Ten tips for the first haemodialysis sessions

Ten tips for the first sessions of hemodialysis

Ten tips for the first hemodialysis sessions

Introduction

Initiating hemodialysis is the most impactful turning point in a patient's kidney care. As a transitional process, this phase has recently been comprehensively reviewed. However, sometimes describing the start of dialysis as “the start of the real disease” instead of “its treatment” may be understandable, but it is an incorrect perception.

The article provides 10 practical tips for the first sessions. It is intended to support nephrologists at various levels of training and multidisciplinary care teams.

The advice is carefully worded; The authors avoid strict guidelines, as this would be difficult to investigate this topic in an evidence-based manner. However, there are reference tables of previous hemodialysis guidelines.

The advice is based on clinical experience and not a systematic review of the evidence, which means that the article may face a challenge in distinguishing between “association” and “causation” in the studies cited.

The ten tips

Tip 1: Ask your patient if he knows what hemodialysis means and if he wants to continue

The article notes that initiating hemodialysis is associated with severe psychological distress and an early mortality risk that is highest during the first weeks. There is also a functional decline (activities of daily living) during the first year for a large percentage

Therefore, they emphasize the importance of education before dialysis so that decisions are made that are compatible with the patient's values and preferences. Ideally, the patient decides - after obtaining factual information - to agree to begin treatment.

But many patients feel that they are not prepared or not informed enough. It is useful when building a new relationship to ask: Does the patient feel that he is “prepared enough?” If he does not know the meaning or reason for dialysis, then his understanding should be re-evaluated when this becomes clinically possible, with the involvement of family members/caretakers, and allocating time for cognitive balance and (digesting) the thought and the new change in his life.

In cases where dialysis is life-saving, treatment may continue with the informed consent process continued as much as possible, with options explained such as:

• Peritoneal dialysis

• Home hemodialysis

• Conservative care

Tip 2: Focus on volume first

The article refers to an idea proposed by medical leaders at hemodialysis providers in the United States to improve outcomes

The meaning is not to neglect the removal of toxic substances, but rather to correct excess extracellular volume (fluid excess) and achieve dry weight as an early goal because controlling fluids is often easier than treating other uraemic complications.

However, at the beginning of dialysis, it is not known how much fluid the patient has increased nor his ability to tolerate fluid removal. So the article suggests:

• Determine the target weight (dry weight or target weight) early using objective methods that are used repeatedly

• Involving the patient in decisions regarding the amount of fluid withdrawal from the first sessions

• Explain that weight gain between sessions is not the same as chronic fluid overload

• • Be aware that the process of determining dry weight may be misunderstood, and that “weight” details (such as clothing) affect calculations

Overall, achieving the optimum condition balances the risk of fluid accumulation and dialysis complications. Lack of awareness of the patient's endurance may lead to a drop in intra-session pressure.

The article also recommends protecting residual kidney function (residual urine volume) because its loss impairs the fluid control plan. Residual function may be supported by continuing loop diuretics if needed (more detailed in Tip 4).

Tip 3: Check transplant eligibility, then put on waiting list (if appropriate)

The authors explain that many patients may feel frustrated by dietary restrictions, medications, procedures, and the psychological burden of initiating dialysis. Therefore, discussing transplant eligibility may break down the barrier and make it easier to build rapport with the dialysis team even at the beginning of treatment.

Transplantation is often a preferred option because it improves survival and quality of life and often costs less than dialysis. Patients who are candidates often appreciate that the dialysis team does not “withhold” their inclusion on the waiting list due to concerns about controlling problems such as phosphates.

However, this discussion must be preceded by a comprehensive clinical review. It is also an essential part of care to begin preparing for transplantation before dialysis begins (in the context of “alert”).

The article also mentions that longer periods of pre-transplant dialysis are associated with poorer post-transplant outcomes, but it is a topic that is compounded by confounding factors such as delayed referral for various reasons.

It is also important to consider that female candidacy/gender disparities still exist in access to the waiting list. The authors suggest a personalized, staged approach to listing patients:

• Continue early baseline assessments (overlapping with routine dialysis checks)

• Avoid overwhelming the patient with excessive information/examinations in the first sessions if he does not want to do so

Tip 4: Check your medications—are they a necessity or an overkill?

If the patient begins the first session after regular follow-up before dialysis, it must be realized that dialysis has become part of the “treatment”, as it can correct some CKD disorders such as:

• Metabolic acidosis

• Hyperkalemia

• Hyperphosphatemia

• High blood pressure associated with volume overload

Iron, erythropoiesis stimulating agents (ESA) and vitamin D can also be given at the end of the session rather than being continued without review.

The problem is that many patients may not be evaluated or the treatment team may still not seek to stop unnecessary medications. So the article suggests a “color system”:

• Red: High-risk medications in advanced CKD that are often avoided (such as NSAIDs, some opioids such as morphine/codeine, etc.)

• Yellow: Medicines that require dose adjustment/careful monitoring due to a narrow treatment window (such as gabapentin/pregabalin…)

• Green: Opportunities to reduce the burden of tablets by stopping medications for which evidence of benefit may be limited in patients on dialysis or may not be necessary (such as oral bicarbonate, phosphate binders in selected cases... PPI... etc.).

Tip 5: Vaccinations... Vaccinations... Vaccinations

The article states that a large proportion of dialysis patients want to take immunizations (vaccines), but knowledge of the national plan is often low, and older people need additional explanation.

The immune response to dialysis may be weaker due to the immune changes associated with uremia... Therefore, it is important that appropriate vaccines are administered.

The article then reviews examples of important vaccines:

• Influenza (discussing the idea of high doses and response differences)

• RSV

• Pneumococci

• COVID-19 (SARS‑CoV‑2) (with emphasis on expanded initial schedules and maintenance doses)

• Other vaccinations such as hepatitis B (with post-vaccination antibody testing) and VZV (usually expected benefit although data are limited)

Tip 6: Three times a week? actually?

The advice discusses the concept of incremental hemodialysis:

If there is residual renal function, a lower frequency (once or twice weekly) may be started.

But the critical point is the existence of a “transition point” from appropriate gradualism to insufficient gradualism, to avoid the dangers of inadequate dialysis between sessions, so it is necessary:

• Calculate the treatment dose in an organized manner

• Re-evaluate remaining function

• Establish escalation criteria.

• Reliable follow-up

Tip 7: Hemodialysis (HD) or Hemodialysis (HDF)?

Advice chooses an individual approach rather than a standardized “routine”. Evidence from trials and analyzes suggests that HDF may reduce overall and cardiovascular mortality compared to HD, but the strength of the evidence may be influenced by the possibility of “fragility” outcomes and by patient inclusion and approach.

This is why the authors recommend that in the first sessions the priority be:

• Safety

• Hematological stability

• Gradual adaptation to extracorporeal treatment

The feasibility of achieving sustainably high convection volumes can then be assessed for the patient's subsequent situation, with change recommended in appropriate cases such as:

• Younger patients

• Transplant candidates

• Good vascular access

Tip 8: Does the patient need an anticoagulant at all? Heparin may be diluted/bypassed

The article explains that unfractionated heparin is the most widely used globally to prevent extracorporeal clotting, but it requires balancing the risk of bleeding.

There are no data proving the superiority of one type of heparin over another in hemodialysis. If the risk of bleeding is high, alternatives may be used such as:

• Saline flushes

• Heparin-coated membranes

• Citrate as an anticoagulant (regional citrate anticoagulation) according to the availability of protocols in place.

They emphasize that during the first sessions, which may be shorter, systemic heparin is often not necessary.

The article also addresses the challenges of patients taking anticoagulants for other reasons (eg, atrial fibrillation) and that traditional prediction tools may not be very accurate for dialysis patients.

Tip 9: Tell all patients to move/be active

Patients on hemodialysis are often sedentary, and this is associated with increased mortality and decreased quality of life. Increasing activity, even to modest degrees, may be beneficial.

The authors differentiate between:

• Physical activity, such as daily movement

• And exercise (exercise) as organized activities to improve fitness

The article talks about suitable types:

• Aerobic endurance (e.g. bike during session)

• Resistance training to improve strength and function

It emphasizes the role of clinicians and multidisciplinary teams (nurse/physiotherapist/family) to set realistic goals.

It is also noteworthy that structured exercise during the session may usually be postponed for the first 3 months, according to expert consensus, but there is evidence of improved performance after starting exercise from an early time in experiments.

Tip 10: Tell “right patients” to eat (in balance)

The article shows the importance of dietary control, but in a way that does not cause excessive fear of eating:

• Reduce sodium (supports volume and pressure adjustment)

• Reducing phosphate toward normal

• Calcium and parathyroid hormone (PTH) control

• Potassium regulation towards normal (according to opinion and experiences with references)

But the danger is that if the patient receives instructions to restrict and abstain from certain foods only in the first sessions, he may become completely afraid of eating.

They therefore focus on the fact that malnutrition/protein and energy deficiency is common and associated with increased mortality.

The article recommends rough protein/energy goals such as:

• Protein 1.0–1.2 g/kg/day

• Energy 25–35 calories/kg/day

He also states that reducing dietary restrictions must be “cautious” at the beginning of dialysis, and that nutrition can be supported with oral nutritional supplements.

The article also addresses the role of fish oil (n‑3 PUFA) supplementation as an exploratory discussion based on a recent trial (PISCES) and other evidence, while acknowledging that independent replication is still required.

Ref

Hecking M, Kolland M, Theodorakopoulou M, et al. Ten tips for the first hemodialysis sessions. Clinical Kidney Journal. 2026;19(9):sfag270. https://doi.org/10.1093/ckj/sfag270