Euvolemia: Confronting an Old Challenge

1/15/2012
Euvolemia:
Confronting an Old Challenge
www.annatexasmeeting.org
Jan 27 & 28, 2012
Anne Diroll, RN CNN
Disclosure
•
This educational program is not intended to replace the
judgment or experience of the attending physician or other
medical professional.
•
The hemodialysis treatment prescription is the sole
responsibility of the attending physician.
•
Please refer to your clinic’s policies and procedures and the
manufacturer’s Instructions For Use for further information.
Consult the appropriate Operator’s Manual for detailed
descriptions, instructions, contraindications, warnings, and
precautions.
•
The clinician/operator should thoroughly read and
understand the information in the Operator’s Manual before
use.
Objectives
• Review cardio-vascular effects of
hypervolemia (too wet)
• Review cardio-renal effects of
hypovolemia (too dry)
• Discuss blood volume monitoring
• Describe the three compartmental
fluid shifts in relationship to the
Guyton Curve
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Terms
• Eu - an imagined place
or state of things in
which everything is
perfect (Greek ex:
utopia)
• vol - volume
• emia - in the blood
• IDW - ideal dry weight
• EDW - estimated dry
weight
• Normalized ECV extracellular volume
Three Compartment Model
Intracellular
Space
Extracellular
Space
Toxins
Fluid
Fluid
IntraVascular
Space
Dialyzer
Toxins
40 Liters
UF Rate
Circulating
Blood Volume
75 ml/kg
Toxins
Fluid
5 Liters
Plasma Refilling Rate
Adapted from: Guyton & Hall, Textbook of Medical Physiology, 10th ed, 2000
Why does euvolemia matter?
IV fluids, oral fluids
Sepsis,bleeding, UF,
diuresis, vomiting, diarrhea,
ascites
HYPOVOLEMIA
 Organ
dysfunction
 Adverse
outcome
Hypoperfusion
NORMOVOLEMIA
Regulation by
normal kidneys
OVERLOAD
 Organ
dysfunction
 Adverse
outcome
Edema
Adapted from: Prowle JR et al. Fluid balance and acute kidney injury, Nat. Rev. Nephrol.
22 Dec 2009; doi:10.1038/nrneph.2009.213
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Volume and ESA Therapy
Current ESA titration does not take into account BV status:
• Hypervolemia increases inflammation*
• Inflammation contributes to ESA resistance**
• Hypervolemia dilutes Hct (%) and HgB (gm/dL)
Red Cell Volume
Hct =
Total Sample Volume
Fixed Concentration at 30% requires
more Red Cells in 1 gallon (4
Liters) than in 1 quart (1 Liter)
1 Gal
30%
BVM required to minimize
Erythropoietin-Stimulating Agents
1 Qt
30%
*Pecoits-Filho R, Goncalves, Barberato SH, Bengali, LindholmB, RiellaMC, Stenvinkel P, Impact of residual renal function on
volume status in chronic renal failure. Blood Purif. 2004;22(3):285-92. Epub 2004 May 27.
** Amgen package insert
Overestimation
• Hypertension
• Stroke
• Congestive Heart
Failure
Too Wet = Fluid Overload
•
•
•
•
•
Due to under UF
Hypotension
Hypertension
CHF
Left Ventricular
Hypertrophy
• LV Dysfunction
• Cardiomyopathy
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Underestimation
• Persistent
hypotensive
episodes
• Alienating patients
from caretakers
• Affecting delivery of
prescribed dialysis
Too Dry = Over UF
•
•
•
•
•
Hypotension
Hypertension
Cramping
Nausea/Vomiting
#1 & #2 cause of
early sign-offs
• Access
complications
Cardiovascular disease in patients with
or without chronic kidney disease, 2009
Figure 4.1 (Volume 1)
December 31 point prevalent Medicare enrollees age 66 & older, with fee-for-service coverage for all of 2009. USRDS 2011
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Overall expenditures for CKD & congestive
heart failure in the Medicare population
Figure 6.7 (Volume 1)
Point prevalent Medicare patients age 65 & older. *Medicare Part D data not available for 2009. USRDS 2011.
Geographic variations in unadjusted incident rates of
congestive heart failure (per 1,000 patient years), by
state: 2007
Figure 6.3 (Volume 1; continued)
Point prevalent
Medicare patients with
CKD, age 66 & older
diagnosed with CKD in
2006.
Geographic variations in unadjusted CV mortality
rates in dialysis patients (deaths per 1,000
patient years), by HSA: 2009
Figure 4.4 (continued; Volume 2)
Period prevalent dialysis
patients; unadjusted.
USRDS 2011. (CD picked up at ASN in Philadelphia, Nov ‘11)
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Unadjusted event rates of cardiovascular diagnoses &
procedures, by dataset & CKD stage, 2007
Figure 6.2 (Volume 1)
December 31 point prevalent Medicare patients age 66 & older & Ingenix i3 patients age 20-64. Patients diagnosed with ESRD prior to January 1, 2007 or those who
changed coverage on January 1, 2007 are excluded. Patients diagnosed with CHF in 2006 are also excluded in estimating the relative risk for incident CHF in 2007.
Similar exclusion criteria for the other events or procedures. CKD defined using claims in 2006. Comorbid conditions defined in 2006 & included in the model.
MAT
(Measures Assessment
Tool)
• 494.80 Patient Assessment: …must provide
each patient with an individualized &
comprehensive assessment of needs
• 494.90 Plan of Care:…& must include
measurable & expected outcomes…Outcome
goals must be consistent with current
professionally accepted clinical practice
standards
494.90 Plan of Care
V543 - Dose of Dialysis: Volume
Management of volume status
Euvolemic and BP 130/80
V547 - Anemia
Adult & Peds Hgb on ESAs Hgb: 10-12 g/dL
Adult & Peds off ESAs
Hgb: >10 g/dL
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494.80 Patient Assessment
V504 - BP & Fluid Management
Interdialytic BP & weight gain,
Target weight
Symptoms
Value - Euvolemic & BP 130/80 (adult);
lower of 90% of normal for age/wt/ht or 130/80 (pediatrics)
V507 - Anemia
Volume
Bleeding
Infection
ESA hypo-response
Contemporary Management
• Dependent on a clinically derived
estimate of dry weight
• Leads to both overestimation and
underestimation of dry weight
Jaeger & Mehta:Assessment of Dry Weight in Hemodialysis
JASN 10:392-403,1999
An Index for Adequacy for
Fluid Management?
The current focus on Kt/V as an index for
adequacy of dialysis in terms of solute removal
ignores the contribution of volume as an
independent factor influencing outcome.
Jaeger,JQ & Mehta, RL: Assessment of Dry Weight in Hemodialysis - An Overview.
JASN 10:392-403,1999.
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“Adequate” Dialysis
50% patients continue to exhibit LVH
Non-regression is associated with persisting stiffness,
severe anemia, persistence of volume overload, BP
Vascular volume increase due to excess salt intake &
inadequate ultrafiltration - major factor in failure of LVH to
regress
Poor control of intravascular volume & persisting HTN &
aortic stiffness dominant causes of LVH
Glassock,Pecoits-Filho,Barbareto D&T Vol 39, Issue 1,pages 16-19 Published Online 14 Jan 2010
Congestive Heart Failure (CHF) and Mortality
Harnett, Foley, et al., Kidney International 1995
432 patients were followed until the end of their lives. Study showed in patients who:
Did not experience CHF:
Average ESRD treatment life of 62 months
Had experienced CHF before, but had no recurrence:
Lost 17 months
Had experienced CHF before, and had a recurrence:
Lost 33 months
Developed CHF de novo during the study:
Lost average 26 months
Therefore: ANY occurrence of CHF = MINIMUM loss of 17 MONTHS of life
No CHF
No CHF
Ave. ESRD Life:
62 months
CHF
50%
CHF de novo:
45 - 29 months
20%
- 17 mth
12%
- 17 mth
No CHF Recurrence
45 months
18%
- 33 mth
CHF Recurrence
29 months
Increased Left Ventricular Mass
LV mass > cardiac fibrosis > heart failure and
sudden cardiac death
Need new approaches to management
LVH = mortality risk
Regression of LVH = mortality
1.0g LV mass = 1% in mortality over 5 years
Glassock,Pecoits-Filho,Barbareto D&T Vol 39, Issue 1,pages 16-19 Published Online 14 Jan 2010
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Drivers of LV Mass
Small increases in extracellular volume
Clinical consequences = heart failure,
arrhythmias, dilated cardiomyopathy
Glassock,Pecoits-Filho,Barbareto D&T Vol 39, Issue 1,pages 16-19 Published Online 14 Jan 2010
Arjun D. Sinha & Rajiv Agarwal - IU Sch of Med & VA, Indianapolis,IN
The Pitfalls of the Clinical Examination in Assessing
Volume Status
Seminars in Dialysis-2009
DOI: 10.1111/j/1525-139X/2009/0087641.x
*Not all low BP is caused by hypovolemia (LVF,LVH)
*Causes of high BP besides hypervolemia
(sympathetic overactivity, arterial stiffness)
*Dissociation of volume & blood pressure
*High BP = hypervolemia misclassifies 25% of patients
*Edema - no association between presence or absence of
pedal edema & objective markers of volume status
(echo, BVM, N-terminal-proBNP)
Relative Plasma Volume Monitoring
•
•
•
•
•
•
•
RPV aids the assessment of DW - RPV slopes
responsive to probing DW
Once @ baseline
Once @ 8 weeks
145 patients
Median RPV slope <1.33%/hr
Nearly 1/2 volume overloaded
Significant reduction in SBP from flat to steep
slope
Arjun Sinha,, Robert Light, and Rajiv Agarwal
Hypertension. 2010; 55: 305-311
FDA cleared/CLIA exempt
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Daily Nocturnal Dialysis, ECHO,
BNP or NT pro-BNP, Troponin-T,
Continuous NIVM/RPV Monitoring,
Individualized Dialysate
Blood Flow
Hgb/Hct
Blood
Chamber
O2 Sat
BV∆%
Emitter
Detector
Implications of current trend toward
prescribing high dialysate sodium in HD
Hypernatric dialysate


serum sodium
sodium removal
thirst
volume overload
Hypertension
>>>>>>>
LVH CHF Stroke Death
Santos SFF,Peixoto AJ. Revisiting the Dialysate Sodium Prescription as a Tool for Better Blood Pressure and Interdialytic Weight
Gain Management in Hemodialysis Patients. Clin J Am Soc Nephrol,2008. Doi:10.2215/CJN.03360807
Dialysate Sodium & Sodium Gradient
• 1,084 clinically stable HD patients
• Dialysate sodium 136-149 mEq/L
• Mean pre-HD plasma Na 136.7 (+/- 2.9 mEq/L)
•
•
•
•
83% patients dialyzed against a positive Na gradient
Mean Na gradient 4.6 (+/- 4.4mEq/L)
Plasma Na increased in 91% patients
Mean post-HD Na 141.3 (+/- 2.5mEq/L)
Mendoza JM, Sun S, Chertow GM, Moran J, Doss S, Schiller B:
Dialysate sodium and sodium gradient in maintenance hemodialysis: a neglected sodium restriction approach?
Nephrol Dial Transplant (2011) 26: 1281-1287 doi: 10.1093/ndt/gfq807
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Dialysate Sodium & Sodium Gradient
(contd)
• Post-HD thirst
directly
correlated with
sodium
gradient
Mendoza JM, Sun S, Chertow GM, Moran J, Doss S, Schiller B:
Dialysate sodium and sodium gradient in maintenance hemodialysis: a neglected sodium restriction approach?
Nephrol Dial Transplant (2011) 26: 1281-1287 doi: 10.1093/ndt/gfq807
Dialysate Sodium & Sodium Gradient
(contd)
• Sodium
gradient
associated
with IDWG of
70 g/mEq/L
Mendoza JM, Sun S, Chertow GM, Moran J, Doss S, Schiller B:
Dialysate sodium and sodium gradient in maintenance hemodialysis: a neglected sodium restriction approach?
Nephrol Dial Transplant (2011) 26: 1281-1287 doi: 10.1093/ndt/gfq807
Objective Marker - BVM
BVM (Blood Volume Monitoring Fresenius®)
Crit Line™ (HemaMetrics)
NIVM (non-invasive vascular
monitoring - Goldstein et al)
RPV (relative plasma volume
monitoring- Agarwal et al)
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Assessment of Dry Weight by Monitoring Changes
in Blood Volume During HD Using Crit-Line
Rodriguez, H., Domenici, R., Diroll, A., and Goykhman, I. (2005). Kidney International, 68: 854–861
In the Rodriguez study, the intervention algorithm was the same. The
difference being that intervention was mandated, not voluntary.
Voluntary non-use of the information was not permitted.
Thus, 10 of the 13 patients who had DW reduced by >1kg, had a
decrease in BP. There was a mean reduction of 17 mmHg for SBP, and
a 13 mmHg for DBP. (157/81 prestudy vs. 140/68 poststudy.) In the
Reddan study, BP's remain unchanged.
Hospitalizations for fluid overload were reduced from 15 admissions in
the 12 months prior to prescriptive use of the Crit Line to 1 admission in
the 18 months following the regular prescriptive use of the Crit Line.
Relationship between Blood
Volume & Blood Pressure
Smith JJ, Kampine JP.Circulatory Physiology-the essentials. 3rd ed.1990. Williams & Wilkins, Baltimore
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Volume & Blood Pressure
Hypovolemia
Hypervolemia
• BP
• BP
• BP
• BP
(BP = Cardiac Output X Peripheral Vascular Resistance)
Sinha AD, Agarwal R: The Pitfalls of the Clinical Examination in Assessing Volume Status. Seminars in Dialysis-2009 DOI: 10.1111/j/1525139X/2009/0087641.x
Brewster & Perazella: Cardiorenal Effects of the Renin-Angiotensin-Aldosterone System, Hospital Physician, June 2004, pp. 11-20.
Diroll A, Hlebovy D: Inverse relationship between blood volume and blood pressure. Nephrol Nursing J 30:460-461, 2003.
Blood Volume Change
Smith JJ, Kampine JP.Circulatory Physiology-the essentials. 3rd ed.1990. Williams & Wilkins, Baltimore
About 10% of the total blood volume can be removed with almost no effect on
either arterial pressure or cardiac output, but greater blood loss usually
diminishes the cardiac output first, and later the pressure
(Guyton & Hall pg 254)
Impact of Loss of Blood Volume
Loss of Blood
Volume
5-10%
MAP immediate
response
Likely Result
Little change
Little change
Spontaneous
recovery
15-20%
80-90 mm Hg
Moderate
hypotension
>20%
60-80 mm Hg
Early shock
Usually reversible
Smith JJ, Kampine JP.Circulatory Physiology-the essentials. 3rd ed.1990.Williams & Wilkins, Baltimore
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Blood Pressure Mosaic
Smith & Kampine: Circulatory Physiology - the essentials 3rd edition Williams & Wilkins 1990
KDOQI Clinical Practice
Guidelines for Cardiovascular
Disease in Dialysis Patients-2009
Intradialytic Hypotension
 IDH - a decrease in systolic blood pressure by ≥20 mm Hg
or a decrease in MAP by 10 mm Hg associated with symptoms
(abdominal discomfort; yawning; sighing; nausea;
vomiting; muscle cramps; restlessness;dizziness or fainting;
and anxiety.)
Long-term effects of IDH include: volume overload due to
suboptimal ultrafiltration and use of fluid boluses for resuscitation;
LVH, with its associated morbidity and mortality;
and interdialytic hypertension.
Case Studies
 UF Goals: 5000 mL to 7000 mL
 underestimates = underfiltration = wet
 overestimates = overfiltration = DAM
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Fluid overload contributes to high BP
Note: BV∆%
Note: UF Removed
Low BV∆
-0.7%
High BP
194/106
Blood Volume Graph
BV ∆ +3%
Ending
BV∆ -4%
(A) Albumin IV Initiated
(B) Albumin IV completed
(C) UFR 1800 ml/hr
(D) UFR 2000 ml/hr
Diroll A, Hlebovy D: Inverse relationship between blood volume and blood pressure. Nephrol Nursing J 30:460-461, 2003
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Fluid overload contributes to low BP
Inverse Relationship between
Blood Volume & Blood Pressure
Date
Pre BP
BP 20-30"
Post BP
Fluid
after albumin
Removed
IV
10/21/02
91/43
76/39
93/49
10/22/02
91/31
76/21
99/18
5500 ml
4200 ml
10/23/02
96/34
80/35
93/34
4700 ml
Diroll A, Hlebovy D: Inverse relationship between blood volume and blood pressure.
Nephrology Nursing Journal 30:460-461, 2003
Increased blood volume
Overstretched
myocardium
Saline Bolus
Decrease UFR
Hypotension
Increased wall tension
Increased cardiac
O2 demand
Decreased cardiac output
Diroll A, Hlebovy D: Inverse relationship between blood volume and blood pressure. Nephrol Nursing J 30:460-461, 2003
8.6% ÷3.3hr
= 2.6%/hr
= Profile A
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BV ∆ ÷ time
12.8% ÷ 3hrs
= 4.3%/hour
= Profile B
BV∆% ÷ time
20.9 ÷ 2 = 10.4
= Profile C
Note ScvO2
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Refill: Indicator of Target Weight
BV Change (%)
10
0
-10
1
Refill = Not dry
-20
2
-30
0
1
2
Time (hours)
3
No Refill =
vascularly dry
4
20 min into treatment BP to 185/92. Refill check done. No refill. UF left
in minimum for remainder of dialysis time. Outcome: BP improves.
Patient has Residual Renal Function.Increased BP due to decreased BV.
128
185
179
156
151
146
Renin-Angiotensin-Aldosterone System
Cascade
hypovolemia
renal hypoxia
renin
angiotensin I
A.C.E.
angiotensin II
aldosterone
vasoconstriction
 BP &  pulse
(consider in patients with urine output)
Guyton & Hall, Textbook of Medical Physiology, 10th ed, 2000.
Brewster & Perazella: Cardiorenal Effects of the Renin-Angiotensin-Aldosterone System,Hospital Physician, June 2004, pp. 11-20.
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The presence of Residual Renal
Function is protective against
mortality.
Specifically, the presence of
Residual Renal Function, even at a
low level, is associated with a lower
mortality risk in hemodialysis
patients.
Shemin D, Bostom AG, Laliberty P, Dworkin LD.
Residual Renal Function and mortality risk in
hemodialysis patients.
Standards of Practice
• Achieve urine elimination pattern within
physiologic limitations
• Retain renal function
ANNA: Standards of Practice & Guidelines for
Care,2005 (pp 42,66)
Adequacy Guidelines
• Level of functioning will be
maintained or improved
ANNA: Standards of Practice &
Guidelines for Care,2005 (pp
42,66)
• Index for measuring these
parameters?
• 24-hour urine volumes?
• Trend urine output for
increases and decreases?
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Assessment of Target Weight
Blood
volume
reduction
Post
dialytic
vascular
refill
Symptoms of
hypovolemia/
post dialysis
fatigue
Dry
weight
change
Yes
No
No
No
Yes
No
Yes
Revise
up
Yes
Yes
No
Revise
down
Yes
Yes
Yes
Revise
down
No
No
No
Revise
down
Rodriguez H, Domenici R, Diroll A, Goykhman I: Assessment of dry weight by monitoring changes in blood volume during hemodialysis using
Crit-Line. Kidney International, Vol 68 (2005), pp 854-861
The influence of blood volume-controlled
ultrafiltration on hemodynamic stability
and quality of life
• BV-controlled HD increases
hemodynamic stability and ultrafiltration
capacity in a heterogenous population
of HD patients….
• Sentveld B et al. The Netherlands.
Hemodialysis International 2008; 12:39-44
References
Reddan, D., Szczech, L., Hasselblad, V. et al (2005). Intradialytic Blood Volume Monitoring in Ambulatory
Hemodialysis Patients: A Randomized Trial Journal of the American Society of Nephrology, 16:
2162–2169, 2005. doi: 10.1681/ASN.2004121053
Arjun Sinha & Rajiv Agarwal (2009). The Pitfalls of the Clinical Examination in Assessing Volume Status.
Seminars in Dialysis. DOI: 10.1111/j/1525-139X/2009/0087641.x
Pecoits-Filho R., Goncalves, S., Barberato, S. et al (2004). Impact of residual renal function on volume
status in chronic renal failure. Blood Purification, 4,22(3): 285-92. Epub 2004 May 27.
Smith JJ, Kampine JP.Circulatory Physiology-the essentials. 3rd ed.1990.Williams & Wilkins, Baltimore
Daljit, K. and Hoth,I. et al (2009). Pediatric myocardial stunning underscores the cardiac toxicity of
conventional hemodialysis treatments. Clinical Journal of American Society of Nephrology, 4: 790 –
797. doi: 10.2215/CJN.05921108.
Cordtz, J. et al (2008). Central venous oxygen saturation and thoracic admittance during dialysis: New
approaches to hemodynamic monitoring. Hemodialysis International, 12: 369-377.
Bauer, P.,,Reinhart, K. and Bauer, M. (2008). Significance of venous oximetry in the critically ill. Med
Intensiva, 32(3):134-142.
Brewster and Perazella (2004). Cardiorenal effects of the renin-angiotensin-aldosterone system, Hospital
Physician, June 2004, pp. 11-20.
Diroll, A. and Hlebovy, D. (2003). Inverse relationship between blood volume and blood pressure.
Nephrology Nursing Journal, 30: 460-461.
Rodriguez, H. et al (2005). Assessment of dry weight by monitoring changes in blood volume during
hemodialysis using Crit-Line. Kidney International, 68: 854–861.
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Fresenius Medical Care, the triangle logo, 2008 and Crit-Line are trademarks of Fresenius Medical Care Holdings, Inc.
or its affiliated companies. All other trademarks are the property of their respective owners.
P/N 101447-01 Rev 01 03/2011
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