Euvolemia: Who cares, and why?

Anne Diroll, RN, CNN
ANNA, Long Island, N
May 7th, 2014
Place photo here
Euvolemia:
Who cares, and why?
“The cornerstone of critical thinking is the ability to ask questions.”
Dennis Bartels in Scientific American, March, 2013
Upon completion of this educational activity, participants will
be able to:
* Avoid the use if high sodium dialysate to prevent an
increased risk of LVH, CHF, stroke and death.
* Use goal-directed blood volume reduction when
determining adequacy to avoid hyper- and/or hypovolemia.
* Use information other than clinical examinations to assess
volume status in dialysis patients so that euvolemia can be
achieved.
OBJECTIVES
Per diem Staff Nurse at Rocklin Dialysis (FMC clinic)
and Consultant Human Factors/Usability Testing
Minor Shareholder: XOMA, Keryx
Will not be discussing off-label or investigational use of any
pharmaceuticals or medical devices
Email: [email protected]
DISCLOSURE
Do Outcomes Vary by Profit Status?
Cohort 150,642 patients
•  For-profit
•  36% ESRD pts dischg’d
from an all-cause
•  37% higher admission rates
admit readmitted
for heart failure and volume
within 30 days
overload
•  Cause specific:
cardiovasc 37%,
all infections 34%,
•  Mortality rates higher at foraccess inf 31%
profits
•  2 LDOs control >2/3 of US
facilities
Straub BM.(2014)Do health outcomes vary by profit status of hemodialysis unit? Clin J Am Soc
Nephrol 9:1-2. doi: 10.2215/CJN.11891113
Dalrymple, LS et al.(2014) Comparison of hospital rates among for-profit and nonprofit dialysis
facilities. Clin J Am Soc Nephrol 9 (1):73-81 doi: 10.2215/CJN.04200413
The Pitfalls of the Clinical Examination in
Assessing Volume Status
•  Dissociation of volume & blood pressure
•  Not all low BP is caused by hypovolemia (LVF,LVH)
•  Causes of high BP besides hypervolemia (sympathetic
overactivity, arterial stiffness)
•  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
Sinha, AD., Agarwal, R. (2009) The Pitfalls of the Clinical Exam in Assessing Volume Status. Sem Dial.
Doi: 10.1111/j/1525-139X/2009/0087641.x
Why does volume matter?
Hypovolemia
Normovolemia
Hypervolemia
• Sepsis
• Overfiltration
• Ascites
• N/V
• Bleeding
• Optimal balance
• Regulated by normal
kidney
• Underfiltration
• DW underestimated
Organ Dysfunction
Adverse Outcomes
Organ Dysfunction
Adverse Outcomes
Adapted from: Prowle JR et al. (2009). Fluid balance and acute kidney injury, Nat. Rev. Nephrol. 6, 107-115. doi:10.1038/nrneph.2009.213
Condition for Coverage
‘manage the patient’s volume status’
§ 494.90(a)(1)
under the “Patient plan of care” condition
www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs
Correlation Grids
V Tag
V504
Patient Assessment § 494.80
BP/fluid management needs
V Tag
V543
Interdialytic BP & weight gain
Target weight
Symptoms
Value – Euvolemic & BP 130/80
V507
Anemia
Volume
Bleeding
Infection
ESA hypo-response
Plan of Care § 494.90
Manage BP and volume status
Management of volume status
Euvolemic and BP 130/80
V547
Achieve and sustain Hgb/Hct
Hgb on ESAs 10-12 g/dL
Hgb off ESAs >10 g/dL
Adapted from: Centers for Medicare & Medicaid Services – Version 1.3
Rates of a CHF diagnosis in ESRD patients
Figure 4.5 (Volume 2)
Point prevalent ESRD patients on January 1 of each year: unadjusted
USRDS 2013.
CV Mortality Rates are High
Period prevalent dialysis patients; unadjusted
USRDS 2011 Annual Data Report, Figure 4.3 (Volume 2)
Hospitalization
12 days / patient year
USRDS 2012 Annual Data Report, Figure 3.2 (Volume 2)
Increased Hospitalizations
14.3% of Medicare
patients hospitalized are
for fluid-related diagnosis
¾ of deaths and hospitalizations
in dialysis patients can be linked
to sudden death or CHF, which
are left ventricular in origin
Arneson, TJ, Liu, J, Qiu, Y, Gilbertson, DT, Foley, RN, Collins, AJ (2010). Hospital treatment for fluid
overload in the medicare hemodialysis population. Clin J Am Soc Nephrol. Jun;5(6):1054-63
Glassock, RJ, Pecoits-Filho, R. & Barberato, SH. (2009). Left ventricular mass in chronic kidney
disease and ESRD, Clin J Am Soc Nephrol 4: S79-S91. doi:10.2215/CJN.04860709
Costs
•  Heart failure was the primary diagnosis in 83% of episodes, fluid
overload in 11%, and pulmonary edema in 6%
•  25,291 patients (14.3%) of prevalent Medicare patients
experienced 41,699 care episodes over ~2 years
•  Average cost was $6,372 per episode; total costs were
approximately $266 million
Arneson, TJ, Liu, J, Qiu, Y, Gilbertson, DT, Foley, RN, Collins, AJ. (2010). Hospital treatment for fluid
overload in the medicare hemodialysis population. Clin J Am Soc Nephrol. 5(6):1054-63
4-Compartment Fluid Model
70mL/kg Adults
Extracellular Volume 11L Intracellular Volume 28L
80mL/kg Infants
80 - 90mL/kg Newborns
Dialysate Intravascular Volume 5L K+ 1-2-3-4 mEq/L
Na+ 137 to 154 mEq/L
K+ 140 mEq/L
Na+ 12 mEq/L
K+ 3.5 to 5.5 mE/L
Na+ 140 mEq/L
K+ 3.5 to 5.5 mE/L
Na+ 140 mEq/L
Adapted from Ahmad, S. (1999). Fluid Movements in relation to ultrafiltration. In M. Knowles (Ed.), Manual of clinical dialysis (p. 32).
London.Science Press Ltd.
Bonanno, FG. Hemorrhagic shock: The “physiology approach” J Emerg Trauma Shock. 2012 Oct-Dec; 5(4): 285-295 doi: 10.4103/0974-2700.102357
Effects of Fluid Overload
Increased fluid
LV work
LV hypertrophy & myocardial fibrosis
RISKS
SCD
IHD
Heart Failure
MI
Arrhythmias
Adapted from: Glassock, RJ, Pecoits-Filho, R. & Barberato, SH. (2009) Left ventricular mass in
chronic kidney disease and ESRD, Clin J Am Soc Nephrol 4: S79-S91. doi:10.2215/CJN.04860709
Cerebral edema in hemodialysis
•  Standard intermittent hemodialysis has been repeatedly shown
to increase cerebral water content in chronic dialysis patients
attending for outpatient treatment
• 
During HD water moves back across the blood brain barrier into
the cerebral extracellular tissues, where it is initially taken up by
the astrocytes and other glial cells causing cell swelling.
•  Rapid passage of bicarbonate into the plasma, with some losses
of CO2 into the dialysate, can lead to an imbalance, with the
development of a paradoxical intracellular acidosis, due to the
transport of CO2 across the blood-brain barrier, which then
exacerbates cerebral astrocyte idiogenic osmole generation
and increases water uptake by the cells.
Davenport, A. (2008) Practical guidance for dialyzing a hemodialysis patient following
acute brain injury. Hemodialysis International. 12:307–312
Factors Affecting HTN in Renal Failure
Essential
Hypertension
Volume
excess
Parathyroid
hormone/Ca2+
Endothelin,
NO, etc.
Na+/K+ ATPase
inhibitors
ReninAngiotensinAldosterone
Sympathetic
activity
Hypertension
Erythropoetin
Toxin(s)
Adapted from Ahmad, S. (1999). Pathogenic factors contributing to hypertension in renal failure.
In M. Knowles (Ed.), Manual of clinical dialysis (p. 112). London: Science Press Ltd.
Volume-Dependent Hypertension in
Hemodialysis
85-90% HTN is
volume
dependent
Therapeutic Interventions
•  Prudent diet
•  Volume reduction
•  Achieve dry weight
•  Low sodium bath
•  Ultrafiltration
Mailloux, LU, Bellucci, AG, Napolitano, B & Mossey, RT. (1994). The contribution of hypertension
to dialysis patient outcomes. ASAIO Journal. 40(2):130-137.
Antihypertensives: Hypertension &
Hypotension - The Vicious Cycle – 1994
Predialysis hypertension
Interdialytic weight gain
Dry weight never achieved
Minimal weight loss
LVH on ECHO?
Antihypertensive drugs
Normotension
Volume repletion
Dialysis-induced hypotension
(autonomic and/or V. dysfunction?)
Adapted from: Mailloux, LU, Bellucci, AG, Napolitano, B & Mossey, RT. (1994). The contribution
of hypertension to dialysis patient outcomes. ASAIO Journal. 40(2): p.134.
Anemia:
Achieving & Sustaining Hgb/Hct
• 
Hypervolemia dilutes
Hgb AND Hct
• 
Current ESA therapy
does not account for
volume
33%
• 
Hypervolemia
increases
inflammation
• 
Inflammation contributes to ESA resistance
Reyes-Bahamonde J, Raimann JG, Thijssen S, Levin NW, & Kotanko P. (2013) Fluid Overload
and Inflammation—A Vicious Cycle. Seminars in Dialysis Vol 26, No 1 (January–February) pp.
16–39 DOI: 10.1111/sdi.12024
Pecoits-Filho, R et al. (2004). Impact of residual renal function on volume status in chronic renal
failure. Blood Purif. 22(3):285-92.
Amgen Package insert.
Effects of Fluid Deficit
Over
ion &
t
a
r
t
l
i
f
a
r
Ult
sion
u
f
r
e
p
o
hyp
•  Access Complications
•  Myocardial Stunning/Cardiac Ischemia
•  Stroke risk/leukoaraiosis
•  Loss of residual renal function
•  Hypotension/Hypertension
•  Cramping/Nausea/Vomiting
•  top causes of early sign-offs
•  leads to decreased adequacy
McIntyre, CW. (2009). Effects of hemodialysis on cardiac function. Kidney Int. 76(4):371-375.
Stevens, LA, Viswanathan G, Weiner, DE. (2010). CKD and ESRD in the Elderly: Current Prevalence, Future
Projections, and Clinical Significance. Adv Chronic Kidney Dis. July ; 17(4): 293–301. doi:10.1053/j.ackd.2010.03.010
Brewster, UC, Perazella, MA. (2004). Cardiorenal effects of the renin-angiotensin-aldosterone system. Hospital
Physician. Jun;40:11-20.
Rocco, MV & Burkart, JM. (1993). Prevalence of missed treatments and early sign-offs in hemodialysis patients.
JASN. Nov:4(5):1178-1183.
Cerebral blood flow in hemodialysis patients
•  Cerebral blood flow
decreases with age.
•  Studies in healthy nonanemic
hemodialysis patients have
shown that cerebral blood
flow is either normal or
decreased, with reduced
regional cortical oxygen
supply.
•  During hemodialysis, middle
cerebral blood flow falls with
increasing ultrafiltration1
Davenport, A. (2008) Practical guidance for dialyzing a hemodialysis patient following acute
brain injury. Hemodialysis International. 12:307–312
1Stefanidis I, Bach R, Mertens PR, et al. (2005) Influence of hemodialysis on the mean blood
flow velocity in the middle cerebral artery. Clin Nephrol. 64:129–137
Myocardial Stunning and Ischemia
Increased Troponins
Silent ST Depression
• cTn1 rose significantly when measured 44 h. after
dialysis sessions complicated by IDH
• Elevated levels predict mortality
• Subclinical ischemia
• W/O plaque rupture
• First reported in 1989
• Reported as 15-40% occurrence
Intradialytic Hypotension
(20-30% occurrence)
UF Rate
Loss of Contractile Function
Cardiac Remodeling
• Dialysis-induced myocardial stunning associated
with increased rate of intradialytic and post
dialytic ventricular arrhythmias
• LVH (75% of pts on dialysis)
• Reduced arterial compliance
• Impaired microcirculation
McIntyre, CW. (2009). Effects of hemodialysis on cardiac function. Kidney Int. 76(4):371-375
Myocardial Stunning
myocardial
hibernation
myocardial
remodelling
scarring
Loss of contractile
function
Aberrant electrical conductivity
sudden
death
Zuidema, MY & Dellsperger, KC. (2012) Myocardial stunning with hemodialysis: Clinical
challenges of the cardiorenal patient. Cardiorenal Med. May 2012; 2(2): 125-133
Hothi, DK et al. (2009) Pediatric myocardial stunning underscores the cardiac toxicity of
conventional dialysis treatments. Clin J Am Soc Nephrol 4: 790-797.
Probability of sudden cardiac death in
2010 incident dialysis patients, by race
Figure 4.10 (Volume 2)
Incident dialysis patients; simple method.
USRDS 2013
Current Treatment
êBP
éBP
•  Normal Saline1
•  Clonidine
•  Decrease UFR
•  Increase UFR
•  Trendellenberg2
•  Broth, pickles3
y,
Nanc
RN
1Standing
2Shem,
orders. LDOs
Samuel. (1978) House of God. Random House, New York
3Anonymous
Clinic, somewhere in America…
Dallas QI, 2012 – Goals of Therapy
•  ECV control using assistive technology
•  Normalized ECV
•  Prevent intradialytic hypotension and cardiac
stunning through controlled ultrafiltration
•  Reduce volume-related hospitalizations
Parker III, T.F. et al. (2013) A quality initiative: Reducing rates of hospitalizations by objectively
monitoring volume removal. Nephrology News and Issues. Mar;27(3): 30-36
Tools to Improve Safe Fluid Removal
•  Education
H.D.
urea
•  Assistive
Technology
Sinha, AD (2011). Why assistive Technology is needed for probing of dry weight. Blood Purification,
31: 197-202. DOI: 10.1159/000321840
Quality Initiative Protocol:
Assess Two Techniques to Control ECV
Education Only Group
•  Eight (8) facilities
Education and Intervention
Group
•  Seven (7) facilities
•  Educational program for
physicians, staff, and patients
•  Show necessity for volume
control
•  Oxygen saturation
•  Control intradialytic ECV to
gain optimal volume removal
and prevent symptoms
•  Salt restriction
•  Clinical assessment of dry
weight
•  Establishment of normalized
ECV using assistive technology
Parker III, T.F. et al. (2013) A quality initiative: Reducing rates of hospitalizations by objectively
monitoring volume removal. Nephrology News and Issues. Mar;27(3): 30-36
Education
• 
Fluid assessment and the importance of proper fluid management
• 
All Physicians, Dieticians, RNs
• 
Extra Tx for fluid removal prn
• 
4-hour Tx time
• 
Update Med lists
• 
Dialysate T 36° C
• 
Max UFR of 13 mL/Kg/hour
• 
• 
• 
No sodium modeling
Dialysate sodium 138 mEq/L
Focused review of sodium content in food
Cool Dialysate
•  Most patients benefited from cold
dialysate (34.5°C) for prevention of
hypoxia1
•  Dialysate temp 36.4 to 35.8°C
adjusted by blood temperature
monitor.
•  Patients had less symptomatic
hypotension, nausea, infusions and
meds for morbid events2 1 Hegbrant
J et al (1997). Beneficial effect of cold dialysate for the prevention of hemodialysisinduced hypoxia. Blood Purification, 15(1):15-24.
2 Veljančić, L., et al. (2011) Simultaneous blood temperature control and blood volume control
reduces intradialytic symptoms. Int J Artif Organs 2011; 34(4): 357-364
Individualized Dialysate Temperature:
Compare LV regional wall motion abnormalities
with ECHOs pre-HD, 2h, 4h (peak stress) and 30” into recovery
Standard 37°C
•  Pre-dialysis temp 36.1
(±0.6)°C
•  CO & Total Peripheral
Resistance did not change
•  Mean number of regional
wall motion abnormalities
per patient at peak stress
significantly higher
Individualized
•  Pre-dialysis temp 36.0
(±0.5)°C
•  Mean intradialytic BP higher
•  CO decreased and Total
Peripheral Resistance
increased
Dialyzing patients at their body temperature seems to be effective,
simple and cost-free.
Jeffries, HJ., Burton, JO., McIntyre, CW. (2011) Individualized Dialysate Temperature Improves Intradialytic Haemodynamics and
Abrogates Haemodialysis-Induced Myocardial Stunning, without Compromising Tolerability. Blood Purif 2011; 32: 63-68
Implications of current trend toward
prescribing high dialysate sodium in HD
HYPERNATRIC DIALYSATE
Decreased sodium
removal
Increased serum
sodium
Volume
overload
Increased
thirst
Hypertension
LVH, CHF, Stroke,
Death
Santos, SFF & Peixoto, AJ. (2008). 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. 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. (2011)
Dialysate sodium and sodium gradient in maintenance hemodialysis: a neglected sodium
restriction approach?
Nephrol Dial Transplant 26: 1281-1287 doi: 10.1093/ndt/gfq807
Thirst
•  Post-HD thirst directly correlated with sodium gradient
Mendoza JM, Sun S, Chertow GM, Moran J, Doss S, Schiller B (2011)
Dialysate sodium and sodium gradient in maintenance hemodialysis: a neglected sodium
restriction approach?
Nephrol Dial Transplant 26: 1281-1287 doi: 10.1093/ndt/gfq807
Sodium Burden
Mendoza JM, Sun S, Chertow GM, Moran J, Doss S, Schiller B. (2011)
Dialysate sodium and sodium gradient in maintenance hemodialysis: a neglected sodium
restriction approach?
Nephrol Dial Transplant 26: 1281-1287 doi: 10.1093/ndt/gfq807
Intrinsic Causes of Hypotension
•  Diabetic hypotonia due autonomic dysfunction, neuropathy, hypoglycemia
•  Uremia – independent risk factor for autonomic dysfunction
•  CV disease – atherosclerosis, CAD, LVH, arrhythmias, valvular disease, pericardial
disease, cardiac underfilling
•  Sepsis
•  GI bleed
•  Hypoalbunemia2
•  Anemia2
•  Chronic inflammation3
•  Vaso-active substances:
• 
i)Nitric Oxide high levels = rapid vasodilation;
•  ii) Adenosine released during tissue ischemia – hypoxia. Dialysis patients have
high adenosine levels. Adenosine suppresses cardiac contractility, causes artery
relaxation.
Sulowicz, W., Radziszewski, A. (2006) Pathogenesis and treatment of dialysis hypotension. Kidney International 70,S36-S39
2KDOQI Clinical Practice Guidelines for Cardiovascular Disease in Dialysis Patients. Section III. © 2005 NKF
3Sklar et al 1999 Am J Kidney Dis 34: 464-470
Treatment for Hypotension
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
Fluids: Normal Saline, mannitol, albumin
Trendellenberg
Limit interdialytic weight gain
No eating just before and during dialysis
No overdosing of anti-hypertensives
Cool dialysate
Isothermic – BTM – modifies dialysate temperature
Midodrine
Serotonin Reuptake Inhibitors
FK352 – adenosine α1 receptor antagonist
L-arginine supplements
Carnitine – because deficiency leads to ESA-resistance and
hypotonia
Oxygen
Blood Volume Monitoring
• 
Bioimpedance
• 
Short, daily hemodialysis
Sulowicz, W., Radziszewski, A. (2006) Pathogenesis and treatment of dialysis hypotension. Kidney International 70,S36-S39
Fluid to treat BP
• Asymptomatic
• Low BP
FLUID
FLUID
OVERLOAD
• Due to valvular or
myocardial
pathology
• Ventricles have
decreased functional
reserve
• Low cardiac output
• Cardiac Failure
• Treatment of one
condition worsens the
other
• Gut edema
CIRCULATORY
SHOCK
Bonanno, FG. (2012). Hemorrhagic shock: The “physiology approach”. J Emerg Trauma Shock. Oct-Dec; 5(4): 285-295 doi: 10.4103/0974-2700.102357
Education + Assistive Technology
• 
< 3% per hour volume reduction = increase UF goal by 200 mL per Tx
• 
3 - 8% per hour volume reduction (not to exceed 15% total) = No
change
• 
> 8% per hour volume reduction = decrease UF goal
• 
Oxygen supplementation for SaO2 of < 90% or SvO2 of < 60%
• 
Refill Assessment: If refill is present, add 200 mL to UF goal next Tx
Hypoxia Definition
“An inadequate supply of oxygen to tissues is called
tissue hypoxia”
West, JB (1985). Gas transport to the periphery. In TM Tracy (Ed.), Respiratory physiology-­‐the essentials. p. 83. Baltimore, MD: Williams & Wilkins Glennie, JA. (2013) Architecture student. UT, Austin,TX. Art used with permission Incidence
•  Hypoxemia occurs in nearly 90% of patients during
hemodialysis, may contribute to intradialytic hypotension,
nausea, and muscle cramps
•  Pleural effusion present in 28% of pre-dialysis chest
radiographs
•  Soft tissue calcification was identified in 79% of patients
on hemodialysis – heart, lungs, stomach
•  Functional pulmonary changes
•  Sleep apnea 60% ESRD patients, contributing to
arrhythmias and pulmonary HTN
Gheuens, E.O., Daelemans, R., & De Broe, M.E. (2000). Pulmonary problems in hemodialysis and
peritoneal dialysis. In N. Lameire & R.L. Mehta (Eds.), Complications of dialysis (pp. 485-491). New
York, NY: Marcel Dekker, Inc.
Hypoxia Causes
HYPOXIC
• Pulmonary
• Hypoventilation
ANEMIC
• ↓ Hemoglobin = hypoxemia
• Dilutional d/t hypervolemia
CIRCULATORY
HISTOTOXIC
• ↓ Cardiac Output
• Hypovolemia
• Sepsis
• Toxic Substances
Guyton, AC & Hall, JE (2000). Respiratory insufficiency – pathophysiology, diagnosis, oxygen therapy. In A Norwitz
(Ed.), Textbook of medical physiology (pp. 490-491). Philadelphia, PA: Saunders.
West, JB (1985). Gas transport to the periphery. In TM Tracy (Ed.), Respiratory physiology-the essentials (p. 83).
Baltimore, MD: Williams & Wilkins.
Hypoxia
Anemia
CP
Vasodilation
Complications
Volume
Overload
Hypotension
Saline Bolus
↓ UFR
Thorn, C.E., Kyte, H., Slaff, D.W. & Shore, A.C. (2011). An association between vasomotion and oxygen
extraction. American Journal of Physiology Heart and Circulatory Physiology, 301(2): H442-H449.
Gheuens, EO et al (2000). Pulmonary problems in hemodialysis and peritoneal dialysis. In N. Lameire &
R.L. Mehta (Eds.), Complications of dialysis (pp. 485-491). NY, NY: Marcel Dekker, Inc.
Diroll, DD (2013). Oxygen as an adjunct to treat intra-dialytic hypotension during hemodialysis.
Manuscript submitted for publication.
Case Study
Monitor-Guided Interventions
Elapsed Time Blood Pressure Pulse BV ∆ Oxygen
Saturation Intervention 0:00 112/63 61 0.0% 82.3% HD commenced 0:30 86/46 62 -2.0% 85% O2 @ 2L per nasal cannula 0:40 97/51 62 -0.5% (refill) 94% UF Goal increased from 3.0L to 4.9L 1:00 108/51 65 -1.5% 94% 1:15 118/56 66 -2.0% 94% 1:30 140/72 69 -2.0% 95% 2:00 136/78 70 -2.5% 94% 2:30 125/64 71 -4.5% 90% 3:00 137/74 71 -5.0% 93% 3:30 125/68 72 -7.3% 92% 4:00 -7.3% 93% HD ended Diroll, DD (2013). Oxygen as an adjunct to treat intra-dialytic hypotension during hemodialysis.
Manuscript submitted for publication.
SvO2 Monitoring is a big deal…
…because it allows rapid
detection of impaired oxygen
delivery…
Cardiac Output is a big
deal because…
BP = CO X SVR
such as from decreased
Cardiac Output
Hemodynamic Monitoring made Incredibly Visual (2006): Lippincott Williams & Wilkins. Ch 7 Cardiac
Output Monitoring. Pg 112.
ScvO2 predicts hypotension
Normal ScvO2 ≈ 75%
Range ≈ 60 to 80%
A drop of 5 to 7 % points from patient’s
baseline is significant1
Cardiac Output = O2 uptake/SaO2 – ScvO2
∴↓ScvO2 = ↓CO = ↓BP (BP = CO X PVR)
Caveat: ScvO2 decreases with movement,
fever, seizures, and suctioning. Patient should
be calm and still when you evaluate ScvO2 in
relation to BP.
Hothi, DK., et al (2009) Pediatric Myocardial Stunning Underscores the Cardiac Toxicity of Conventional Hemodialysis Treatments Clin J Am Soc
Nephrol 4: 790 –797. doi: 10.2215/CJN.05921108.
1Cordtz 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, Bauer M (2008). Significance of venous oximetry in the critically ill. Med Intensiva.;32(3):134-42
Fluid-Related Hospitalizations
Hospitalized
days
(per 1000
treatments)
Hospitalized
days
(per patientyear)
Hospitalizations
(per 1000
treatments)
Hospitalizations
(per patientyear)
Before
After
Before
After
Before
After
Before
After
Education
& Assistive
Technology
1.02
0.53
0.16
0.08
4.17
1.83
0.65
0.29
Education
Only
0.99
1.04
0.15
0.16
4.5
5.54
0.70
0.86
Parker III, T.F. et al.(2013) A quality initiative: Reducing rates of hospitalizations by objectively
monitoring volume removal. Nephrology News and Issues. Mar;27(3): 30-36
All-Cause Hospitalizations
Hospitalized
days
(per 1000
treatments)
Hospitalized
days
(per patientyear)
Hospitalizations
(per 1000
treatments)
Hospitalizations
(per patientyear)
Before
After
Before
After
Before
After
Before
After
Education
& Assistive
Technology
13.87
10.45
2.16
1.63
72.68
64.26
11.34
10.03
Education
11.09
10.68
1.73
1.67
66.35
66.38
10.35
10.35
Parker III, T.F. et al.(2013) A quality initiative: Reducing rates of hospitalizations by objectively
monitoring volume removal. Nephrology News and Issues. Mar;27(3): 30-36
Results
•  Results suggest substantial reduction in ECV-related
hospitalizations using objective monitoring of ECV removal and
attainment of “normalized ECV” versus education only
intervention
•  Statistically significant for all-cause hospitalizations
•  Approaching statistical significance for fluid-related events and
fluid-related hospitalized days
•  Conventional education and assessment of “dry weight”, in this
study, does not appear to be effective
Parker III, T.F. et al. (2013) A quality initiative: Reducing rates of hospitalizations by objectively
monitoring volume removal. Nephrology News and Issues. Mar;27(3): 30-36
Conclusion
1.  Move from a Kt/V model to a Kt/V + volume removal prescriptive
model
2.  Contemporary management, which is dependent on a clinically
derived estimate of dry weight, leads to both an overestimation and
underestimation of dry weight
3.  Future work should focus on the impact of uremic toxin clearance
and volume control as critical components of the measurement of
dose of dialysis
Parker III, T.F. et al. (2013) A quality initiative: Reducing rates of hospitalizations by objectively
monitoring volume removal. Nephrology News and Issues. Mar;27(3): 30-36
Jaeger & Mehta (1999): Assessment of dry weight in hemodialysis. JASN, 10:392-403,
Ahmad, S. (1999). Dose of hemodialysis. In M. Knowles (Ed.), Manual of clinical dialysis (p. 52).
London: Science Press Ltd.
What’s good for the heart is good for the
brain – assistive technology
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
Continuous O2 sat monitoring
Evaluate ScvO2
Hypoxia Avoidance
BVM to set accurate DW
Revascularization – PTCA, stents, CABG
More frequent HD
Convert to PD
Cool dialysate
Thermoregulaltion
Dialysate magnesium manipulation
Individualized Sodium Dialysate
Sinha, AD (2011). Why assistive Technology is needed for probing of dry weight. Blood Purification,
31: 197-202. DOI: 10.1159/000321840
McIntyre, CW. (2009) Effects of hemodialysis on cardiac function. Kidney Int. 76(4):371-375
Cordtz J., et al (2008) Central venous oxygen saturation and thoracic admittance during dialysis:
New approaches to hemodynamic monitoring. Hemodialysis International; 12:369-377
If we have time…
Discuss the dissociation between pressure and volume
ADDITIONAL OBJECTIVE
Pressure and volume distribution in the systemic circulation. Note the inverse relationship
between internal pressure and volume in different portions of the circulatory system
Smith JJ, Kampine JP.(1990) Circulatory Physiology-the essentials. 3rd ed. Ch 1. Blood and the Circulation. Page 10. Williams & Wilkins, Baltimore
Change in BV does not mirror
intradialytic changes in BP
•  72 stable adult outpatients
•  BV measurement was 91.6% (+/- 0.6)
•  BV measurement had no relationship with pre-, intraor postdialysis blood pressure recordings
•  Did correlate with a postdialysis change in
extracellular fluid volume
Booth J, Pinney J, Davenport A: Do changes in relative blood volume monitoring correlate to hemodialysis-associated
hypotension? Nephron Clin Pract. 2011;117(3):c179-83. doi: 10.1159/000320196. Epub 2010 Aug 30
Plasma Volume (PV) & BP
Design
Conclusions
•  60 non-diabetics
•  Relationship between BP &
volume not linear
•  Excluded if Plasma Refill Rate
•  Could not find correlation
affected (cardiac)
between Δ in BW & SBP
•  Hypertensive (n=26) ΔPV%
•  No correlation between
12.9 (±7.3)
intradialytic Δ in PV, BW &
•  Normotensive (n=34)ΔPV%
alterations of SBP or DBP
12.5 (±6.6)
during HD
Khalaj,A-R., Sanavi, S., Afshar, R., Rajabi, M-R (2010) Effect of Intradialytic Change in Plasma
Volume on Blood Pressure in Patients Undergoing Maintenance Hemodialysis.J Lam Physicians. JulDec; 2(2): 66-69. doi: 10.4103/0974-2727.72151
Non-invasive monitoring of
hemodynamic variables
•  Impedance cardiography
(IPG-104 Mini-Lab®)
•  EKG lead I
•  MAP – cuff sphygmanometer
•  BVM (Crit Line®)
•  CO calculated
(SV X HR)
•  Degree hypovolemia
seems not to play a key
role in the origin of acute
intradialytic hypotensive
episodes
•  SVR calculated(MAP/CO)*80
Straver, B. (2005) Hypotension during hemodialysis. © B.Straver, Amsterdam, the Netherlands. ISBN
90 6464 5 51 5. Ch 2. Systemic Vascular Resistance in intradialytic hypotension determined by
means of impedance cardiography.
34% hypotensive episodes in PICU
No difference between BVM & Control Groups
•  Hypotension 33% in BVM group
•  Hypotension 36% in control
group
Body Weight
36 Kg
(10-85)
Median age
11 yo
(1.8 to 18)
•  Mean UF significantly higher in
BVM group 48 vs. 33 mL/kg
•  Mean decrease in BV did not
exceed 13% over entire session
in patients without hypotension
•  The use of BVM allowed a higher
UF rate without influencing the
frequency of hypotensive
episodes
AKI
70 patients
with
Blood Volume
Monitoring
(BP+HR+BVM)
64 patients
without
Blood Volume
Monitoring
(BP+HR)
Merouani, A., et al. (2011) impact of blood volume monitoring on fluid removal during intermittent
hemodialysis in critically ill children with acute kidney injury. Nephrol Dial Transplant (2011) 26:
3315-3319 doi: 10.1093/ndt/gfq855
Blood Volume Monitoring
•  Does it reduce episodes of IDH? Does it predict IDH?
•  No!1
•  IDH occurs when cardiovascular compensatory mechanisms can
no longer compensate for the reduction in blood volume
•  Yes!2
•  By means of continuous and automatic control of BV, it is possible
to reduce the incidence of hypotension during hemodialysis in
patients suffering from this disorder2
1Micklos,
L. Does Blood Volume Monitoring Use Decrease Episodes of Intradialytic Hypotension in Chronic Hemodialysis Patients? (2013)
Neph Nurs J Sept-Oct Vol.40, No.5
2Santoro,
A., et al, (2002) Blood volume controlled hemodialysis in hypotension-prone patients: A randomized, multicenter controlled trial.
KI 62, 1034–1045; doi:10.1046/j.1523-1755.2002.00511.x
Dasselaar, JJ., Huisman, RM., de Jong, PE., Franssen, CFM. (2005) Measurement of relative blood volume changes during hemodialysis: 59
Merits and limitations. NDT 20, 2043-2049
Central Venous Pressure
•  Review - very poor relationship between CVP and
blood volume as well as inability of CVP/CVP to
predict hemodynamic response to a fluid
challenge.
•  CVP is a measure of right atrial pressure alone; and
not a measure of blood volume or ventricular
preload.
•  CVP should not be used to make clinical decisions
regarding fluid management
Marik, PE., Baram, M., Vahid, B.: (2008) Does Central Venous Pressure Predict Fluid
Responsiveness? CHEST; 134:172–178)
No correlation observed between drop in
Blood Volume and drop in MAP
Drop in Stroke Volume
•  ΔCO had a strong significant
correlation with ΔMAP
Fall in Systemic Vascular
Resistance
•  Severe inappropriate
vasodialtion
•  Decrease in sympathetic tone
during HD
•  Nitric Oxide release
3 groups – Non-H/SVR-H/SV-H. No differences in tissue hydration. ΔBV not a
statistically significant determinant of BP, while ΔSV was. Intra-individual
reproducibility of cause of IDH clear in 70% of hemodialysis patients.
Straver, B. (2005) Hypotension during hemodialysis. © B.Straver, Amsterdam, The Netherlands. ISBN
90 6464 5 51 5. Ch 3. A new classification of intradialytic hypotension. Ch 4. Clinical reproducibility
of intradialytic hypotension characteristics.
CfC
TAG NUMBER: V504
REGULATION: Blood pressure, and fluid management needs.
INTERPRETIVE GUIDANCE
•  Because of the adverse effects of ESRD, many patients experience
lability of blood pressure and fluid management, the management
of which may require reassessment of medication needs,
adjustments in target weight, and changes to the POC.
•  The comprehensive assessment should include evaluation of the
patient’s pre/intra/post and interdialytic blood pressures,
interdialytic weight gains, target weight, and related intradialytic
symptoms (e.g., hypertension, hypotension, muscular cramping)
along with an analysis for potential root causes.
•  For pediatric patients weighing less than 35 kg., blood volume
monitoring during hemodialysis should be available in order to
evaluate body weight changes for gains in muscle weight vs. fluid
overload.
(pg
189 of 299. October 2008) www.cms.gov/Medicare/Provider-Enrollment-and-Certification/
SurveyCertificationGeninfo/downloads//SCletter09-01.pdf
Blood Pressure
BP = Cardiac Output X Peripheral Vascular Resistance
Hypervolemia =
BP or
BP
Hypovolemia =
BP or
BP
Smith & Kampine: Circulatory Physiology - the essentials 3rd edition Williams & Wilkins 1990.
Sinha AD, Agarwal R (2009) The Pitfalls of the Clinical Examination in Assessing Volume Status. Seminars in
Dialysis DOI: 10.1111/j/1525-139X/2009/0087641.x
Brewster, UC, Perazella, MA (2004) Cardiorenal Effects of the Renin-Angiotensin-Aldosterone System,
Hospital Physician, June, pp. 11-20.
Diroll A, Hlebovy D (2003) Inverse relationship between blood volume and blood pressure. Nephrol
Nursing J 30:460-461,
Mosaic Octagon of Blood Pressure
Adapted from Page, I.H., Circ Res 34:133, 1974
Interventions to Prevent Hypotension
Dialysis-based
Daily HD
Thermoregulation
O2 Therapy/
Hypoxia
Avoidance
Dialysate Na+ of
138 mEq/L
pH/Bicarb
Slower UFR
Non Dialysisbased
Dietary Na+
Reduction
Diabetes Control
McIntyre, CW. (2009). Effects of hemodialysis
on cardiac function. Kidney Int. 76(4):
371-375
Ahmad, S. (1999). Complications of
hemodialysis. In M. Knowles (Ed.), Manual of
clinical dialysis (p. 35). London: Science Press
Ltd.
Quotable quotes
•  There are no randomized controlled trials among patients on
conventional hemodialysis to help identify goal BP targets
•  Much uncertainty remains regarding the ideal BP to improve
outcomes among patients on 3X/week conventional
hemodialysis
•  CMS bases dialysis adequacy solely on urea removal. Factors
such as BP control, attainment of euvolemia, and ensuring
isonatric dialysis are not captured nor incentivized.
Inrig, JK.(2013) Peridialytic hypertension and hypotension: another U-shaped BP-outcome
association. KI 84, 641-644. doi:10.1038/ki.2013.247
?Target BVR
1Steep
slope = BVR 1.6% to 3.6% per hour
Examples:
3-hour run, total BVR = 4.8 to 10.8%
4-hour run, total BVR = 6.4 to 14.4%
Improvements:
1Flat
1Agarwal,
2BP
reduction
1higher
albumin level
1higher
Hgb
slope = BVR 0.3% to 1.1% per hour
1.72 higher hazard of mortality
R. (2010) Hypervolemia is associated with increased mortality among hemodialysis patients.
Hypertension. Jul; DOI: 10.1161/HYPERTENSIONAHA.110.154815
2Sinha, AD, Light, RP, & Agarwal, R.(2009) Relative plasma volume monitoring during hemodialysis aids
the assessment of dry weight. Hypertension. Dec. DOI:10.1161/HYPERTENSIONAHA.109.143974
The End!
Content
Anne Diroll,
Formatting & Graphics
Daniel Diroll,
RN, CNN
BS (Phys Ed)
MA (Kinesiology)
BSN, RN