When kidneys fail, dialysis is neces­sary to remove waste products such as urea from the blood. By itself, urea is only mildly toxic, but a high urea level means that the levels of many other waste products that are more harm­ful and not as easily measured are also building up.

To see whether dialysis is removing enough urea, the dialysis clinic should periodically—normally once a month— test a patient’s blood to measure dialysis adequacy. Blood is sampled at the start of dialysis and at the end. The levels of urea in the two blood samples are then compared. Two methods are generally used to assess dialysis adequacy, URR and Kt/V.

URR stands for urea reduction ratio, meaning the reduction in urea as a result of dialysis. The URR is one mea­sure of how effectively a dialysis treat­ment removed waste products from the body and is commonly expressed as a percentage.

Example: If the initial, or predialysis, urea level was 50 milligrams per deci­liter (mg/dL) and the post dialysis urea level was 15 mg/dL, the amount of urea removed was 35 mg/dL

50 mg/dL – 15 mg/dL = 35 mg/dL

The amount of urea removed (35 mg/dL) is expressed as a percentage of the pre-dialysis urea level (50 mg/dL).

35/50 = 70/100 = 70%

Although no fixed percentage can be said to represent an adequate dialysis, patients generally live longer and have fewer hospitalizations if the URR is at least 60 percent. As a result, some experts recommend a minimum URR of 65 percent.

The URR is usually measured only once every 12 to 14 treatments, which is once a month. The URR may vary con­siderably from treatment to treatment. Therefore, a single value below 65 per­ cent should not be of great concern, but a patient’s average URR should exceed 65 percent.

• K stands for the dialyzer clear­ance, the rate at which blood passes through the dialyzer, expressed in milliliters per minute (mL/min)

• t stands for time

• Kt, the top part of the fraction, is clearance multiplied by time, representing the volume of fluid completely cleared of urea during a single treatment

• V, the bottom part of the fraction, is the volume of water a patient’s body contains

Example: If the dialyzer’s clearance is 300 mL/min and a dialysis session lasts for

180 minutes (3 hours), Kt will be 300 mL/min multiplied by 180 minutes. The result comes to 54,000 mL, or 54 liters.

Kt = 300 mL/min multiplied by 180 minutes Kt = 54,000 mL = 54 liters

The body is about 60 percent water by weight. If a patient weighs 70 kilograms (kg), or 154 pounds (lbs), V will be 42 liters.

V = 70 kg multiplied by .60 = 42 liters

So the ratio—K multiplied by t to V, or Kt/V— compares the amount of fluid that passes through the dialyzer with the amount of fluid in the patient’s body. The Kt/V for this patient would be 1.3.

The fact that a patient who loses more weight during dialysis will have a higher Kt/V does not mean it is better to gain more water weight between dialysis sessions so more fluid has to be removed, because the extra fluid puts a strain on the heart and circulation. However, patients who lose more weight during dialysis will have a higher Kt/V for the same level of URR.

Kt/V = 54/42 = 1.3

The Kt/V is mathematically related to the URR and is in fact, derived from it, except that the Kt/V also takes into account two additional factors:

• urea generated by the body during dialysis

• extra urea removed during dialysis along with excess fluid

The Kt/V is more accurate than the URR in measuring how much urea is removed dur­ing dialysis, primarily because the Kt/V also considers the amount of urea removed with excess fluid. Consider two patients with the same URR and the same post dialysis weight, one with a weight loss of 1 kg—about 2.2 lbs—during the treatment and the other with a weight loss of 3 kg—about 6.6 lbs. The patient who loses 3 kg will have a higher Kt/V, even though both have the same URR.

The fact that a patient who loses more weight during dialysis will have a higher Kt/V does not mean it is better to gain more water weight between dialysis sessions so more fluid has to be removed, because the extra fluid puts a strain on the heart and circulation. However, patients who lose more weight during dialysis will have a higher Kt/V for the same level of URR.

A patient’s monthly lab tests should include either a URR or a Kt/V.

On average, a Kt/V of 1.2 is roughly equivalent to a URR of about 63 percent. Thus, another standard of adequate dialysis is a minimum Kt/V of 1.2. The Kidney Disease Outcomes Quality Initiative (KDOQI) group has adopted the Kt/V of 1.2 as the standard for dialysis adequacy.1 Like the URR, the Kt/V may vary considerably from treatment to treatment because of measure­ment error and other factors. So while a single low value is not always of concern, the average Kt/V should be at least 1.2. In some patients with large fluid losses during dialysis, the Kt/V can be greater than 1.2 with a URR slightly below 65 percent—in the range of 58 to 65 percent. In such cases, the KDOQI guidelines consider the Kt/V to be the primary measure of adequacy.

If a patient’s average Kt/V—usually the average of three measurements—is consistently below 1.2, the patient and the nephrologist need to discuss ways to improve it. Since the V value is fixed, Kt/V can be improved either by increasing K or t.

Increase Blood Flow through the Dialyzer

Increasing K depends primarily on the rate of blood flow through the dialyzer. No matter how good a dialyzer is, how well it works depends primarily on moving blood through it. In many patients, a good rate is difficult to achieve because of vascular access problems.

If a patient’s blood flow rate is good, further improvements in clearance can be obtained by using a big dialyzer or, in some cases, by increas­ing the flow rate for dialysis solution from the usual 500 mL/min to 600 or 800 mL/min. A good flow rate for adult patients is 350 mL/min and higher. A few centers are even using two dialyzers at the same time to increase K in larger than average patients.

However, the rate of blood flow through the dialyzer is key, and a good vascular access is crucial to make sure a patient is getting good clearance.

Increase Time on Dialysis

The other way to improve the Kt in Kt/V is to increase t by dialyzing for a longer period. For example, if the Kt/V is 0.9 and the goal is 1.2, then 1.2/0.9 = 1.33, so 1.33 times more Kt is needed. If K is not changed, this means the length of the session needs to increase by 33 per­ cent. If the inadequate sessions lasted 3 hours, they should be increased to 4 hours.

Identify and Eliminate Circulation Problems

If during any given month a patient’s Kt/V is extremely low, the measurement should be repeated, unless a reason for the low Kt/V is obvious. Obvious reasons include treatment interruption, problems with blood or solu­tion flow, and a problem in sampling either the pre- or post dialysis blood. If no reason for the sudden drop is apparent, then a problem with needle placement, like accidental needle reversal, or with the vascular access, such as recirculation, should be suspected.

Points to Remember

• The two methods generally used to assess dialysis adequacy are URR and Kt/V.
• A patient’s average URR should exceed 65 percent.
• A patient’s average Kt/V should be at least 1.2.
• A patient’s URR or Kt/V can be increased either by increasing time on dialysis or increasing blood flow through the dialyzer.

• The End-Stage Renal Disease Program pro­motes research to reduce medical problems from bone, blood, nervous system, metabolic, gastrointestinal, cardiovascular, and endo­crine abnormalities in kidney failure and to improve the effectiveness of dialysis and transplantation.
• The HEMO Study, completed in 2002, tested the theory that a higher dialysis dose or high-flux membranes would reduce patient mortality—death—and morbidity—medical problems. Doctors at 15 medical centers recruited more than 1,800 hemodialysis patients and randomly assigned them to high or standard dialysis doses. The study found no increase in the health or survival of patients who had a higher dialysis dose.
• The Frequent Hemodialysis Clinical Trials will compare the conventional, three-times-a­ week schedule of hemodialysis with schedules that include shorter daily sessions or longer overnight sessions. Researchers will deter­ mine whether more frequent hemodialysis improves blood pressure control, nutritional status, anemia, quality of life, heart health, and vascular access condition.
• The U.S. Renal Data System (USRDS) col­lects, analyzes, and distributes information about kidney failure in the United States. The USRDS is funded directly by the NIDDK in conjunction with the Centers for Medicare & Medicaid Services. The USRDS publishes an Annual Data Report, which characterizes the total population of people with kidney failure; reports on incidence, prevalence, mortality rates, and trends over time; and develops data on the effects of various treatments. The report, available at www.usrds.org, also helps identify problems and opportunities for more focused special research on kidney issues.

What Is Urea?

Your body normally makes and removes waste from what you do every day, such as exercise and eating food for energy. Urea is one type of waste your body makes and must remove. People who use dialysis can’t remove waste through their kidneys, so the buildup of urea can make them very sick.

What Is the Urea Reduction Ratio?

The Urea Reduction Ratio (URR) shows how much urea is in your blood when you start and finish a dialysis session. Your URR amount tells you and your dialysis medical team how well dialysis worked, and how much waste was cleaned from your body.

How Is the URR Calculated?

Why Is the URR Important?

How Does Medicare Help to Make Care Better for People with End-Stage Renal Disease?