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CMS SOM App. H, Tag V235

ANSI/AAMI RD52:2004 Requirements as Adopted by Reference 42 CFR 494.40(a)

activein force · 2026-07-22 – presentas-observed

5.4.5 Additives: mixing spikes

Concentrate additives should be mixed with liquid acid concentrates according to the

manufacturer’s instructions, taking care to ensure that the additive is formulated for use in

concentrates of the appropriate dilution ratio. When liquid additives are used, the volume

contributed by the additive should be considered when calculating the effect of dilution on

the concentration of the other components in the resulting concentrate. When powder

additives are used, care should be taken to ensure that the additive is completely dissolved

and mixed before the concentrate is used.

Page 93 of 420

Interpretive Guidance § 494.40(a)

ANSI/AAMI RD52:2004

5.4.5 Additives

Manufacturers provide acid concentrates with a wide range of electrolyte compositions for

different proportioning ratios. Most typical dialysate prescriptions can be obtained by using one

or more of these commercially available concentrates. If particular formulations are not

available, manufacturers provide additives that can be used to adjust the level of potassium or

calcium in the dialysate. These additives are commonly referred to as “spikes.”

6.4.2 Additives

When additives are used to increase concentrations of specific electrolytes in the acid

concentrate, mixing procedures shall be followed as specified by the additive manufacturer.

Additional Guidance:

Depending on State law which will vary from State to State, the nurse practice act must be

considered in determining the appropriateness of the staff being allowed to use a “spike” to

change the concentration of electrolytes in the acid concentrate. Since the concentrate is a

prescription medication, many states require a licensed nurse to perform this task. When facility

policy allows use of “spikes,” appropriate additives should be accurately mixed according to

manufacturer’s directions, labeled as required by these rules, and should be documented in the

patient record to accurately reflect the composition of the dialysate used for treatment.

History

Rev.

Provenance

Source
cms.gov
Retrieved
2026-07-22
Edition
som-2026-07-22
Content hash
17c97e86e215defc8c3688400b936fcbaffec0f19d9b0a9c221251fe7fb12350
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