Haemodialysis continues to expand in the UK, with over 25,000 patients now being treated, representing a 10% increase since the publication of the previous Renal Association guideline for haemodialysis. In addition, the patient group continues to develop: the typical patient is now 67 years old with a median history of 3.2 years on renal replacement therapy. The authors of this guideline aimed principally to update the previous guideline according to the latest research and experience, but also to expand the scope into areas not previously covered but relevant to haemodialysis practice.
The guideline was written collaboratively: lead and co authors for each section conducted literature reviews and wrote first drafts of the statements and rationale. Feedback and discussion were provided by all authors via email exchanges and meetings, revised versions were produced with editorial input from the chair, and these were subsequently agreed upon by all authors. Two current haemodialysis patients provided advice on tone and readability.
Systematic literature searches were undertaken by lead authors to identify all relevant evidence published up until the end of June 2018. Compound search terms were used, which included a dialysis identifier (haemodialysis[tiab] OR haemodialysis[tiab] OR dialysis[tiab]) followed by title/abstract filtered topic terms (“dialysis dose,” Kt/V, augmented, intensive, conservative, incremental, pregnancy, membrane, hydration, “dry weight,” “fluid overload,” dialysate, potassium, bicarbonate, buffer, phosphate, “dialyser reaction,” hypersensitivity, “blood loss,” “needle dislodgment,” exsanguination, “home haemodialysis,” “nocturnal haemodialysis,” exercise, “physical training”) followed by negative terms (e.g., to exclude animal studies and acute kidney injury), and finally with date and language restrictions (“1990/01/01″[dp]: “3000”[dp] AND english[lang]). Searches were conducted in MEDLINE, PUBMED, Embase, and The Cochrane Library, supplemented with papers handpicked from the reference lists of review papers.
The strengths of the recommendations and the level of supporting evidence are coded as previously, using the Modified GRADE system.
There are a few changes in scope; for example, dialysis water treatment is now covered in another guideline, as are many aspects of dialysis, including:
- Planning, initiation & withdrawal of Renal Replacement Therapy
- Vascular Access for Haemodialysis
- Cardiovascular Disease
- Blood Borne Viruses
- Assessment of the Potential Kidney Transplant Recipient
- Nutrition
- Anaemia
- CKD Mineral and Bone Disorder
- Water Treatment Facilities, Dialysis Water, and Dialysis Fluid Quality
We have removed the section on targets for blood testing since these are better covered in other guidelines, and have not covered infrastructure or workforce, as these will be addressed separately by the Renal Association in a different format.
However, in most ways the update is broader than previous versions. For example, new sections have been written covering fluid management (surely an essential topic but not really covered previously or elsewhere) and dialysate (often underestimated in importance). In other areas this update seems to make no substantial change to previous guidance (as with dialysis dose, for example, where the literature remains dominated by previous large trials), however whilst key concepts remain valid, their understanding has developed, and the guideline aims to provide greater context, encouraging a more holistic interpretation. Discussions about dialysis often become overly technical – these concepts are important but hard to fit into a narrative so we have moved a few aspects into the appendix, where we aim to provide simplified summaries. We have tried to maintain a high standard of readability since conceptual understanding is the key goal, and as the guideline is not intended to replace review articles or original papers, it seems correct to favour readability over detail.