Volume Balance and Intradialytic Ultrafiltration Rate in the Hemodialysis Patient

Abstract

PURPOSE OF REVIEW Volume management in hemodialysis patients is often challenging. Assessing volume status and deciding how much fluid to remove during hemodialysis, the so-called ultrafiltration rate (UFR), has remained a conundrum. RECENT FINDINGS To date there is no objective assessment tool to determine the needed UFR during each hemodialysis session. Higher volume overload or higher UFR is associated with poor outcomes including worse mortality and unfavorable clinical outcomes. We suggest combined use of the following criteria to determine UFR or post-dialysis target dry weight: pre-hemodialysis blood pressure and its intradialytic changes, muscle cramps, dyspnea from pulmonary vascular congestion, peripheral edema, tachycardia or palpitation, headache or lightheadedness, perspiration, post-dialysis fatigue. Restricting fluid and salt intake – and high-dose loop diuretic use in case of residual kidney function – can be helpful in controlling fluid gains. More frequent and more severe hypotensive episodes are associated with poor outcomes including higher death risk.

Systematic Fluid Assessment in Haemodialysis: Development and Validation of A Decision Aid

“…A core group made up of nurses and physicians conducted a series of meetings to develop the decision aid, which was based on empirical experience and a literature review identifying and appraising physiological parameters routinely measured in haemodialysis care for assessment of fluid status (Wizemann & Schilling ; Kraemer ; Lindley et al . ; Chou & Kalantar‐Zadeh ). For review and evaluation of the content and comprehensiveness, the tool was then circulated to a larger group of interdisciplinary stakeholders, and experts in the use of BIS, including clinical scientists, dieticians, physiotherapists and physicians, and also to patients’ representatives.…”

“…Current fluid management in haemodialysis is mainly based on clinical assessment, such as weight gain between dialysis sessions, pre‐ and post‐dialysis blood pressure (BP) and patient‐reported symptoms (Lindley et al . ; Chou & Kalantar‐Zadeh ). However, it is not always straightforward.…”

Management of heart failure in patients with end-stage kidney disease on maintenance dialysis: a practical guide

“…During dialysis, patients should be monitored for signs that too much fluid has been removed, or that ultrafiltration has been done too rapidly. These signs include not only hypotension, but also tachycardia, lightheadedness, muscle cramps, and loss of appetite (Chou and Kalantar-Zadeh, 2017;Kalantar-Zadeh et al, 2009). When changes to the ultrafiltration goal are made, the patient's symptoms should be reassessed to determine whether an adequate dry weight has been achieved.…”

Intermittent pneumatic compression in patients with ESRD. A systematic review

“…3 This device is comprised of an air pump machine and either sleeves or boots that have separate compartments that inflate sequentially; commonly cycles of compression and decompression are used with the goal of generating pressure gradients along tissue with a subsequent increase of blood flow and venous return, 4,5 hence it is an emerging tool for palliative intervention in patients with endstage renal disease (ESRD) while receiving hemodialysis (HD). The hemodynamic challenge of HD relies on achieving an adequate volume balance to avoid situations in which patients are over or under dialyzed 6 resulting in further complications like intradialytic hypotension (IDH), interruption of treatment and significant distress to patients. 7 Currently, about 400,000 adults are on HD in the USA, 8 and it is estimated that IDH occurs in approximately 1 of every 4 treatments and also it is commonly associated with distressing symptoms such as lightheadedness, weakness, muscle cramps, and nausea and vomiting.…”