Education Use Only
For educational use only — The physician’s written order and the unit protocol always govern
Medical Associates  ·  Department of Nephrology ← Nursing cards  ·  Maintenance Hemodialysis  ·  urinenephrology.org
Dialysis Nursing Reference Card  ·  Maintenance Hemodialysis

N2 — Dialysate Prescription Check

Confirm sodium, calcium, bicarbonate, magnesium, glucose, and temperature before the patient connects.
Andrew Bland, MD, FACP, FAAP Reviewed September 2026 · v1.0 draft Prints on one sheet, front and back
N2 — Dialysate Prescription Check FRONT
Front · at the chair

When: machine setup, before every treatment.

Do this

  1. Read the acid concentrate label against the order: potassium, calcium (mEq/L), magnesium, dextrose, and acid type (acetate or citrate). Read the printed label, not the jug color.
  2. Confirm the machine is set for the proportioning ratio of the concentrate you hung [5].
  3. Enter sodium, bicarbonate, and any profile exactly as ordered. The alkali the patient receives is bicarbonate plus the acetate in the acid concentrate — know whether your machine’s number includes it [7].
  4. Check conductivity and pH with an independent meter or strip before every treatment and compare with the machine reading. Recheck whenever a new acid concentrate is hung mid-treatment [5].
  5. Set dialysate temperature per your unit protocol (cooling and intradialytic hypotension: N5: Intradialytic Hypotension: Chair-Side Response).
  6. Diabetic patient on insulin or a sulfonylurea with a low pre-dialysis glucose: check glucose during and after treatment per protocol [6].

Call the nephrologist when

  • The ordered concentrate is unavailable and a substitute would change calcium, potassium, magnesium, or glucose.
  • Pre-dialysis serum sodium is below 130, above 145, or 5 or more below the patient’s usual value — before starting.
  • Pre-dialysis bicarbonate (total CO2) is below 18 or above 28 mEq/L [7].
  • Low calcium with symptoms, or a patient on a calcimimetic with palpitations, tingling, or a prolonged QTc.
  • Glucose is below 70 mg/dL during or after treatment [6].
  • Symptoms suggest a composition problem: early cramps, hypotension out of proportion to fluid removal, tingling around the mouth, headache or confusion, or back or chest pain with dark venous blood (hemolysis — N12: Chair-Side Emergencies).

Don’t

  • Don’t silence or override a conductivity or pH alarm to start or continue treatment [5].
  • Don’t change dialysate sodium, or add a sodium profile, to treat cramps or low BP without an order [1].
  • Don’t substitute a different acid concentrate without an order.
  • Don’t use 3.5 mEq/L calcium or anything below 2.5 mEq/L as a routine bath [2,3].
N2 — Dialysate Prescription Check BACK
Back · why, and the evidence

Why

  1. Raising dialysate sodium from 135 to 140 mEq/L cut the odds of intradialytic hypotension by a third but raised pre-dialysis BP by 7/4 mmHg and weight gain by 0.2 kg [1].
  2. Dialysate calcium below 2.5 mEq/L was associated with double the odds of sudden cardiac arrest in the unit [2]; KDIGO suggests 2.5–3.0 mEq/L [3].
  3. Each 4 mEq/L higher dialysate bicarbonate was associated with 8% higher mortality (DOPPS) [4].
  4. A wrong concentrate can make dialysate that harms the patient, and several patients are often exposed before the error is found. That is why CMS requires an independent pH check before every treatment [5].
  5. Even with glucose in the dialysate, 21% of diabetic patients had silent hypoglycemia during or after dialysis on continuous glucose monitoring [6].

Go deeper

References

  1. Miskulin DC, et al. Dialysate sodium lowering in maintenance hemodialysis: a randomized clinical trial. Clin J Am Soc Nephrol. 2024;19:712-722. PubMed 38349776
  2. Pun PH, et al. Dialysate calcium concentration and the risk of sudden cardiac arrest in hemodialysis patients. Clin J Am Soc Nephrol. 2013;8:797-803. PubMed 23371957
  3. KDIGO CKD-MBD Update Work Group. KDIGO 2017 CKD-MBD guideline update. Kidney Int Suppl. 2017;7:1-59. PubMed 30675420
  4. Tentori F, et al. Association of dialysate bicarbonate concentration with mortality in DOPPS. Am J Kidney Dis. 2013;62:738-746. PubMed 23707043
  5. Centers for Medicare & Medicaid Services. ESRD Surveyor Training Interpretive Guidance v1.1 (2008), tags V249–V250. cms.gov
  6. Hayashi A, et al. Hemodialysis-related glycemic disarray proven by continuous glucose monitoring. Diabetes Care. 2021;44:1647-1656. PubMed 34045240
  7. Ashby D, et al. Renal Association clinical practice guideline on haemodialysis. BMC Nephrol. 2019;20:379. PubMed 31623578

Reviewed by Andrew Bland, MD, FACP, FAAP · v1.0 draft 2026-09-26. For education; the physician’s written order and the unit protocol always govern.