Advanced Dialysis Nursing in GCC — Comprehensive Guide

Haemodialysis (HD) Fundamentals

HD Circuit Overview

Blood PumpPeristaltic — drives blood through circuit

Dialyser (Artificial Kidney)Semi-permeable membrane; hollow fibres

Dialysate Flow Rate500–800 mL/min (counter-current to blood)

Blood Flow Rate (Qb)200–400 mL/min

Venous Pressure MonitorDetects access stenosis or clotting

Air DetectorUltrasonic — clamps venous line if air detected

Dialysate Temp35–37°C (cool ↓ IDH risk)

Dialysis Adequacy — Kt/V

Target: Single-pool Kt/V ≥ 1.4 per session (3×/week). URR ≥ 65%.

KDialyser clearance (mL/min)

tDialysis time (minutes)

VVolume of urea distribution (body water)

URR Formula(Pre-BUN − Post-BUN) / Pre-BUN × 100

Monthly CheckBlood samples pre/post session

If Kt/V < 1.4↑ time, ↑ Qb, check access recirculation

Vascular Access Types

Type	Key Points
AVF	Native fistula; gold standard. Maturation 6–8 weeks. Longest survival.
AVG	Synthetic graft; usable in 2–4 weeks. Higher infection/thrombosis risk.
Tunnelled CVC / Permcath	Immediate use. Highest infection risk. Last resort for long-term.
Non-tunnelled CVC	Short-term/acute only. <3 weeks maximum.

AVF Assessment

Palpate for thrill (continuous vibration) — absent thrill = stenosis/thrombosis
Auscultate for bruit (machinery murmur) — harsh/discontinuous = stenosis
Inspect for aneurysms, skin changes, pseudoaneurysm
Check arm elevation test — fistula should flatten
Document pulse strength and augmentation test
Assess for steal syndrome (cold/pale/painful hand)
Pre-session: no BP cuff or venepuncture on fistula arm

Needling Techniques

Two main approaches for AVF cannulation:

Rope-LadderRotating sites along entire vessel — preserves vessel wall

Buttonhole (Constant-site)Same site each session — tunnel formation; lower aneurysm risk but higher infection risk

Buttonhole Scab RemovalSterile technique; soak & remove before cannulation

Area TechniqueAvoid — causes aneurysm formation

Needle Gauge15–17G standard; 14G for high Qb

Post-session CompressionManual or clip — min 5–10 min; avoid tight wrap

Dialysate Composition

Electrolyte	Standard Range	Clinical Note
Sodium (Na⁺)	138–145 mmol/L	Low Na ↑ cramps; High Na ↑ thirst/HTN
Potassium (K⁺)	2.0–3.0 mmol/L	Adjust for pre-dialysis K⁺ levels
Calcium (Ca²⁺)	1.25–1.5 mmol/L	Low for hypercalcaemia patients
Bicarbonate	32–38 mmol/L	Corrects metabolic acidosis
Magnesium (Mg²⁺)	0.5–0.75 mmol/L	Contributes to cramp prevention
Glucose	5.5–11 mmol/L	Avoid hypoglycaemia in diabetics

Ultrafiltration (UF) & Dry Weight

UFR Limit: ≤ 13 mL/kg/hr. Higher rates → ↑ intradialytic hypotension, cardiac stress, mortality.

UFR CalculationUF volume (mL) ÷ patient weight (kg) ÷ session hours

Dry Weight (Target Weight)Weight at which patient is euvolaemic — no oedema, no hypotension

IDWG Target< 1 kg/day; < 5% body weight between sessions

Signs Dry Weight Too LowIDH, cramps, fatigue post-session

Signs Dry Weight Too HighHypertension, oedema, SOB, pulmonary congestion

ReassessMonthly or after illness/hospitalisation

HD Intradialytic Complications

Intradialytic Hypotension (IDH) — Most Common Complication

Definition: SBP drop ≥ 20 mmHg OR MAP drop ≥ 10 mmHg with symptoms (dizziness, nausea, cramps, syncope).

Immediate Management Steps

Place patient supine / Trendelenburg position
Reduce or stop ultrafiltration immediately
Administer 100–200 mL normal saline bolus (or 100 mL 20% mannitol)
Reduce blood flow rate temporarily if haemodynamically unstable
Re-check BP every 5 minutes; document
Notify physician if BP does not recover within 10–15 min

Prevention Strategies

Cool dialysate (35–36°C) — isothermal/cold profiling
Sodium profiling during session
Pre-session midodrine (oral α₁-agonist)
Limit UFR to ≤ 13 mL/kg/hr
Avoid food during dialysis (splanchnic vasodilation)
Sequential UF profiling
Reassess dry weight regularly

Muscle Cramps

Common cause: low sodium dialysate, excessive UF, low dry weight
Give 100 mL hypertonic saline (3%) or 50% dextrose 50 mL
Reduce UF rate during cramping episode
Passive stretching of affected muscle
Quinine sulphate (specialist prescribed) for recurrent cramps
Review and adjust dry weight if persistent

Access Recirculation

DefinitionDialysed blood re-enters arterial needle before returning to circulation

Normal Recirculation< 5% (AVF), < 10% (AVG)

CausesStenosis, reversed needle placement, low flow

ConsequenceReduced Kt/V — inadequate dialysis

DetectionUDT method, blood temperature monitoring, BUN sampling

ActionRe-site needles; refer for fistulogram/Doppler

Air Embolism — Life-Threatening Emergency

EMERGENCY: Frothy/churning blood in venous chamber, sudden severe dyspnoea, cyanosis, chest pain, neurological changes. Potentially fatal.

STOP blood pump immediately
Clamp venous bloodline — prevent further air entry
Position: LEFT lateral decubitus + Trendelenburg (Durant's manoeuvre) — traps air in right ventricle apex
Administer 100% O₂ by non-rebreather mask
Call emergency — cardiac arrest team if unconscious
Do NOT restart dialysis
Hyperbaric oxygen if available and patient stable
Document volume of air and time of event

Prevention

Ensure all line connections are tight and primed
Check air detector alarm is functional before each session
Use luer-lock connections exclusively
Do not use air to prime bloodlines
Inspect for disconnections during session

Haemolysis

STOP dialysis immediately — do NOT return blood to patient.

SignsPink/cherry-red discolouration of blood in venous line; port-wine urine

SymptomsChest/back pain, dyspnoea, burning at access site, anxiety

CausesKinked/obstructed bloodlines, overheated dialysate (>42°C), hypo-osmolar dialysate, bleach contamination, chloramine contamination

ManagementClamp lines; O₂; monitor K⁺ (hyperkalaemia risk); ECG; emergency bloods; notify physician

Dialyser Reactions

Type	Onset	Features	Management
Type A (Anaphylactic)	First 5–30 min	Bronchospasm, urticaria, angioedema, hypotension, cardiac arrest	Stop — do NOT return blood. Adrenaline/antihistamine/steroids. Emergency call.
Type B	30–60 min	Chest/back pain, nausea — milder. No anaphylaxis.	Continue at reduced Qb; O₂; symptom relief; investigate cause.

Arrhythmias During Dialysis

Most common: AF, ventricular ectopics, ventricular tachycardia
Triggers: rapid electrolyte shifts (K⁺, Ca²⁺), cardiac disease, digoxin toxicity
ECG monitor in at-risk patients throughout session
If K⁺ pre-dialysis < 5 mmol/L — use 3 mmol/L K⁺ bath (not 2 mmol/L)
Check digoxin levels — dialysis alters distribution
Notify physician; adjust dialysate electrolytes if needed
Defibrillator must be available in every HD unit

Needle Dislodgement — Major Haemorrhage Risk

Critical: Venous needle dislodgement can cause death from exsanguination within minutes, especially at night or if patient unresponsive.

Apply firm direct pressure to access site immediately
Clamp venous bloodline — stop pump
Maintain pressure for minimum 10 minutes
Assess blood loss — call physician
Tape needles securely with non-occlusive technique
Use enuresis pads under fistula arm for early detection
Wearable access monitors (VenousBlood alert systems) recommended for overnight HD

Peritoneal Dialysis (PD)

CAPD vs APD

Feature	CAPD	APD (Nocturnal Cycler)
Full name	Continuous Ambulatory PD	Automated PD / NIPD / CCPD
Exchanges	3–5 manual exchanges/day	Machine-driven; 3–5 at night
Dwell time	4–6 hrs (day), 8–10 hrs (night)	Short dwells overnight (1–2 hrs)
Lifestyle	Manual; no machine needed at night	Machine at bedside; frees daytime
Suitability	High/high-average transporters	Low/low-average transporters
Peritonitis risk	Slightly higher (more connect/disconnect)	Fewer daily connections

PD Exchange Technique (Aseptic)

Wash hands thoroughly — 2-minute scrub before setup
Prepare clean work surface; mask worn by patient and nurse
Check bag: clarity, volume, expiry date, intact seal
Connect drain bag — open drain clamp; allow full drain (gravity, 20–30 min)
Inspect effluent: clear = normal; cloudy = peritonitis suspect
Connect fresh dialysate bag; warm to body temperature
Open fill clamp — allow infusion (gravity, 10–15 min)
Clamp and disconnect using aseptic technique; apply protective cap
Record: drain volume, fill volume, effluent appearance, UF balance

Peritonitis — Most Serious PD Complication

Key Sign: Cloudy effluent is peritonitis until proven otherwise. Cell count > 100 WBC/mm³ with > 50% neutrophils confirms diagnosis.

Classic TriadCloudy effluent + abdominal pain + fever

DiagnosisEffluent cell count, Gram stain, culture (aerobic + anaerobic)

Common OrganismsCoNS (most common), S. aureus, Gram-negative enteric, Pseudomonas, fungi

IP Antibiotics (Empiric)Vancomycin (Gram-pos) + 3rd gen cephalosporin or aminoglycoside (Gram-neg) — intraperitoneal route preferred

DurationMinimum 2 weeks; fungal peritonitis → remove catheter immediately

Nursing Actions

Send 10 mL effluent to microbiology — cell count, C&S
Administer empiric IP antibiotics per local protocol
Flush peritoneum with rapid exchanges if severe
Document all observations and report to physician/renal team
Patient education — review technique asepsis
Consider catheter removal if no improvement in 5 days

Tenckhoff Catheter & Exit Site Care

Exit site inspection at every exchange: redness, swelling, discharge, crust
Clean exit site with chlorhexidine 0.05% or mupirocin cream (if S. aureus carrier)
Use sterile gauze dressing — change at least weekly or if wet/soiled
Immerse catheter — no bathing/swimming (shower only with bag cover)
Secure catheter to skin to prevent trauma — directional fixation
Tunnel infection: erythema/induration along tunnel track — IV antibiotics; may require catheter removal
Report any discharge to nursing team immediately

PD Adequacy & Membrane Transport

Target: Weekly Kt/V ≥ 1.7 (combined residual renal function + peritoneal clearance)

Transport Type	D/P Creatinine Ratio	Implication
High	> 0.81	Rapid absorption of glucose → short dwells better (APD); UF failure risk
High-Average	0.65–0.81	Good solute clearance
Low-Average	0.50–0.65	Longer dwell times improve clearance
Low	< 0.50	Poor clearance — consider HD transfer

UF Failure & Encapsulating Peritoneal Sclerosis

UF FailureNet UF < 400 mL with 4.25% glucose 4-hr dwell

CausesHigh transport, aquaporin-1 loss, peritonitis scarring, catheter issues

EPS (Encapsulating Peritoneal Sclerosis)Rare but life-threatening; fibrous cocoon encases bowel

EPS Risk FactorsLong PD duration (>8 yrs), repeated peritonitis, high glucose exposure

EPS SignsBowel obstruction, recurrent UF failure, ascites post-PD cessation

ManagementTransfer to HD; tamoxifen; surgical peel in severe cases

PD in Ramadan — Key Adjustments

GCC-Specific: Many Muslim patients wish to fast during Ramadan. PD timing can often be adjusted respectfully.

CAPD: shift exchanges to non-fasting hours (before Fajr / after Iftar)
APD: programme cycler to run overnight — no daytime exchanges needed
Icodextrin-based bag for long daytime dwell (avoids glucose absorption during fast)
Monitor fluid balance carefully — reduced oral intake affects hydration
Document weight and blood pressure at each session
Consult Islamic scholar + renal team for individualised plan
Empower patient — inform them dialysis is a medical necessity; fatwa permits

CRRT in Critical Care

CVVH

Continuous Veno-Venous Haemofiltration

Convection only — solute drag via replacement fluid. Best for fluid/middle-molecule removal.

CVVHD

Continuous Veno-Venous Haemodialysis

Diffusion only — dialysate flow counter-current to blood. Best for small solute (urea/K⁺) clearance.

CVVHDF

Continuous Veno-Venous Haemodiafiltration

Diffusion + Convection combined. Most effective broad-spectrum clearance. Most common ICU mode.

CRRT Effluent Dose & Circuit

Target Effluent Rate: 25–30 mL/kg/hr (prescribed dose should be higher to account for downtime).

Blood Flow Rate (Qb)100–200 mL/min (lower than IHD)

Dialysate Flow (CVVHD/F)1,000–2,500 mL/hr

Replacement Fluid (CVVH/F)Pre-dilution or post-dilution delivery

Pre-dilution AdvantageExtends filter life; reduces haematocrit in filter

Post-dilution AdvantageMore efficient clearance (higher sieving coefficient)

Filter Lifespan Target≥ 24 hours; frequent clotting → review anticoagulation

Filter Clotting Signs↑ TMP (transmembrane pressure), ↓ effluent rate, dark filter appearance

Anticoagulation — Heparin vs Citrate

Parameter	Systemic Heparin	Regional Citrate
Mechanism	Anti-thrombin III activation; systemic effect	Chelates ionised Ca²⁺ in circuit — regional only
Target (Heparin)	aPTT 45–65 sec (circuit); 45–60 sec (systemic)	—
Post-filter iCa	—	0.25–0.35 mmol/L (circuit anticoagulated)
Systemic iCa	—	1.0–1.2 mmol/L (calcium replacement infusion)
Monitoring	aPTT 4–6 hourly; platelet count	iCa pre/post-filter; serum total Ca/citrate ratio
Contraindications	HIT, active bleeding, thrombocytopaenia	Severe liver failure (citrate accumulation risk)
Citrate Toxicity Signs	—	↑ total Ca but ↓ ionised Ca; metabolic alkalosis, tetany
Preferred	If liver failure / no HIT risk	First-line in most ICUs (KDIGO 2012)

Haemofilter Change — Nursing Procedure

Prepare new circuit set on CRRT machine as per manufacturer
Prime new circuit with 0.9% saline + heparin per protocol (2,000–5,000 U/L)
Obtain medical order for filter change if planned vs emergency clot
Stop CRRT — disconnect blood lines using ANTT
Assess: patient haemodynamics, current fluid balance, anticoagulation status
Connect new circuit; verify all connections are secure and primed
Restart CRRT — document time off, reason for change, effluent volumes
Send clotted filter for inspection if premature failure — document for audit

Reasons for Premature Filter Clotting

Inadequate anticoagulation dose
High haematocrit / haemoconcentration (post-dilution)
Slow blood flow rate (< 100 mL/min)
Line kinking or patient position
High plasma viscosity (hyperproteinaemia)
Air in circuit
Long machine downtime without rinseback

Drug Dosing on CRRT

Important: CRRT significantly increases clearance of water-soluble, low-protein-bound drugs. Standard dosing leads to sub-therapeutic levels.

Drug	CRRT Adjustment	Monitoring
Vancomycin	Loading dose 25 mg/kg; then 7.5–15 mg/kg q12h (dose depends on effluent rate)	Trough AUC-guided; target AUC 400–600
Meropenem	1 g q8h or 2 g q8h extended infusion for resistant organisms	Clinical response; β-lactam TDM if available
Piperacillin-Tazobactam	4.5 g q8h extended infusion (4-hr)	Clinical response
Linezolid	Standard 600 mg q12h — minimal CRRT removal	Platelet count (thrombocytopaenia)
Fluconazole	400–800 mg q24h (highly removed by CRRT)	Clinical/microbiological response

Phosphate Replacement & CRRT-to-IHD Transition

Hypophosphataemia on CRRTVery common — phosphate cleared by convection/diffusion; replacement often needed

Target Serum Phosphate0.8–1.4 mmol/L

Replacement RouteIV replacement fluid or TPN supplementation; daily monitoring

Criteria to Transition CRRT → IHD

Haemodynamically stable — vasopressor requirement ≤ low dose noradrenaline
No significant fluid overload requiring continuous UF
Acceptable electrolyte stability without continuous monitoring
Patient able to tolerate intermittent UF volumes
Renal function unlikely to recover (or AKI resolving → consider stopping)

Dialysis Access Care

CVC Dressing Change — ANTT Protocol

Standard: Chlorhexidine 2% in 70% isopropyl alcohol. Dressing change every 7 days maximum (or sooner if soiled/loose).

Don non-sterile gloves; remove old dressing; inspect exit site — redness, discharge, swelling
Remove non-sterile gloves; perform hand hygiene (ABHR 30 sec)
Don sterile gloves; establish sterile field with dressing pack
Clean exit site: chlorhexidine 2% / 70% IPA using friction x30 sec; allow to dry completely (30 sec)
Apply transparent semi-permeable dressing (e.g., Tegaderm CHG if available)
Secure CVC to skin — avoid tension on exit site
Label dressing with date, time, nurse initials
Document exit site condition in patient record

Heparin Lock vs Citrate Lock

Preferred: 4% Sodium Citrate (HDTL — Haemodialysis Taurolidine-Citrate Lock) — reduces catheter-related bloodstream infections vs heparin.

Parameter	Heparin Lock	4% Citrate Lock
Concentration	5,000 U/mL or 1,000 U/mL	4% sodium citrate
Infection risk	Higher (promotes biofilm)	Lower (antibiofilm + antimicrobial)
Bleeding risk	Systemic if accidental flush	Minimal systemic effect
Halal consideration	Porcine-derived (see GCC tab)	No animal product concern
Volume	Fill dead space only (1.3–1.5 mL/lumen)	Same — fill dead space only
Flush before use	Aspirate and discard before dialysis	Aspirate and discard before dialysis

tPA (Alteplase) for Blocked Catheter

Indication: Unable to aspirate from one or both lumen; blood flow < 200 mL/min during HD; thrombotic occlusion suspected.

Standard Dose2 mg in 2 mL per lumen (fill dead space — usually 1.3–1.5 mL)

Dwell Time30–60 minutes (or per unit protocol; some protocols up to 120 min)

AspirationAfter dwell: aspirate and discard tPA + clot debris (do NOT flush in)

Second DoseCan repeat once if first dose unsuccessful

Success Rate~90% restoration of catheter patency

ContraindicationsActive bleeding, recent stroke (< 3 months), neurosurgery, allergy

Access Flow & Patency Documentation

Document pre/mid/post blood flow rate achieved at each session
Record arterial and venous pressure readings — trend monitoring
Venous pressure > 200 mmHg at 300 mL/min Qb = suspect venous stenosis
Arterial pressure more negative than −200 mmHg = arterial inflow problem
Log access type, site, and needle gauge for each session
Quarterly Doppler ultrasound surveillance for AVF/AVG
Refer to interventional radiology if access flow < 600 mL/min (AVF) or < 800 mL/min (AVG)

AVF Steal Syndrome

DefinitionBlood diverted from distal limb to fistula → ischaemia

SymptomsCold hand, pallor, paraesthesias, pain (especially during dialysis), finger necrosis (severe)

AssessmentDigital pressure/pulse oximetry; Doppler; digital brachial index < 0.6 = significant steal

GradingI–IV (IV = tissue loss/necrosis → urgent referral)

ManagementSurgical: DRIL (distal revascularisation interval ligation), PAI (proximalisation), banding, or AVF ligation

Nursing RoleReport signs promptly; do not use fistula arm if steal grade III–IV without specialist review

TOS — Thoracic Outlet Syndrome & AVF Abandonment

TOS Relevance to DialysisCentral vein stenosis from repeated CVC use — impairs AVF maturation; arm oedema

Signs of Central StenosisArm swelling after AVF creation, facial/neck oedema, ↑ venous pressures

InvestigationFistulogram / venogram; CT venogram

AVF Abandonment IndicationsNon-maturing fistula after 3–4 months; steal causing limb threat; uncontrollable aneurysm; persistent infection

Post-AbandonmentEnsure alternative access planned before ligation; patient counselling

GCC Dialysis Context

~35%

ESKD in GCC attributed to T2DM (highest globally)

~25%

ESKD cases from hypertensive nephrosclerosis in GCC

GCC nations with rapidly expanding renal replacement programmes

GCC Dialysis Regulatory Landscape

Country	Regulator	Key Notes
Dubai	DHA (Dubai Health Authority)	DHA-licensed dialysis centres; nurse registration required
Abu Dhabi	DOH (formerly HAAD)	Thiqa insurance covers dialysis; DOH standards enforced
Saudi Arabia	MOH / CBAHI accreditation	Largest GCC ESKD burden; national kidney programme (SCOT)
Qatar	MOPH / JHCMQ accreditation	Hamad Medical Corporation runs main renal services
Kuwait	MOH Kuwait	Significant expatriate dialysis population
Bahrain	NHRA	Small programme; some patients travel regionally
Oman	MOH Oman	National Renal Care Programme; expanding peritoneal dialysis

Renal Transplant vs Long-Term Dialysis

Clinical Preference: Transplant offers better survival and QoL, but living donor rates vary across GCC due to cultural and religious considerations.

KSA operates largest deceased donor programme in the Arab world (SCOT)
UAE, Qatar: growing deceased donor programmes through hospital-based coordinators
Cultural hesitancy around brain death declaration remains a barrier in some communities
Islamic Fiqh Academy permits organ donation (1988 resolution) — fatwa available
Many GCC patients opt for long-term HD due to limited donor availability
Pre-dialysis education on transplant listing should be part of CKD stage 4 nursing care plan

Ramadan Fasting on Dialysis

GCC Nursing Consideration: Large proportion of dialysis patients are Muslim. Individualised planning around Ramadan is essential and respectful.

Main Risk (HD)Extended fasting → fluid restriction challenge → excessive IDWG between sessions

Scheduling StrategySchedule 3× weekly HD sessions around Iftar (evening) or Suhoor (pre-dawn) hours

Iftar-Time HDStart after Iftar meal — patient hydrated; minimises UF demand mid-fast

Dietary CounsellingAvoid high-K⁺ fruits at Iftar (dates = moderate K⁺, but large volumes problematic)

PD in RamadanExchanges shifted to night time; APD ideal (see PD tab)

Islamic RulingMajority of scholars: dialysis breaks fast → patient exempted. Compensation via fidya (feeding the poor).

Nursing RoleNon-judgmental; provide options; involve patient in decision; document plan

Water Quality Standards in GCC Dialysis Units

Critical: GCC has high TDS (Total Dissolved Solids) in source water. Robust water treatment is mandatory for safe dialysis.

Reverse Osmosis (RO) is mandatory — dual-pass RO systems in many GCC units
High ambient temperatures → bacterial growth in water loops — ↑ endotoxin risk
AAMI/ISO standards: bacteria < 100 CFU/mL; endotoxins < 0.25 EU/mL (ultrapure: < 0.001 EU/mL)
Monthly bacteriological sampling + quarterly endotoxin testing mandatory
Carbon filters: change regularly (chloramine removal)
Water loop heat or chemical disinfection per protocol
Nursing role: report discoloured water; record water treatment alarms; do not start dialysis if water fails QC

Halal Anticoagulation — Heparin

Islamic Ruling: Porcine (pig-derived) heparin is generally permitted under the principle of darurah (necessity) when no suitable halal alternative exists.

Standard unfractionated heparin (UFH) is predominantly porcine-derived
Bovine heparin: available as an alternative but less common commercially
Enoxaparin (LMWH): also porcine-derived; same ruling applies
Citrate anticoagulation for CRRT: no animal product — halal by default
Argatroban / Bivalirudin (synthetic): fully halal; used for HIT patients
Patient communication: explain necessity and the Islamic principle of necessity
Document patient informed consent regarding anticoagulant choice

Arabic Patient Education — Fluid & Diet

Communication: Use validated Arabic educational materials and involve family in education sessions where culturally appropriate.

Topic	Key Message (Arabic Cultural Context)
Fluid restriction	500 mL/day + residual urine output. Explain consequences of weight gain — heart failure, difficult dialysis. Use visual tools (marked cups).
Potassium	Avoid: dates (large quantities), dried fruits, nuts, tomato, potato. Boil vegetables in excess water — discards potassium.
Phosphate	Limit dairy, cola drinks, processed foods, seeds. Phosphate binders must be taken with meals — not after.
Salt restriction	Reduces thirst → easier fluid control. Arabic cooking can be high in salt — practical recipe adaptations.
Ramadan	Discuss modified dietary plan; manage expectations; celebrate patient's faith while protecting health.
Missed sessions	Each missed session increases risk of life-threatening hyperkalaemia; use empathetic language, not threats.

Advanced Dialysis Nursing — GCC Clinical Guide

Dialysis Session Monitoring Tracker

Pre-Session Assessment

Mid-Session Check

Post-Session