Scaling Hemodialysis Target Dose to Reflect Body Surface Area, Metabolic Activity, and Protein Catabolic Rate: A Prospective, Cross-sectional Study

Sivakumar Sridharan, Enric Vilar, Andrew Davenport, Neil Ashman, Michael Almond, Anindya Banerjee, Justin Roberts, Kenneth Farrington

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BACKGROUND: Women and small men treated by hemodialysis (HD) have reduced survival. This may be due to use of total-body water (V) as the normalizing factor for dialysis dosing. In this study, we explored the equivalent dialysis dose that would be delivered using alternative scaling parameters matching the current recommended minimum Kt/V target of 1.2.

STUDY DESIGN: Prospective cross-sectional study.

SETTING & PARTICIPANTS: 1,500 HD patients on a thrice-weekly schedule, recruited across 5 different centers.

PREDICTORS: Age, sex, weight, race/ethnicity, comorbid condition level, and employment status.

OUTCOMES: Kt was estimated by multiplying V by 1.2. Kt/body surface area (BSA), Kt/resting energy expenditure (REE), Kt/total energy expenditure (TEE) and Kt/normalized protein catabolic rate (nPCR) equivalent to a target Kt/V of 1.2 were then estimated by dividing Kt by the respective parameters.

MEASUREMENTS: Anthropometry, HD adequacy details, and BSA were obtained by standard procedures. REE was estimated using a novel validated equation. TEE was calculated from physical activity data obtained using the Recent Physical Activity Questionnaire. nPCR was estimated using a standard formula.

RESULTS: Mean BSA was 1.87m(2); mean REE, 1,545kcal/d; mean TEE, 1,841kcal/d; and mean nPCR, 1.03g/kg/d. For Kt/V of 1.2, there was a wide range of equivalent doses expressed as Kt/BSA, Kt/REE, Kt/TEE, and Kt/nPCR. The mean equivalent dose was lower in women for all 4 parameters (P<0.001). Small men would also receive lower doses compared with larger men. Younger patients, those with low comorbidity, those employed, and those of South Asian race/ethnicity would receive significantly lower dialysis doses with current practice.

LIMITATIONS: Cross-sectional study; physical activity data collected by an activity questionnaire.

CONCLUSIONS: Current dosing practices may risk underdialysis in women, men of smaller body size, and specific subgroups of patients. Using BSA-, REE-, or TEE-based dialysis prescription would result in higher dose delivery in these patients.

Original languageEnglish
Pages (from-to)358-366
Number of pages9
JournalAmerican Journal of Kidney Diseases
Issue number3
Early online date20 Sept 2016
Publication statusPublished - 1 Mar 2017


  • Hemodialysis target dose
  • dialysis dosing
  • Kt/V
  • metabolism
  • energy expenditure
  • dialysis adequacy
  • body size
  • physical activity
  • sex differences
  • end-stage renal disease (ESRD)


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