How much weight gain is acceptable between hemodialysis cycles for ESRD patients?
There is no safe fluid removal in hemodialysis;The more fluid volume you remove the increased risk you have, the safest one is in long nocturne HD (8hours).
the risk of CV events rises beyond 10ml/h/kg during a traditional HD session of 4 hours.
see the following data;
Kidney Int. 2011 Jan;79(2):250-7. doi: 10.1038/ki.2010.383. Epub 2010 Oct 6.
Rapid fluid removal during dialysis is associated with cardiovascular morbidity and mortality.
Flythe JE1, Kimmel SE, Brunelli SM.
I try to remove < 1 liter/hour in typical patient 60-70 kg if blood pressure is not low (according to his/her inter-dialysis weight gain). However I don't think to total body water, but to "dangerous water" (i.e. pulmonary imbibition with reduced oxigen saturation by pulseoximetry). If there is not dangerous water (SO2>97%) I don't want to risk hypotension, but energic fluid removal is required if SO2 is low.
The appropriate fluid removal is highly related to the comorbid status of the patient. Complicating conditions are congestive heart failure and/or autonome diabetic neuropathy both decreasing intravasal fluid, which can be mobilised (removed). A general landmark of maximum fluid removal target is 1% of whole body fluid per hour, but this overall goal must be modified by patient status as said. There are several tools available which may guide absolute and relative (time-dependent) ultrafiltration, e.g. relative blood volume, body temperature and of course blood pressure. One of the most clinical and relevant measures is regional left ventricual wall motion abnomality, but this can only be accessed by an experimental design.
In our experience and with the wide spectrum of comorbidities in our ESRD patients under hemodialysis treatment , we always are talking about individual aproach.
Of course there plenty of parameters that must be watched before know the exactly total ultrafiltration and so average gain of weight between sessions.
First thing to do is the exact knowledge of residual urine output on that patients . Some diseases like tubulointerstittial chronic diseases ( chronic pyelonephritis , myeloma , lythiasis ......) allow for years urinary output higher than 500 ml a day .
Also th CHF or neurological effect of diabetic patients do important influence on fluid management because easier trend to overload symptoms.
One general approach is gain of weight between sessions not higher than 500 ml + urinary output a day .
There is no safe fluid removal during hemodialysis session. The amount of fluid removal depends on water status before HD, dry weight and cardiovascular condition, et al. According to an article published in Circulation, fluid removal more than 2 L may increase risk of complications and death. Of course, for patients with acute congestive heart failure, 2L could be too limited. I have met a patient who tried to have 5L removal. The result is hypotension at 1 hour after initiating HD. I our center, fluid removal over 4.1L canot be printed by the system.
Thanks for your reply
below 10cc /kg/hr UF is safe but as you said it depends on V/S
between 10 to 13cc/kg/hr it starts to influence on heart contractility so that ended to CHF.
more than 13cc/kg/hr we face to acute complications of hemodialysis plus chronic effects
fluid removal depend on the dry weight we set and remove the fluid during each dialysis session to a maximum of 10 ml/kg/hr,
in situation with gross fluid overload or pulmonary oedema we can remove larger amount of fluid by doing isolated ultrafiltration - 15 min session removing 500ml or 30 min session removing 1000ml without risk of hypotension. . iso UF has very minimal risk of hypotension as there is no dialysate passing to the dialyser and blood is very cold at room temperature leading to vasoconstriction which keeps the BP high. also blood is hyperosmolar relative to other fluid compartment during iso UF which will pull water into blood from other fluid compartment like interstitial fluid maintaing BP
EDTNA/ERCA guidelines say that by consensus the IDWG should be no more than 4% of patients dry weight or between 1.5-2.0kg. In life threatening fluid overload the safest way to remove large volumes of fluid is using iso uf as above but no more than 1000ml over half an hour with very close monitoring.
Hi Jane, your answer is excellent. Can you share the link to EDTNA/ERCA guidelines?
http://onlinelibrary.wiley.com/doi/10.1111/j.1755-6686.2003.tb00270.x/abstract
Hope this link works for you
No more than 1 l/h for and average person. More results in frequent silent myocardial stunning and cerebral microinfartcs. If patients is overhadrated, additional HD procedure should better be arranged.
Permissive hypervolemia to avoid miocardial stunning. Have you read the editorial entitled "Euvolemia in Hemodialysis Patients: A Potentially Dangerous Goal?" by Huang recently published on Seminars in dialysis ?
The 2008 Series dialysis machine has a maximum Ultrafiltration rate of 4000 ml/hr. It is rarely if ever used.
Safe rule of thumb: 10 ml/kg/hour.
Higher rate would need close monitoring and still may result in sudden drop of blood pressure..