(2012)

A.S. Levey et al.

GFR estimation: from physiology to public health

Am J Kidney Dis

(2014)

A. Harris et al.

Cost-effectiveness of initiating dialysis early: a randomized controlled trial

Am J Kidney Dis

(2011)

G.A. Whalley et al.

Effect of early initiation of dialysis on cardiac structure and function: results from the Echo substudy of the IDEAL Trial

Am J Kidney Dis

(2013)

J.C. Fink et al.

Significance of serum creatinine values in new end-stage renal disease patients

Am J Kidney Dis

(1999)

W.H. Kazmi et al.

Effect of comorbidity on the increased mortality associated with early initiation of dialysis

Am J Kidney Dis

(2005)

M. Lassalle et al.

Age and comorbidity may explain the paradoxical association of an early dialysis start with poor survival

Kidney Int

(2010)

D.C. Crews et al.

Comparative effectiveness of early versus conventional timing of dialysis initiation in advanced CKD

Am J Kidney Dis

(2014)

A.K. Jain et al.

Timing of peritoneal dialysis initiation and mortality: analysis of the Canadian Organ Replacement Registry

Am J Kidney Dis

(2014)

D.N. Churchill

An evidence-based approach to earlier initiation of dialysis

Am J Kidney Dis

(1997)

C.T. Chan et al.

Novel techniques and innovation in blood purification: a clinical update from Kidney Disease: Improving Global Outcomes

Kidney Int

(2013)

M. Walsh et al.

A systematic review of the effect of nocturnal hemodialysis on blood pressure, left ventricular hypertrophy, anemia, mineral metabolism, and health-related quality of life

Kidney Int

(2005)

M.R. Marshall et al.

Home hemodialysis and mortality risk in Australian and New Zealand populations

Am J Kidney Dis

(2011)

R.S. Suri et al.

A multinational cohort study of in-center daily hemodialysis and patient survival

Kidney Int

(2013)

W. Kolff et al.

The artificial kidney, a dialyzer with a great area

Acta Med Scand

(1944)

R. Saran et al.

US Renal Data System 2014 annual data report: epidemiology of kidney disease in the United States

Am J Kidney Dis

(2015)

A.M. O’Hare et al.

Trends in timing of initiation of chronic dialysis in the United States

Arch Intern Med

(2011)

B.A. Cooper et al.

A randomized, controlled trial of early versus late initiation of dialysis

N Engl J Med

(2010)

R.S. Suri et al.

Daily hemodialysis: a systematic review

Clin J Am Soc Nephrol

(2006)

R.M. Lindsay et al.

Is more frequent hemodialysis beneficial and what is the evidence?

Curr Opin Nephrol Hypertens

(2004)

KDOQI clinical practice guideline and clinical practice recommendations: hemodialysis adequacy, peritoneal dialysis adequacy, and vascular access: update 2006

Am J Kidney Dis

(2006)

B.F. Culleton et al.

Effect of frequent nocturnal hemodialysis vs conventional hemodialysis on left ventricular mass and quality of life: a randomized controlled trial

JAMA

(2007)

G.M. Chertow et al.

In-center hemodialysis six times per week versus three times per week

N Engl J Med

(2010)

Jardine M, Zuo L, Gray N. Impact of extended weekly hemodialysis hours on quality of life and clinical outcomes: the...

C.W. McIntyre et al.

Hemodialysis-induced cardiac dysfunction is associated with an acute reduction in global and segmental myocardial blood flow

Clin J Am Soc Nephrol

(2008)

M.T. Eldehni et al.

Randomized clinical trial of dialysate cooling and effects on brain white matter

J Am Soc Nephrol

(2015)

H.J. Jefferies et al.

Frequent hemodialysis schedules are associated with reduced levels of dialysis-induced cardiac injury (myocardial stunning)

Clin J Am Soc Nephrol

(2011)

R.S. Suri et al.

Effects of frequent hemodialysis on perceived caregiver burden in the Frequent Hemodialysis Network trials

Clin J Am Soc Nephrol

(2014)

R.S. Suri et al.

Risk of vascular access complications with frequent hemodialysis

J Am Soc Nephrol

(2013)

Cited by (804)

Development and Validation of the Rating of CKD Knowledge Among Older Adults (Know-CKD) With Kidney Failure
2024, American Journal of Kidney Diseases
Few older adults with kidney failure engage in shared decision making (SDM) for kidney replacement therapy. The lack of instruments to assess SDM-relevant knowledge domains may contribute to this. We assessed the reliability and validity of a new instrument, the Rating of CKD Knowledge Older Adults (Know-CKD).
Multistage process, including a stakeholder-engaged development phase, pilot testing, and validation of a knowledge instrument using a cross-sectional survey of older adults with CKD.
363 patients aged 70+ years with nondialysis advanced chronic kidney disease (CKD) (estimated glomerular filtration rate [eGFR] < 30 mL/min/1.73 m²) in Boston, Chicago, Portland, ME, and San Diego from June 2018 and January 2020.
Educational level, higher literacy (Single Item Literacy Screener [SILS]) and numeracy (Subjective Numeracy Scale [SNS]), having participated in clinic-sponsored dialysis education, and self-reported “feeling informed” about options for treatment.
Validity and reliability of the Know-CKD instrument.
Reliability was assessed with the Kuder-Richardson-20 coefficient. Construct validity was demonstrated by testing a priori hypotheses using t test, analysis of variance (ANOVA) tests, and linear regression analyses.
The mean (± SD) participant age was 77.6 ± 5.9 years, and mean eGFR was 22.7 ± 7.2 mL/min/1.73 m²; 281 participants (78%) self-reported as White. The 12-item Know-CKD assessment had good reliability (Kuder-Richardson-20 reliability coefficient = 0.75), and a mean score of 58.2% ± 22.3 SD. The subscales did not attain acceptable reliability. The proportion answering correctly on each item ranged from 20.1% to 91.7%. In examining construct validity, the hypothesized associations held; Know-CKD significantly associated with higher education (β = 6.98 [95% CI, 1.34-12.61], P = 0.02), health literacy (β = −12.67 [95% CI, −19.49 to −5.86], P ≤ 0.001), numeracy per 10% higher (β = 1.85 [95% CI, 1.02-2.69], P ≤ 0.001), and attendance at dialysis class (β = 18.28 [95% CI, 13.30-23.27], P ≤ 0.001). These associations were also observed for the subscales except for prognosis (not associated with literacy or numeracy).
Know-CKD is only available in English and has been used only in research settings.
For older adults facing dialysis initiation decisions, Know-CKD is a valid, reliable, and easy to administer measure of knowledge. Further research should examine the relationship of kidney disease knowledge and SDM, patient satisfaction, and clinical outcomes.
The Rating of CKD Knowledge Among Older Adults (Know-CKD) study measures knowledge of chronic kidney disease (CKD) and is designed for older adults. Most existing knowledge measures for CKD focus on people of all ages and all CKD stages. This measure is useful because it will allow researchers to assess how well patient education efforts are working. Patient education is a way to help patients make decisions about their care. We describe how the measure was developed by a team of doctors, researchers, and patients, and how the measure performed among persons with advanced CKD aged 70 years and older. Know-CKD can inform efforts to improve shared decision-making research and practice for older patients with kidney disease.
Longitudinal Changes in Kidney Solute Clearance in a Prospective Cohort of Patients Initiating Chronic Hemodialysis
2024, Kidney International Reports
Longitudinal changes in residual kidney function have not been well-examined in patients starting chronic hemodialysis (HD).
We analyzed urine volume and kidney solute clearances from timed urine collections and corresponding plasma samples from 42 patients randomized to incremental HD (n = 21) and conventional HD (n = 21) in the TwoPlus pilot study. Samples were collected before HD initiation (baseline); and at 6, 12, 24, and 48 weeks. We assessed temporal trends in urine volume, kidney urea and creatinine clearance, and correlations between urine volume and kidney solute clearance.
Residual kidney function parameters in all patients declined over time; the pattern of decline differed between urine volume and kidney solute clearances. Urine volume declined at a steady rate with median (quartile 1, quartile 3) percentage change relative to baseline of −10% (−36 to 29) at week 6 and −47% (−76 to 5) by week 48. Kidney urea and creatinine clearances exhibited a larger decline than urine volume at week 6, −32% (−61 to 8) and −47% (−57 to −20), respectively. The rate of decline subsequently slowed, reaching about 61% decline for both solutes by week 48. Conventional HD demonstrated larger declines in urine volume and kidney urea clearance than incremental HD at week 6. Urine volume showed moderate correlation with urea (R = 0.47) and weaker correlation with creatinine (R = 0.34).
Despite gradual decrement in urine volume and kidney solute clearances, residual kidney function persists nearly 1 year after HD initiation. This knowledge could motivate increased practice of individualizing HD prescriptions by incorporating residual kidney function.
Symptom Science in Kidney Disease
2024, Advances in Kidney Disease and Health
Physical and emotional symptoms are highly prevalent among patients with kidney disease and are directly linked to impaired health-related quality of life. Symptom science is a field of research aimed at advancing knowledge of the holistic mechanisms driving symptoms, how best to assess symptoms accurately, and developing novel and patient-centered approaches to symptom management. Patients with kidney disease have identified symptom science as a top research priority, and opportunities abound for ongoing patient engagement in symptom-related research efforts and clinical care. This review describes the burden of symptoms experienced by patients with kidney disease, explores the spectrum of patient engagement in symptom care and research, and discusses approaches for symptom assessment and management, taking into consideration the multitude of factors that may contribute to symptoms.
Single-pool model urea clearance index is associated with sarcopenia and nutritional status in patients undergoing maintenance hemodialysis: a cross-sectional study
2024, BMC Nephrology
The error of estimated GFR in predialysis care
2024, Scientific Reports
Comprehensive geriatric assessment predicts listing for kidney transplant in patients with end-stage renal disease: a retrospective cohort study
2024, BMC Geriatrics

View all citing articles on Scopus

View full text

Special SectionKDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 Update

Abstract

Section snippets

Work Group Membership

KDOQI Leadership

KDOQI Guideline Development Staff

Section I: use of the clinical practice guideline

Table of Contents

Tables

Figures

Abbreviations and Acronyms

Current CKD Nomenclature Used by KDOQI

Executive Summary

Guideline 1: Timing of Hemodialysis Initiation

Guideline 2: Frequent and Long Duration Hemodialysis

Guideline 3: Measurement of Dialysis---Urea Kinetics

Guideline 4: Volume and Blood Pressure Control---Treatment Time And Ultrafiltration Rate

Guideline 5: Hemodialysis Membranes

Acknowledgements

Hemodialysis Adequacy: 2015 Update Work Group

Kidney Int

Kidney Int

Am J Kidney Dis

Kidney Int

Am J Kidney Dis

Am J Kidney Dis

Semin Nephrol

Am J Kidney Dis

Am J Kidney Dis

Am J Kidney Dis

Am J Kidney Dis

Kidney Int

Am J Kidney Dis

Kidney Int

Am J Kidney Dis

Am J Kidney Dis

Kidney Int

Am J Kidney Dis

Am J Kidney Dis

Am J Kidney Dis

Am J Kidney Dis

Am J Kidney Dis

Am J Kidney Dis

Am J Kidney Dis

Am J Kidney Dis

Am J Kidney Dis

Am J Kidney Dis

Kidney Int

Am J Kidney Dis

Am J Kidney Dis

Am J Kidney Dis

Kidney Int

Kidney Int

Am J Kidney Dis

Kidney Int

The artificial kidney, a dialyzer with a great area

Acta Med Scand

US Renal Data System 2014 annual data report: epidemiology of kidney disease in the United States

Am J Kidney Dis

Trends in timing of initiation of chronic dialysis in the United States

Arch Intern Med

A randomized, controlled trial of early versus late initiation of dialysis

N Engl J Med

Daily hemodialysis: a systematic review

Clin J Am Soc Nephrol

Is more frequent hemodialysis beneficial and what is the evidence?

Curr Opin Nephrol Hypertens

KDOQI clinical practice guideline and clinical practice recommendations: hemodialysis adequacy, peritoneal dialysis adequacy, and vascular access: update 2006

Am J Kidney Dis

Effect of frequent nocturnal hemodialysis vs conventional hemodialysis on left ventricular mass and quality of life: a randomized controlled trial

JAMA

In-center hemodialysis six times per week versus three times per week

N Engl J Med

Hemodialysis-induced cardiac dysfunction is associated with an acute reduction in global and segmental myocardial blood flow

Clin J Am Soc Nephrol

Randomized clinical trial of dialysate cooling and effects on brain white matter

J Am Soc Nephrol

Frequent hemodialysis schedules are associated with reduced levels of dialysis-induced cardiac injury (myocardial stunning)

Clin J Am Soc Nephrol

Effects of frequent hemodialysis on perceived caregiver burden in the Frequent Hemodialysis Network trials

Special Section
KDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 Update