# Dialysis Quality: Clearance Is One Dimension

Improving an adequacy number beyond an effective range does not automatically improve survival or wellbeing. Ask what patient problem the change is intended to solve.

![Infographic: Dialysis Quality: Clearance Is One Dimension](https://urinenephrology.org/visual-reference/images/mastery-hd-adequacy.png?v=20261003c)

## Know the thrice-weekly dose measure

KDOQI 2015 recommends a target single-pool Kt/V of 1.4 per session, with a minimum delivered value of 1.2 for thrice-weekly HD. These are not weekly standard Kt/V or equilibrated Kt/V; schedules and residual kidney function change how adequacy is assessed.

## Check delivered therapy

Treatment time, access function, interruptions, recirculation, and sampling technique can distort or reduce measured delivery.

## Review the monthly pattern

Interpret chemistry, anemia, nutrition, mineral metabolism, symptoms, and volume together. A green laboratory dashboard can coexist with poor function.

## Include mental and cognitive health

Depression, impaired cognition, sleep, and treatment burden affect quality of life and attendance. Appropriate assessment and support belong in routine care.

## Investigate the missed delivery

When a result falls below the intended dose, verify sampling and actual time, blood flow, interruptions, and access performance. Correct those causes before increasing a machine setting. Then reassess symptoms, volume, nutrition, cognition, and treatment burden, which a urea result does not capture.

## Avoid chasing a surrogate alone

Improving an adequacy number beyond an effective range does not automatically improve survival or wellbeing. Ask what patient problem the change is intended to solve.

## Supporting evidence

- [PubMed 26498416](https://pubmed.ncbi.nlm.nih.gov/26498416/)

## Source lessons

- [adequacy nutrition cognition quality metrics](https://urinenephrology.org/mastery/maintenance-hd/adequacy-nutrition-cognition-quality-metrics.html)

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