Patient Safety with Fluid Removal with In-Center Hemodialysis.

Abstract

Fluid management, which is discussed in the article “Ultrafiltration Rate Levels in Hemodialysis Patients Associated with Weight-Specific Mortality Risks,”1 published in this issue of CJASN, has been an aspect of dialysis care that I believe should be the top priority for doctors to manage and has been getting much more attention this past decade. Failure to establish and maintain an appropriate dry weight can lead to serious complications. I would add that if the patient crashes because of dialysis fluid removal and they believe that the treatment itself is causing them pain, it can lead them to miss or shorten treatment or even discontinue vital care. The authors concluded that “ultrafiltration rates associated with various levels of higher mortality risk depend on body weight, but not in a 1:1 ratio, and are different in men versus women, in high–body weight older patients, and in high-vintage patients.”1 As a youth, I had both my kidneys removed as the doctors believed this could help my high BP. After my double nephrectomy, my BP remained very high, and I was hospitalized frequently for it. I was switched to peritoneal dialysis, and within weeks, my BP normalized to 100/70, and I no longer required BP medication. I found myself having to increase my fluid and sodium intake to help maintain my BP. Thankfully, because of either a working kidney transplant or effective fluid management on dialysis, I have not had high BP in decades. Ultrafiltration and fluid removal is a delicate balance, and the goal of hourly fluid ultrafiltration removal is dependent on changes in the intravascular volume. Using volume monitoring, I witnessed my body reacting differently every time I had a hemodialysis treatment, despite the fact that my ultrafiltration goal for my dry weight guestimate was consistent. I could see the difference in my tolerance level if I consumed more sodium in between treatments. It is not surprising to me that weight is a factor in ultrafiltration efficacy. People who maintain higher body weight most likely have a better appetite and may consume more salt, leading them to consume more fluids. Albumin levels would be good to study in comparison and to see if people who have normalized albumin levels tolerate ultrafiltration better. If diabetes is not properly managed, the patient's thirst affects fluid removal goals. In addition, the arbitrary dry weight number the physician sets as a guestimate for dialysis ultrafiltration could change because of hospitalization, changes in eating habits, or other health events. The use of ultrafiltration profiling, in which a predetermined rate of fluid is programmed to be removed per hour, lacks a timely feedback function showing how the patient is tolerating the volume shifts. The feedback is only apparent when the patient has symptoms either of fluid overload or crashing. The kidney community lacks education about crashing on dialysis. When you crash, it does not mean you are at a correct dry weight. The opposite is also true: If you do not have any crashing and have a smooth treatment, this does not mean you are at a correct dry weight. I have heard numerous stories of my peers losing 10–20 pounds of fluid with a functioning kidney transplant within days of surgery. I have experienced great anxiety when my ultrafiltration rate was increased, and I know my peers do as well. Again, the opposite is true: If we think it is too low, we worry about how it will limit our ability to drink fluid in between treatments. It is well documented that people on peritoneal dialysis keep their existing kidney function longer. Preserving existing kidney function plays a big role in our overall health. I was able to keep my existing kidney transplant function for a year during hemodialysis because of the fact that blood volume depletion was monitored and minimized to not dry out my kidney. Ultrafiltration rates can have serious consequences in our overall health. You cannot take too little, and you cannot take too much—you have to take the right amount. Fluid removal is a dynamic process. A sex-, weight-, and vintage patient–indexed ultrafiltration rate measure demonstrates the health disparities of patients on dialysis. However, without an understanding of albumin levels with blood volume changes, along with a patient's overall assessment, it is unclear how this measure will improve patient care or reduce mortality.