# Hemodialysis Prescription and Complications

Write separate goals for clearance, net fluid removal, and electrolyte shifts, then check what was actually delivered and tolerated.

![Infographic: Hemodialysis Prescription and Complications](https://urinenephrology.org/visual-reference/images/dialysis-prescription.png?v=20261003c)

## Separate the prescription levers

Duration/frequency and dialyzer blood/dialysate flows affect clearance. Net ultrafiltration controls fluid removal. Dialysate potassium, calcium, sodium, and bicarbonate affect electrolyte shifts. A single change rarely solves every solute, volume, and tolerance problem.

## Know what adequacy measures

For conventional thrice-weekly HD, KDOQI targets single-pool Kt/V 1.4 with minimum delivered 1.2. Low delivery prompts review of missed/shortened time, sampling, access recirculation, and blood flow. Do not apply this per-session target to every schedule.

## Calculate the fluid burden

UF rate = net mL removed ÷ weight in kg ÷ hours. Synthetic example: 3 L over 4 hours in a 60-kg patient is 12.5 mL/kg/h. If poorly tolerated, revisit target weight and consider longer/additional treatment rather than simply forcing the same removal.

## Respond to hypotension

Symptoms plus a BP fall require immediate assessment and unit-protocol response, often reducing or pausing UF. Check bleeding, infection, arrhythmia, cardiac ischemia, and excessive volume removal. Repeated episodes demand prescription and medication-timing review, not routine rescue alone.

## First treatments may need gentler clearance

Severe azotemia and neurologic vulnerability increase disequilibrium concern. Plan lower initial clearance or a slower modality while still treating urgent hyperkalemia or edema. Do not use the same full maintenance prescription automatically at initiation.

## Recheck after the session

Review delivered time, symptoms, weight/BP, access function, and electrolyte trends. Potassium rebounds after treatment; an immediate low post-HD value does not justify automatic replacement. Chest pain, severe neurologic symptoms, hemolysis, or respiratory distress triggers emergency assessment.

## Supporting evidence

- [Official clinical guidance](https://kdigo.org/wp-content/uploads/2016/10/KDIGO-2012-AKI-Guideline-English.pdf)
- [PubMed 26498416](https://pubmed.ncbi.nlm.nih.gov/26498416/)

## Source lessons

- [dialysis prescription complications](https://urinenephrology.org/2025_UDPA_Lectures_Live/dialysis/dialysis-prescription-complications.html)

Read alongside the full lessons; the findings and decisions shown here require the stated clinical context.