The Importance of Fluid
Management in the Dialysis
Patient
Deborah Glidden, MSN,ARNP
Introduction
“Mr. Smith, your fluid gains have been quite
excessive between treatments…
Introduction
Response:
“Yea, no worries though. You get all the fluid
off each treatment. I can handle it”
Introduction
“Ms. Jones, you gained 5 kg. since Monday.
Are you restricting your fluid & salt intake
as we discussed?”
Response:
“I have to drink. I’m thirsty all the time. But I
don’t use the salt shaker anymore.”
Introduction
Let’s review basic facts re: CV morbidity &
mortality:
• prevalence is high for dialysis population
• CHF is one of the most common causes of death
• part of controlling CHF is controlling extracellular
volume (ECV)
McIntyre CW. Effects of hemodialysis on cardiac function. Kidney International 2009; 76; 371-375.
Parker TF, Hakim R, et al. Reducing rates of hospitalizations by objectively monitoring volume removal.
Nephrology News & Issues 2013 March; 27 (3); 30-36.
Objectives
• Understand the impact of volume overload
on morbidity & mortality
• Describe the consequences of chronic
volume overload on the CV system
• Identify barriers to effective ECV control
• Determine strategies for minimizing IDWG
• Identify strategies to avoid intradialytic CV
complications
ESRD: Morbidity & Mortality
Foley RN, Parfrey PS, Sarnak MJ. Clinical epidemiology of cardiovascular disease in chronic renal
disease. AJKD 1998; 32: S112-S119.
CHF: Morbidity & Mortality
• CHF is most common CV disease
(excluding HTN)
• 2-year mortality rate is high
– 49% HD
– 57% PD
www.usrds.org/2013/pdf/v2_ch4 _13.pdf
CHF: Morbidity & Mortality
Survival
CHF
Fluid overload
Pulmonary
edema
5 yr
12.5%
20.2%
21.3%
2 yr
36.4%
48.3%
46.8%
1 yr
54.1%
65.8%
64.9%
Retrospective analysis: long-term survival of incident HD pts
#310,456 hospital admits with CHF, fluid overload, pulmonary edema
Banerjee D, Ma JZ, et al. Long-term survival of incident hemodialysis patients who are hospitalized for
congestive heart failure, pulmonary edema, or fluid overload. CJASN 2007; 2 (6); 1186-1190.
Banerjee study, cont’d
Independent predictors of mortality:
• Older age
• Male gender
• White race
• Diabetes & HTN as cause for renal failure
• Previous CV comorbidities
• CHF
Banerjee D, Ma JZ, et al. Long-term survival of incident hemodialysis patients who are hospitalized for
congestive heart failure, pulmonary edema, or fluid overload. CJASN 2007; 2 (6); 1186-1190.
Adjusted rates of hospital admissions, by
modality & diagnosis code type: cardiovascular
Figure 3.9 (Volume 2)
Period prevalent ESRD patients. Adj: age/gender/race/primary diagnosis; ref: ESRD patients, 2010.
USRDS 2013 ADR
Adjusted rates of hospital admissions,
by modality & diagnosis code type: CHF
Figure 3.10 (Volume 2)
Period prevalent ESRD patients. Adj: age/gender/race/primary diagnosis; ref: ESRD patients, 2010.
USRDS 2013 ADR
Adjusted rates of hospital admissions,
by modality & diagnosis code type: dysrhythmia
Figure 3.13 (Volume 2)
Period prevalent dialysis patients. Adj: age/gender/race/primary diagnosis; ref: ESRD patients, 2010.
USRDS 2013 ADR
All-cause rehospitalization or death 30 days
after live hospital discharge, by cause-specific
cardiovascular index hospitalization, 2011
Figure 3.19 (Volume 2)
Period prevalent hemodialysis patients, all ages, 2011, unadjusted; includes live hospital discharges from January 1 to
December 1, 2011.
USRDS 2013 ADR
Costs of Fluid Overload
2-year Retrospective analysis of Medicare
patients b/w 2004-2006 evaluating costs of
fluid overload treatment
Results:
 14.3% prevalent Medicare pts (25,291) had
41,699 care episodes over 2 years
 Est avg cost/episode--$6,372
 Total costs were ~ $266 million
Arneson TJ, Liu J, Qiu Y, et al. Hospital treatment for fluid overload in the Medicare hemodialysis
population. CJASN 2010 June; 5(6); 1054-1063.
Physiologic Consequences of Fluid
Overload, General
Edema—facilitates skin breakdown
Kraemer M, Rode C, Wizemann V. Detection limit of methods to assess fluid status changes in dialysis
patients. KI 2006; 69; 1609-1620.
Physiologic Consequences of Fluid
Overload, General
Dyspnea-- lead to pulmonary complications
Kraemer M, Rode C, Wizemann V. Detection limit of methods to assess fluid status changes in dialysis
patients. KI 2006; 69; 1609-1620.
Physiologic Consequences of Fluid
Overload, General
GI complications—decreased appetite, PEW
Kraemer M, Rode C, Wizemann V. Detection limit of methods to assess fluid status changes in dialysis
patients. KI 2006; 69; 1609-1620.
CV Consequences
HTN—80% due to chronic hypervolemia
-- increases workload on heart
-- leading to LVH: highly predictive of
increased incidence of:
•
MI
•
CHF
•
sudden death
Jaeger JQ, Mehta RL. Assessment of dry weight in hemodialysis: an overview. JASN 1999; 10; 392-403.
CV Consequences
LVH can lead to diastolic dysfunction which
has been linked to increased incidence of
intradialytic morbid events.
Jaeger JQ, Mehta RL. Assessment of dry weight in hemodialysis: an overview. JASN 1999; 10; 392-403.
CV Complications: UF
Promotes non-physiological fluid shifts
hemodynamic instability
Flythe JE, Kimmel SE, Brunelli SM. Rapid fluid removal during dialysis is associated with cardiovascular
morbidity and mortality. KI 2011 January; 79(2); 250-257.
CV Complications: UF
Hemodynamic instability contributes to:
• tissue ischemia
• maladaptive cardiac structural changes
• myocardial stunning
• arrhythmia
• cardiac sudden death
Flythe JE, Kimmel SE, Brunelli SM. Rapid fluid removal during dialysis is associated with cardiovascular
morbidity and mortality. KI 2011 January; 79(2); 250-257.
UF Rates & Mortality
Prospective analysis by Flythe & colleagues
-- to determine association b/w UFR & allcause and CV-related mortality.
-- also sought to identify threshold at which
higher UFR to be associated with decreased
survival.
Flythe JE, Kimmel SE, Brunelli SM. Rapid fluid removal during dialysis is associated with
cardiovascular morbidity and mortality. KI 2011 January; 79(2); 250-257.
Flythe Study Results
Significant association b/w CV mortality &
UFR >13mL/hr/kg
No significant association with UFR 1013mL/hr/kg
EXCEPT in high risk pts (ie, CHF)
Flythe JE, Kimmel SE, Brunelli SM. Rapid fluid removal during dialysis is associated with cardiovascular
morbidity and mortality. KI 2011 January; 79(2); 250-257.
Slow IV refill (due to high UFR)
Circulating volume
Transient ischemia
Myocardial stunning (RWMA)
Flythe JE, Kimmel SE, Brunelli SM. Rapid fluid removal during dialysis is associated with
cardiovascular morbidity and mortality. KI 2011 January; 79(2); 250-257.
Irreversible loss of myocardial
contractility
Compromised systolic function
Survival
Flythe JE, Kimmel SE, Brunelli SM. Rapid fluid removal during dialysis is associated
with cardiovascular morbidity and mortality. KI 2011 January; 79(2); 250-257.
McIntyre Study
Purpose: determine
differences in occurrence &
severity of myocardial
stunning in stable pts
receiving:
Conventional in-center HD
3x/week (CHD3)
In-center short daily HD 56 days/week (CSD)
Home short daily HD 5-6
days/week (HSD)
Nocturnal home HD (HN)
Results:
Myocardial stunning
decreased with increasing
dialysis intensity:
CHD3 > CSD > HSD > HN
&
Myocardial stunning was associated
with increased rate of intra/post
dialytic ventricular arrhythmias.
McIntyre CW. Haemodialysis-induced myocardial stunning in Chronic
Kidney Disease—a new aspect of cardiovascular disease. Blood
Purification 2010; 29; 105-110.
Barriers to Effective ECV
Control
Goal
• Avoid hypovolemia during dialysis sessions
• Preventing fluid overload b/w sessions
Complicated by many factors…
 Iatrogenic factors
 Patient factors
Iatrogenic Factors
Shortened Td
• Do not allow for safe and effective UFR
• Study by Tentori & colleagues :
assessed association of Td with clinical
outcomes:
– used DOPPS data b/w 1996-2008
– 930 facilities in 12 countries
– patient sample: 37,414
Tentori F, Zhang J, et al. Longer dialysis session length is associated with better intermediate
outcomes and survival among patients on in-center three times per week hemodialysis: results
from the Dialysis Outcomes and Practice Patterns Study (DOPPS). NDT 2012; 27; 4180-4188.
Shortened Td
Facility mean Td:
214 minutes in United States (shortest)
256 minutes in Australia-New Zealand (longest)
Tentori F, Zhang J, et al. Longer dialysis session length is associated with better intermediate outcomes
and survival among patients on in-center three times per week hemodialysis: results from the Dialysis
Outcomes and Practice Patterns Study (DOPPS). NDT 2012; 27; 4180-4188.
Shortened Td
Results:
Patients with longer Td—lower risk of allcause & CV mortality
AND
 Strong association b/w longer Td and lower risk of
sudden death
Tentori F, Zhang J, et al. Longer dialysis session length is associated with better intermediate outcomes
and survival among patients on in-center three times per week hemodialysis: results from the Dialysis
Outcomes and Practice Patterns Study (DOPPS). NDT 2012; 27; 4180-4188.
Shortened Td
Results, cont’d:
Longer Td—
•
•
•
•
•
•
Lower pre & post dialysis systolic BP
Greater weight loss
Higher albumin levels
Higher Hb for same EPO dose
Lower PO4 & WBC
Decreased risk of hospitalization for CHF/fluid overload
Tentori F, Zhang J, et al. Longer dialysis session length is associated with better intermediate outcomes
and survival among patients on in-center three times per week hemodialysis: results from the Dialysis
Outcomes and Practice Patterns Study (DOPPS). NDT 2012; 27; 4180-4188.
Inaccurate assessment of EDW
• No standard measure of EDW
• Obtained through trial and error
• Other methods: Crit-line, BIA, biochemical
markers i.e. BNP, ANP—look promising
but have limitations…$$$
• Only setting goal for last post-weight, not
EDW
Jaeger JQ, Mehta RL. Assessment of dry weight in hemodialysis: an overview. JASN 1999; 10; 392-403.
Agarwal R. Volume overload in dialysis: the elephant in the room , no one can see. American Journal of
Nephrology 2013. 38; 75-77.
Use of sodium profiling
Associated with
• thirst
• IDWG
• BP
:
Tomson CRV. Advising dialysis patients to restrict fluid intake without restricting sodium intake is not
based on evidence and is a waste of time. NDT 2001; 16; 1538-1542.
Patient-centered Factors
Non-adherence to fluid & salt restriction
Adherence
WHO Adherence Meeting, June 2001:
“the extent to which a person’s behavior
corresponds with the agreed
recommendations of a HCP in terms of
taking medications, following a
recommended diet &/or executing lifestyle
changes…”
Kugler C, Maeding I, Russell CL. Non-adherence in patients on chronic hemodialysis: an international
comparison study. Journal of Nephrology 2011; 24(03); 366-375.
Non-adherence to fluid restriction
Prevalence is high:
Self-reported NA to fluid restrictions was:
74.6%
Patients at highest risk:
younger males & smokers
Kugler C, Vlaminck H, et al. Non-adherence with diet and fluid restrictions among adults having
hemodialysis. Journal of Nursing Scholarship 2005; 37(01); 25-29.
Non-adherence to salt restriction
“advising dialysis patients to restrict fluid
intake when they have not had advice on
how to limit their salt intake is inhumane…
and a waste of time”
Tomson CRV. Advising dialysis patients to restrict fluid intake without restricting sodium intake is not
based on evidence and is a waste of time. NDT 2001; 16; 1538-1542.
Rationale
Salt intake
ECF osmotic gradient
H2O moves from cells to ECF space
Stimulates thirst center of hypothalamus
Fluid intake
NKF KDOQI Clinical Practice Guidelines. 2006 Updates; Guideline 5. Control of volume and blood
pressure.
Barriers: Miscellaneous
• Medications causing dry mouth, i.e.
clonidine
• Hyperglycemia causes increased thirst
Barriers: Psychosocial & Cognitive
Factors
• Plays a role in adherence
• Influenced by:
–
–
–
–
–
Age
Gender
Locus of control
Social adjustment
Past psychiatric history
Sensky T, Leger C, Gilmour S. Psychosocial and cognitive factors associated with adherence to
dietary and fluid restriction regimens by people on chronic haemodialysis. Psychother
Psychosom 1996; 65(1); 36-42.
Effective Fluid Management
Strategies
Goal of successful fluid management
According to Chazot:
…to reach a consistently low ECF state in the
constraints of intermittent HD therapy
where large & variable volume swings can
occur…
while at the same time, avoiding
intradialytic morbid events
Chazot C, Wabel P, Chamney P, et al. Importance of normohydration for the long-term survival of
haemodialysis patients. NDT 2011; 1-7.
Longer dialysis treatments
• Allows more time for UF
• Decreases risk of CV morbidity
• Maintain UFR <13mL/hr/kg; closer to
10mL/hr/kg for high risk
Flythe JE, Kimmel SE, Brunelli SM. Rapid fluid removal during dialysis is associated with cardiovascular
morbidity and mortality. KI 2011 January; 79(2); 250-257.
Avoid Sodium Profiling
• Per KDOQI: puts pt in + sodium balance
• Stimulates “thirst switch”
http://www.kidney.org/professionals/kdoqi/guideline_uphd_pd_va/hd_guide5.htm
Achieve optimal dry weight
• Usually determined by clinical assessment:
--BP
--edema
--dyspnea
--pt’s tolerance to UF
• Be aware of “silent overhydration”
• Edema may not appear until fluid overload of
up to 10% of body weight
http://www.kidney.org/professionals/kdoqi/guideline_uphd_pd_va/hd_guide5.htm
Sodium/salt restriction
• Recommended daily sodium intake:
2000mg
• Education is the key!
– Read nutritional labels
– If food tastes salty—it is!
– Canned, processed foods have high sodium
content
http://www.kidney.org/professionals/kdoqi/guideline_uphd_pd_va/hd_guide5.htm
Pearl:
Patients accustomed to high salt intake should
gradually decrease salt intake to provide
ample time for taste adjustments.
http://www.kidney.org/professionals/kdoqi/guideline_uphd_pd_va/hd_guide5.htm
Diuretic use
• Continue use of loop diuretics in pts with
RRF
• Large doses promote loss of Na++ & water
• Monitor K+ for hypokalemia
• Effectiveness of therapy may be short
• Question often re: urine output
http://www.kidney.org/professionals/kdoqi/guideline_uphd_pd_va/hd_guide5.htm
Assign fluid manager
• Work in similar capacity as anemia/vascular
manager
• Focus: to maintain ECV control with
monitoring & protocol
• Be part of IDT
http://www.nephrologynews.com/articles/109507-why-a-fluid-manager-makes-sense-in-your-dialysisclinic
Fluid manager, responsibilities
For oversight of:
• Extra treatments
• Updating BP med lists
• UFR (max rate per MD)
• Root cause analysis of inter/intra dialytic
events
• Work closely with dietician
http://www.nephrologynews.com/articles/109507-why-a-fluid-manager-makes-sense-in-your-dialysisclinic
Miscellaneous
• Optimize diabetic management to prevent
hyperglycemia
• Avoid use of clonidine
• Assess/treat depression/offer psychosocial
support
Improve adherence
“One of the most important factors affecting
adherence is the relationships that dialysis
staff members establish with their patients”
Good communication b/w patient & staff is a
MUST for effective clinical practice.
Krueger KP,et al. Medication adherence and persistence: a comprehensive review. Advances in Therapy .
July/August 2005; 22(4); 313-356.
Summary
• Volume overload is an important risk factor for CV
morbidity & mortality
• CHF is one of the most common CV diseases in ESRD pts
that comes with high mortality rate
• Hospitalization costs of fluid overload were over $266
million in one retrospective analysis
• Consequences of chronic volume overload are HTN, LVH
&
incidence of intradialytic morbid events
• High UFR >13mL/hr/kg increases risk of CV deaths
Summary
• Many barriers to effective fluid mgt both
treatment & patient-related
• Non-adherence is a major barrier
• Can be overcome through education of both
staff & patients
• Good communication b/w staff & pts is a
good first step towards improving
adherence
In conclusion:
Currently, our focus on dialysis adequacy
only takes into account solute removal…
Is it time to redefine adequacy to include
effective volume control???