Nephrology and Dialysis Care Best Practices

01Purpose and scope

This manual supports the course Nephrology and Dialysis Care. It describes how nephrologists, dialysis nurses, patient care technicians, dietitians, social workers, and pharmacists divide the work of caring for people with chronic kidney disease, people starting dialysis, and people already receiving maintenance treatment in a unit, clinic, or at home.
The manual covers outpatient chronic kidney disease clinics, in-center hemodialysis units, home hemodialysis, and peritoneal dialysis. Acute kidney injury in hospitals is touched on only where it overlaps with maintenance care, because inpatient practice runs under hospital protocols that differ from unit routines.
This guidance does not replace qualified professional judgment, approved unit procedures, prescriber orders, or the authorization required for any treatment decision. Rules on staffing, scope of practice, facility licensure, and reporting vary by jurisdiction, so confirm current requirements with the state or national health authority that governs the setting.

02Core principles

Kidney function is estimated, not measured directly in routine care. Clinicians usually calculate estimated glomerular filtration rate (eGFR) from serum creatinine using a published equation, and they stage disease using eGFR together with albuminuria following the KDIGO framework. Equations are revised from time to time, so check which one the unit or health system has adopted before comparing results over time.
Dialysis is a prescription, not a generic service. The prescription sets treatment time, frequency, blood flow, dialyzer type, dialysate composition, and the fluid removal goal. Each element changes the others. A longer session can allow gentler fluid removal, while a higher dialysate sodium may reduce cramping but increase thirst and interdialytic weight gain.
Volume status is the central clinical problem for most patients on dialysis. The target dry weight is the estimated weight at which the patient is neither overloaded nor dehydrated. It is refined over time from blood pressure, symptoms, lung examination, edema, and intradialytic response, not fixed from a single reading.
Vascular access is the lifeline of hemodialysis. An arteriovenous fistula or graft generally carries a lower infection risk than a central venous catheter, so access planning begins early. Catheters are sometimes unavoidable, and their care demands the same discipline as any other high-risk device.
Treatment burden and patient goals shape every choice. Modality selection, transplant evaluation, dietary limits, and travel to a unit all involve trade-offs that the patient must understand. Shared decision making is part of the standard of care, not an optional extra.

03Planning and preparation

Start with a complete baseline before any dialysis session. This includes a recent medication reconciliation, current laboratory values (potassium, bicarbonate, phosphorus, calcium, hemoglobin, albumin, and iron indices), hepatitis B and other infectious disease screening as required by the unit, vaccination status, and a documented allergy history. Many dialysis medications need dose adjustment for kidney function, so pharmacist review is worth scheduling early.
Confirm the modality and access plan in writing. For a new patient, the team should discuss home therapy options, in-center schedules, and the timeline for creating a fistula or graft. Where transplantation may be appropriate, referral and evaluation should begin before dialysis is urgent. Transplant candidacy depends on factors that individual centers and national allocation rules define, so the referral pathway should be confirmed with the transplant program.
Prepare equipment and water before patient arrival. Dialysis water must meet the treatment water standards published by AAMI and ISO, and the unit should have a documented water treatment system with routine testing schedules. Dialysate concentrate lots, dialyzer labels, and bloodline sets should be checked against the prescription. Verify that the machine's conductivity and temperature alarms are functioning before any patient is connected.
Plan staffing for the patients you have. A unit with several patients who need close monitoring, such as those with recent intradialytic hypotension or a new catheter, needs a nurse-to-patient ratio and escalation path that matches that acuity. Ratios are often set by facility policy and state rules, so do not assume a default.

04Recommended workflow

1
: Review the prior treatment record, the current prescription, and any new laboratory results or hospital discharge summaries before the patient is seen. Note any change in weight trend, blood pressure pattern, missed sessions, or new medications.
2
: Assess the patient at arrival. Check identity using the unit's two-identifier policy, obtain pre-dialysis weight, measure blood pressure and heart rate with the patient seated and then standing when safe, and examine the access site for redness, swelling, bruit or thrill changes, and bleeding. Ask about symptoms such as dizziness, cramps, chest pain, shortness of breath, and fever.
3
: Confirm the prescription and the machine setup. Verify dialysate type and concentrate, dialyzer size, blood flow rate, heparin or other anticoagulation dose, and the ultrafiltration goal. Calculate the net fluid removal from pre- and post-weight, and confirm that the goal matches the order. Check the machine's self-test and water conductivity display.
4
: Cannulate or connect the access using aseptic technique. For fistulas, follow the unit's cannulation pattern (buttonhole or rope ladder) and document needle sites. For catheters, use strict hub disinfection and never use a lumen that has not been confirmed to flow and aspirate appropriately. Secure lines and confirm the patient is comfortable before starting the pump.
5
: Monitor during treatment at intervals set by the unit protocol. Record blood pressure, pulse, blood flow, venous pressure, arterial pressure, transmembrane pressure, and ultrafiltration volume. Watch for signs of intradialytic hypotension, air in the lines, access complications, and symptoms such as cramping or nausea. Adjust the ultrafiltration rate or dialysate temperature according to protocol, and report any change that falls outside prescribed limits.
6
: Handle intradialytic events in a defined order. For symptomatic hypotension, the usual first steps are reducing ultrafiltration, placing the patient in a supine or Trendelenburg position as tolerated, and checking for bleeding or arrhythmia. Escalate to the physician or nephrologist according to unit policy if the patient does not respond. Document each intervention and its time.
7
: Complete end-of-treatment care. Take post-dialysis weight and vital signs, remove and secure access with appropriate hemostasis, and confirm that the catheter lock solution is administered as ordered. Record total ultrafiltration, treatment time, and any blood or fluid losses. Give the patient discharge instructions covering fluid and potassium guidance, medication timing, and what symptoms require a call.
8
: Close the record and hand off the next steps. Enter laboratory orders, medication changes, and access follow-up. Flag any concern for the next shift or the rounding nephrologist. Communicate with the patient's primary care clinician when a change affects their diabetes, blood pressure, or other ongoing care.

05Quality checks, risk controls and compliance

Water and dialysate quality are the first controls. Routine water testing covers chemical and microbiological parameters on the schedule the unit's water management program defines. Dialysate conductivity checks at the start of each shift and at the machine level help catch concentrate errors. When a water or dialysate result is out of range, the unit should follow its written response plan, which normally includes stopping treatment on affected machines and notifying the medical director.
Infection prevention is a central risk area. Hand hygiene before and after patient contact, use of personal protective equipment, disinfection of the access site and catheter hubs, and proper handling of blood-contaminated items are all required. Catheter-related bloodstream infection is one of the most consequential complications in hemodialysis, so catheter care bundles and surveillance data deserve regular review. For peritoneal dialysis, exit site care and aseptic connection technique are the main controls against peritonitis.
Medication risk is concentrated in a few drug classes. Potassium-raising drugs, heparin or other anticoagulants, erythropoiesis-stimulating agents, iron products, and insulin or other glucose-lowering agents all need careful dosing and monitoring. Drugs cleared by dialysis may need to be timed around treatment. Any change in a high-alert medication should be verified by a second clinician when unit policy requires it.
Compliance requirements depend on setting and location. In the United States, Medicare certification of dialysis facilities is governed by the ESRD Conditions for Coverage found in 42 CFR Part 494, and state survey agencies apply additional rules. Other countries have their own licensing and quality frameworks. Confirm the current text of any rule with the authoritative body, because regulations change and summaries can become outdated.
Quality indicators give the team a shared picture of performance. Commonly tracked measures include delivered dialysis dose (Kt/V or urea reduction ratio, with targets set by the prescriber and by current guidelines), interdialytic weight gain, proportion of patients with catheters, intradialytic hypotension episodes, hemoglobin and phosphorus control, serum albumin, and hospitalization rates. Each measure should have a definition, a data source, and a named owner. Indicators are useful for spotting trends but are weak evidence about any single patient.

06Collaboration and documentation

Dialysis care is a team sport with clear roles. The nephrologist writes or approves the prescription, reviews laboratory trends, and decides on referrals and major changes. The registered nurse assesses the patient, manages access and treatment, and escalates concerns. The technician operates the machine and performs routine checks under supervision. The dietitian sets nutrition and fluid guidance, the social worker addresses financial and practical barriers, and the pharmacist manages drug reconciliation. Each person should know where their responsibility ends.
Interdisciplinary rounds are the usual forum for shared decisions. A typical monthly or quarterly review covers each patient's adequacy, anemia and mineral bone management, volume status, access, nutrition, mood, and goals. Minutes should record the decisions and the owner of each follow-up action, so that nothing depends on memory.
The treatment flowsheet is the primary legal and clinical record for each session. Entries should be made at the time of care, legibly, with the clinician's initials or electronic signature. Record deviations from the prescription, the reason for the deviation, the notification made, and the response. Avoid vague entries such as patient fine. Specific observations, such as a blood pressure trend with symptoms and actions taken, are far more useful to the next clinician.
Handoffs between units, hospitals, and home settings are a frequent source of error. When a patient transfers, send the current prescription, most recent laboratory results, access status, medication list, and any known allergies or infections. For patients on home dialysis, confirm that the home team has the same written prescription and an emergency contact path.

07Measures and continuous improvement

Track a small set of measures that the unit can act on. Each measure should have a clear numerator and denominator, a data collection method that is practical, and a review frequency. Start with the measures tied to the highest risk in your population, such as catheter use, hypotension, and potassium excursions, rather than trying to monitor everything at once.
Use a structured improvement cycle to test changes. A plan-do-study-act cycle is a common and simple method. Choose one change, such as a standard pre-cannulation checklist, run it for a defined period on one shift, measure the result, and decide whether to adopt, adjust, or abandon it. Changes that work on paper often fail in practice because of workflow, so involve the staff who will do the task.
Review outliers rather than averages. A unit may have a stable average interdialytic weight gain while a few patients consistently gain far more fluid. Those patients need individual review of diet, medication, and adherence. Similarly, a single catheter infection should trigger a root cause review even if the overall rate looks acceptable.
Feedback from patients and staff is data too. Short, anonymous surveys and regular huddles often identify problems that clinical measures miss, such as long waits for transport, confusion about diet rules, or equipment that is hard to use. Close the loop by reporting back what changed as a result.

08Common mistakes and how to prevent them

Relying on a single pre-dialysis weight. Weight can be affected by food, clothing, and the scale itself. Compare weights on the same scale, record the method, and look at trends over several sessions before changing the dry weight.
Setting ultrafiltration goals that are too aggressive for the patient. Removing fluid quickly to reach the target weight often causes intradialytic hypotension, cramping, and missed sessions. Where the gap between the patient's weight and the target is large, the prescriber may need to spread fluid removal over more sessions or adjust the target.
Ignoring potassium changes between sessions. Missed or shortened treatments, high-potassium diets, and some medications can raise potassium quickly. Review pre-dialysis potassium every time and confirm the patient understands the dietary guidance.
Using a catheter lumen without confirming function. A lumen that does not aspirate or flush freely may be malposed or occluded. Stop, confirm the problem, and notify the clinician rather than forcing the line.
Documenting after the fact without times. Retrospective entries, especially for events like hypotension, make it hard to reconstruct what happened. Record the time of each observation and intervention as it occurs.
Treating access as a separate problem. Access complications can cause missed clearance, extra staff time, and hospitalization. Include access assessment in every treatment and link surveillance findings to the surgical or vascular access team quickly.

09Practical checklist

Confirm identity, the current prescription, and any laboratory results before the patient is connected.
Obtain pre-dialysis weight on the usual scale and record it with the method used.
Check blood pressure, pulse, and symptoms, and compare them with the prior session.
Verify dialysate type, concentrate lot, dialyzer, anticoagulation dose, and ultrafiltration goal against the order.
Confirm that water conductivity and machine alarms are normal at the start of the shift.
Inspect the access site and document its condition before cannulation or lock administration.
Monitor vital signs and machine parameters at the intervals set by the unit protocol.
Escalate intradialytic events according to policy and document the time and response.
Complete post-dialysis weight, vital signs, hemostasis, and catheter lock where applicable.
Give the patient clear instructions on fluids, potassium, medications, and warning symptoms.
Send handoff information to the next team or care setting, including the prescription and recent labs.
Review unit quality measures on the agreed schedule and record actions with named owners.

★Learning sources

Micro Degree: Nephrology and Dialysis Care
Micro Degree: Healthcare Administration Practice
Micro Degree: Physiotherapy Assistant Operations
Micro Degree: Cardiac Care Support

?Frequently asked questions

Who sets the dialysis prescription and can a nurse change it?

The nephrologist or other prescribing clinician writes the dialysis prescription, and staff should not change it without a valid order. Nurses and technicians may adjust within limits set by unit protocol, such as reducing ultrafiltration when a patient becomes symptomatic, but they must document and notify the prescriber. Unit policy and state scope-of-practice rules define the exact boundaries.

How often should dialysis water and dialysate be tested?

Testing frequency depends on the water treatment standards the unit follows, the equipment in use, and the facility's written water management program. Routine chemical and microbiological testing is required, and conductivity checks are usually done at the start of each shift. Confirm the current schedule with the medical director and the applicable accreditation or survey requirements.

What should a new staff member learn first in a dialysis unit?

Start with patient identification, safe cannulation or catheter connection, machine alarm response, and the escalation path for hypotension and access bleeding. Shadow an experienced colleague through several full sessions before working independently. Competency should be verified by the unit under its written policy, not assumed from prior experience elsewhere.

Does this manual cover medical decisions for patients?

No. This manual describes how the work is organized and carried out, but it does not replace clinical judgment, prescriber orders, or approved unit procedures. Decisions about individual patients, including modality, medication changes, and transplant referral, require the treating clinicians and the patient.