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Assessment of dialysis adequacy using urea reduction ratio and KTV in four
pediatric hemodialysis canters

Article · January 2015

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THE IRAQI POSTGRADUATE
PEDIATRIC MEDICAL JOURNAL
HEMODIALYSIS VOL. 14,NO.4, 2015

Assessment of Dialysis Adequacy Using Urea Reduction Ratio

and KT/V in four Pediatric Hemodialysis Centers in Baghdad
Ali Ahemd, Nariman F.Ahmed Azat, Shatha Ali

ABSTRACT:
BACKGROUND:
The 21st century has been set to enhance dialysis adequacy. Numerous studies have confirmed the
association between the delivered dose of hemodialysis and patients outcomes. There is thus some
evidence regarding the relationship between dialysis dose and quality of life.
Aim:
OBJECTIVE:
To assess dialysis adequacy using (Urea Reduction Rate and KT/V), and to determine the association
between dialysis dose and different Hemodialysis characteristics in children with End Stage Renal
Failure undergoing Hemodialysis.
METHOD:
This was an observational cross-sectional study that was conducted for three months, from
(November 2014 till January 2015); we enrolled 50 children with End Stage Renal Failure in four
hemodialysis centers in Baghdad. Samples for blood urea (predialysis and postdialysis) were drown
to calculate the adequacy dose.
RESULTS:
Thirty two (64%) of patients were male and 18(36%) were females; with male to female ratio was
(1.7:1).The mean urea reduction ratio and Kt/V were 59.63 ± 7.345% and 1.29 ± 0.275, respectively,
with fair dialysis adequacy .A Kt/V less than 1.2 and a urea reduction ratio less than 65% were found
in 42%, and 38% of the hemodialysis patients, respectively. There was a significant correlation
between dialysis dose and (Blood flow rate, Dialysis hours, Dialysis frequency /week and Effective
surface area), while there was insignificance correlation with (gender, age, volume of ultrafiltration.
CONCLUSION:
Our results were better than neighbor countries with fair dialysis adequacy. It is important to
regularly measure the parameters of dialysis adequacy in order to assess whether targets are achieved
in accordance with K/DOQI guidelines.
KEY WORDS: adequacy ,hemodialysis,children

INTRODUCTION:
There are about 1.8 million patients with (ESRD) Assessment of adequacy: (4)
all over the world that need a kind of renal For practical reasons HD adequacy has been
replacement therapy (RRT).(1) measured using small, easily measured solutes such
The 21st century has been set to enhance dialysis as urea.
adequacy, in attempts to improve patients’ quality Two commonly used measures of HD adequacy
of life. World- wide, currently more than 500 000 are:
people are undergoing hemodialysis treatment. (2) urea reduction ratio (URR ) and Kt/V urea
The National Cooperative Dialysis Study The URR is easy to perform and is the index of
established that greater the efficiency of dialysis, dialysis dose which is most widely used in the UK.
lesser is the mortality and complications of uremia. Single- pool Kt/V urea: This method has been
(3)
validated in major adult studies to predict
morbidity. because it assumes that urea is removed
*Children Welfare Teaching Hospital, from a single pool, a delayed postdialysis sample is
**Medical College of Baghdad, not required. This is clearly a great practical
***Al-Nahrin College of Medicine, advantage, and is the easiest to calculate

THE IRAQI POSTGRADUATE MEDICAL JOURNAL 522 VOL. 14,NO.4, 2015

PEDIATRIC HEMODIALYSIS

K: dialyzer clearance of urea; t: dialysis time; V: Urea reduction ratio (URR):It is measured as
patients total body water. follows:
The dialysis care team should deliver a Kt/V of at URR= {(Predialysis BUN- Post dialysis BUN) ÷
least 1.2 (single-pool, variable volume) for both Predialysis BUN} × 100
adult and pediatric hemodialysis patients. (4) Kt/V urea: In the study we use the single- pool Kt/V
AIM OF THE STUDY: only: (6, 5)
This study was designed to assess dialysis The second-generation formula for estimating
adequacy using (Urea Reduction Rate and spKt/V, which was reported and validated by
KT/V)and To determine the association between Daugirdas, is recommended. (6)
dialysis dose and different Hemodialysis Kt/V urea was calculated using simplified formula of
characteristics in four pediatric Hemodialysis Daugirdas. (7)
Centers in Baghdad. SpKt/V = −Log n (R − 0.008t) + (4 − 3.5R)
PATIENTS AND METHOD: UF/BW
This was an observational cross-sectional study K: Dialyzer urea clearance supplied by the
that was conducted for three months, from manufacturer in liters per minute (l/min).
(November 2014 till January 2015), in four t: The duration of dialysis in minutes (min).
hemodialysis centers hospitals in Baghdad, to V: The volume of distribution of urea in liters (l).
describe the relation between hemodialysis Sp: Single pool
adequacy and various variations.  Log n is the natural logarithm
Study sample:  R is the postdialysis BUN ÷ predialysis BUN
Randomly we enrolled 50 children with CKD on  t is the length of the dialysis session in hours
HD from four HD pediatric centers {Ibn Al-Balady  UF is the ultrafiltration volume in liters
Hospital 18 (36%), Child Central Teaching  BW is the patient's postdialysis weight in
Hospital 16 (32%), Al-Kadhimiya Teaching kilograms
Hospital 9(18%) and Al-Karama Teaching Hospital Methods for blood sampling:
7(14%)}. At the initiation of the study, 51 patients The following points were considered in blood
were enrolled. During the course of the study, one sampling collection
patient died because of cardiovascular Both samples (predialysis and postdialysis) were
complication of CKD during HD, and ruled out drawn during the same treatment session.
from the study. The studied samples (50 patients) The risk of underestimating predialysis BUN level
attended HD unit and were on regular hemodialysis because of saline dilution or by sampling the blood
sessions according to special schedules of that after treatment was avoided.
hospital; patients who have been on maintenance Stop dialysate flow technique: At the end of the
hemodialysis for at least three months duration dialysis time, dialysate flow was stopped but kept
were considered for the study. the blood pump running. After 5 min with no
Informed consent was obtained from all the dialysate flow a blood sample was taken from
patients and /or their relatives with explaining the anywhere in the blood circuit (i.e. the arterial or
aim of the study. venous port), the withdrawal of (10-15cc) as dead
Data Collection: space. Blood samples then centrifuged in order to
A preformed questionnaire had been used for obtain blood serum and hence the urea.
patients in study group. It includes demographic Statistical analysis:
data = names, ages, gender). Data were computerized using Microsoft Excel
Enquiry about investigations included :( Blood program 2010; statistical analysis was done using
Urea (hence BUN calculated), Serum Creatinine; the (SPSS version 19) software for windows and
other parameters recorded like height and surface the t-test and chi square were used to compare the
area as needed; the weight and blood pressure means of different groups for continuous variables.
obtained pre &intradialysis. While GFR calculated Study confidence interval was 95%.
according to Schwartz formula (5). In the statistical evaluation, the following levels of
Adequacy formulae: we use two famous formulae significance are used:
as follow:

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PEDIATRIC HEMODIALYSIS

Non-significant NS P > 0.05

Significant S 0.05 ≥ P > 0.01
Highly significant HS P ≤ 0.01

RESULTS:
This study included 50 pediatric patients with end years); only two patients (4%) were below 5 years
stage renal disease who were on maintenance old
hemodialysis. URR& Kt/V in the study sample:
Gender: thirty two (64%) of patients were male Table -1- the results of the current study showed
and 18(36%) were females. male to female ratio that an acceptable number of patients were
was (1.7:1). adequately dialyzed (p value were highly
AGE: the age of patients in the study group ranged significant (0.000).
between (4 years to 16 Years). Most of the  58% of patients (n=29) had Kt/V ≥ 1.2 (ranging
patients (46%) were between the age group (10-15 from 1.21 - 2.28).
 62% of patients (n=31) had URR ≥ 65%.

Table 1: Kt/V and URR % of the study sample

Descriptive statistics
N Mean S.D. Min. Max. p-value
Kt/V < 1.2 21 (42%) 0.89 0.24 0.45 1.19 0.000
≥ 1.2 29 (58%) 1.57 0.31 1.21 2.28 (HS)
total 50 1.29
URR % < 65 19 (38%) 52.29 8.22 35 64.98 0.000
≥ 65 31 (62%) 69.9 6.47 65 82 (HS)
total 50 59.63

2- correlation between Demographic data and adequacy of hemodialysis based on Kt/v and URR
prescribed dialysis dose (KTV and URR):Data values. No significant differences found with
presented in table (1) showed the various tested respect to gender, and age among study population.
variables (age and gender) in association with

Table 2: Correlation between Demographic data and prescribed dialysis dose (KTV and URR).

Demographic data
Variables No. Kt/V URR %
(%) <1.2 ≥ 1.2 p-value < 65 ≥ 65 p-value
No. No. No. No.
(%) (%) (%) (%)
Genders Males 32 15 17 0.352 13 19 0.157
(64) (71.43) (58.62) (NS) (52.6) (54.8) (NS)
Females 18 6 12 6 12
(36) (28.57) (41.38) (47.4) (45.2)
Age <5 2 0 2 0.410 1 1 0.422
(year) (4) (6.90) (NS) (5.2) (3.2) (NS)
5-10 15 6 9 7 8
(30) (28.57) (31.03) (36.8) (25.8)
10-15 23 9 14 6 17
(46) (42.86) (48.28) (31.7) (54.8)
> 15 10 6 4 5 5
(20) (28.57) (13.79) (26.3) (16.2)
Total 50 21 29 19 31

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PEDIATRIC HEMODIALYSIS

3- Hemodialysis characteristics: Table (3) shows patients and all of them were in good adequacy.
the following: The P value was significant.
3-1 blood flow rate (BFR): the blood flow rates 3-3 Dialysis sessions per week: also the patients
ranged from 100 (ml/min) to 350 (ml/min), most were divided into 3 groups, most of patients (70%)
patients in our study 19 (38%) patients were were dialyzed twice weekly, 20 (68.9%) patients
dialyzed with (BFR) between 201-250ml/ min, had a Kt/V ≥1.2, and 22 (70.9%) patients had a of
among these patients 51.8% (N=15) patients had URR ≥65%. The P value was highly significant.
Kt/V ≥ 1.2, and 48.4 (N=15) patients had URR ≥ 3-4 Volume of UF: 72% (N=36) of patients with
65. The p value was highly significant in this UF between < 1liter/UF to >2liter /UF, and 9(18%)
group. patients with no UF. The P value was not
3-2 Dialysis hours: according to dialysis hours the significant.
patients were divided into 3 groups, most of them 3-5 Effective Surface Area: we have 3 groups (0.8,
35(70%) patients were dialyzed for 3 hours, from 1and 1.2m2), 26(56%) patients dialyzed with 1m2,
this group; 23(79.3%) patients had a Kt/V ≥1.2, of those, 18 (62.1%) patients had a Kt/V ≥1.2, and
and 25(80.6%) had a URR ≥65%, the patients who 19 (61.3%) patients had a URR > 65%. Also the P
were dialyzed more than 3 hours were only 5(10%) value was significant.

Table 3: Hemodialysis characteristics.

Variables No. Kt/V URR %

(%)
<1.2 ≥ 1.2 p-value < 65 ≥ 65 p-value
No. No. No. No.
(%) (%) (%) (%)
Blood Flow 100-150 11 9 2 0.004 8 3 0.003
(ml/min) (22) (42.9) (6.9) (HS) (42.1) (9.6) (HS)
151-200 8 7 1 4 4
(16) (33.3) (3.4) (21.1) (12.9)
201-250 19 4 15 4 15
(38) (19.1) (51.8) (21.1) (48.4)
251-300 7 1 6 2 5
(14) (4.7) (20.6) (10.5) (16.2)
301-350 5 0 5 1 4
(10) (17.3) (5.2) (12.9)
Dialysis 2 10 9 1 0.025 9 1 0.034
hours (20) (42.8) (3.4) (S) (47.3) (3.2) (S)
(hr.)
3 35 12 23 10 25
(70) (57.2) (79.3) (52.7) (80.6)

>3 5 0 5 0 5
(10) (17.3) (16.2)
Dialysis 1 4 4 0 0.002 3 1 0.003
session (8) (19.1) (HS) (15.7) (3.2) (HS)
(weeks) 2 35 15 20 13 22
(70) (71.4) (68.9) (68.5) (70.9)
3 11 2 9 3 8
(22) (9.5) (31.1) (15.8) (25.9)
Volume of No 9 5 4 0.579 2 7 0.429
UF (18) (23.81) 13.79 (NS) (10.5) (22.5) (NS)
(L.) 0-1 18 7 11 8 10
(36) (33.33) 37.93 (42.2) (32.3)
1.1-2 18 6 12 7 11
(36) (28.57) 41.38 (36.8) (35.5)

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PEDIATRIC HEMODIALYSIS

2.1-3 5 3 2 2 3
(10) (14.29) 6.90 (10.5) (9.7)
Effective 0.8 19 9 10 0.032 8 11 0.012
Surface (38) (42.8) (34.4) (S) (42.1) (35.5) (S)
Area (m2) 1 26 8 18 7 19
(52) (38.1) (62.1) (36.8) (61.3)
1.2 5 4 1 4 1
(10) (19.1) (3.5) (21.1) (3.2)
Total 50 21 29 19 31

DISCUSSION:
Increasing evidence demonstrates that mortality Adequacy and age: 46% of our sample was
among ESRD patients is lower with sufficient between 10-15 years age group, and it is consistent
hemodialysis treatments. (8) to the Indian study with a median age of 13years
The lack of published Data on hemodialysis old. (13) While median age in Doaa study in Egypt
practice in pediatrics in Iraq and For the was 5.6years old and Turkish children were 9.5. (14)
potential impact of intervention required to And this may reflect geographic variability in age
improve this type of renal replacement of onset and the type of etiology of CKD in
modality.This study tried to highlight some of children, and, as we see later in this chapter.
hemodialysis practices and associated findings for Difference in clearance rates among the various
patients treated in four major pediatric age groups were statistical insignificant (p=0.410,
hemodialysis centers in Baghdad. p=0.22) for Kt/V & URR, respectively.
Demographic data: -URR& Kt/V in the study sample:
Adequacy and gender: the majority of ESRD According to the KDOQI guidelines for
patients in almost all countries are in males rather hemodialysis patients, the minimally adequate dose
than females this gender distribution reflects the of dialysis should be a single-pool Kt/V of 1.2 or a
higher incidence of congenital disorders in boys URR of 65%, and the recommended target dose
versus girls that lead to ESRD . ( 9, 10) nationally should be a Kt/V of 1.4 or a URR of 70%. (15)
conducted study, suggested that females were with In the current study the mean Kt/V and URR for
a better response to clearance of uremia toxins, the patients were 1.29± 0.275 and 59.63± 7.335,
compared to males. (11) Our findings in this respect respectively, 58% of all patients achieved the Kt/V
are consistent with various reports as males were goal and 62% had target URR. These results were a
represented by a higher percentage (64%) little bit better than neighbor countries; in Iranian
compared to females population (36%), and study the mean single-pool Kt/V and URR were
demonstrate a higher level of clearance among 1.17 and 61%, respectively. (16) In Palestine the
female population as 71.43% of the males were mean Kt/V and URR were 1.06 ± 0.05 and 54.4 ±
with Kt/V values (< 1.2), compared to 28.57% 19.3, respectively. (17) While in Five European
among females population, and (URR <65% )in Countries and the United States as following:
male was 52.6% and female 47.4%, However, Adequacy of Hemodialysis Compared With Five
these variation were of no statistically significant European Countries and the United States
values (p=0.352, and P=0.157 respectively).these
finding goes with Allam study. (12)

Variable France* Germany* Italy* Spain* UK* USA†

Mean Sp Kt/V 1.51 1.30 1.32 1.32 1.38 1.55

* Based on the Euro-Dialysis Outcomes and Practice Patterns Study. (18)

† Based on the 2007 annual report of ESRD clinical performance measures project. (19)

THE IRAQI POSTGRADUATE MEDICAL JOURNAL 526 VOL. 14,NO.4, 2015

PEDIATRIC HEMODIALYSIS

The substantial discrepancy in hemodialysis Cooperative Study on the adequacy of dialysis

adequacy between forementioned developed recently reported the association between excessive
countries and Iran at least, to some extent, may be ultrafiltration and mortality, independent of
resulted from more frequent use of high-flux delivered Kt/V urea. (28) Our findings with respect
dialysis. While in our study we will see the to ultrafiltration rate and clearance show a clear
different parameters that affecting the adequacy. trend of improvements in Kt/V values and URR till
Hemodialysis characteristics: 2 liter/UF and then decreased after more UF rate,
1-Blood flow rate: Blood flow is one of the this may be due to decrease sessions frequency
principle determinants of dialyzer urea clearance (poor compliance, far address, poor socioeconomic
and low blood flow rates lead to lower urea status) with interadialytic fluid retention, and may
clearance. (20) lead to less dialysis efficiency. although this
Blood flow rates affected by poor vascular access, relation was statistically insignificant, unlike Allam
recirculation, insufficient anticoagulation and findings (12) .
human errors, some of these problems can be 5- Effective Surface Area: The use of larger
solved especially when it comes to vascular access. surface area dialyzers permits high rates of urea
(21)
In the current study blood flow rates clustered clearance to be achieved offering theoretical
in five groups. Most of our sample 38% of them lie advantage of improving blood purification by
between 201-250 ml/min, similar finding in Al- removing higher and middle molecular – weight
Kadhimiya study. (22) solutes. (29) Furthermore, many studies reported
Increased blood flow rates found to be associated excellent survival among patients treated with
with increased rate of clearance. Our findings in larger surface filter area, which in turn reflects to
this respect in consistent with previous reports that, better dialysis adequacy. (30) With respect to
indicates better clearance rates in association with filtration area, our study population placed on three
increased flow rates. (16, 23) different membrane size filters (0.8, 1 and 1.2m 2).
2- Dialysis hours: There are numerous When these groups compared with regard to their
observational studies supporting the positive clearance rates, 62.1% of those who were on 1m2
association between the length of hemodialysis were with a Kt/v value of ≥ 1.2, 61.3% with URR
session and survival rate. (24) Our finding, 70% ≥65%, compared to only 34.4% among those who
dialyzed for 3 hours, of them 65.75% and 71.4% were on 0.8m2, and URR with 35.5%,and last small
with good adequacy (Kt/V≥1.2, URR ≥65%, sample group (1.2m2) was statistically negligible.
respectively), and all who dialyzed >3 hours with Such finding is in agreement with previous reports
very good adequacy, (p=0.025, 0.034).this on membrane size and clearance rates. (29,30)
supported by Allam study (12), Laurent et.al. (25) It is CONCLUSIONS AND RECOMMENDATIONS
important to note that patient’s non-compliance, The dialysis adequacy using the (Kt/V and URR) in
lack of enough dialysis machines and facilities and the current study was acceptable and the
access to these facilities are major time limiting hemodialysis adequacy was influenced by several
factors for dialysis. factors such as: Blood flow rate ,Dialysis hours per
3-Dialysis session per week: Studies have session ,Dialysis frequency per week and Effective
documented the relationship between less frequent surface area
dialysis per week and poorer outcome. (26) The We recommend regularly measuring dialysis
majority of the study population (70%) was adequacy on monthly bases in the dialysis units in
dialyzing twice times per week and 57.1% of them order to determine what degree of enough dialysis
were with a Kt/v value of ≥ 1.2, and 73.3% with the patients are receiving during their treatments
URR≥65%, by increasing the frequency of dialysis and this should be a routine protocol and better
per week to thrice, the Kt/V&URR increased as registration and follow up.
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