4/26/2013 Why does volume matter? Euvolemia: Hypovolemia

4/26/2013
Anne Diroll, RN, CNN
Why does volume matter?
California Dialysis Council
Long Beach, CA
April 2013
Place photo here
Euvolemia:
Confronting an Old Challenge
Hypovolemia
Normovolemia
Hypervolemia
•Sepsis
•Overfiltration
•Ascites
•N/V
•Bleeding
•Optimal balance
•Regulated by normal
kidney
•Underfiltration
•DW underestimated
Organ Dysfunction
Adverse Outcomes
“The cornerstone of critical thinking is the ability to ask questions.”
Organ Dysfunction
Adverse Outcomes
Dennis Bartels in Scientific American, March, 2013
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
Correlation Grids
V Tag
‘manage the patient’s volume status’
V504
Patient Assessment § 494.80
BP/fluid management needs
V Tag
V543
Interdialytic BP & weight gain
Target weight
Symptoms
Value – Euvolemic & BP 130/80
§ 494.90(a)(1)
Plan of Care § 494.90
Manage BP and volume status
Management of volume status
Euvolemic and BP 130/80
under the “Patient plan of care” condition
V507
Anemia
V547
Volume
Bleeding
Infection
ESA hypo-response
www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs
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
4-Compartment Fluid Model
CV Mortality Rates are High
Intravascular Volume 5L
Intracellular Volume
28L
Dialysate
Extracellular Volume 11L
Period prevalent dialysis patients; unadjusted
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.
USRDS 2011 Annual Data Report, Figure 4.3 (Volume 2)
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Hospitalization
Effects of Fluid Overload
12 days / patient year
Increased fluid
LV work
LV hypertrophy & myocardial fibrosis
RISKS
SCD
IHD
Heart Failure
Adapted from: Glassock, RJ, Pecoits-Filho, R. & Barberato, SH. Left ventricular mass in chronic
kidney disease and ESRD, Clin J Am Soc Nephrol 4: S79-S91, 2009. doi:10.2215/CJN.04860709
USRDS 2012 Annual Data Report, Figure 3.2 (Volume 2)
Factors Affecting HTN in Renal Failure
Essential
Hypertension
Na+/K+ ATPase
inhibitors
Volume-Dependent Hypertension in
Hemodialysis
ReninAngiotensinAldosterone
Volume
excess
Parathyroid
hormone/Ca2+
Endothelin,
NO, etc.
MI
Arrhythmias
Sympathetic
activity
Hypertension
85-90% HTN is
volume
dependent
Erythropoetin
Therapeutic Interventions
• Prudent diet
• Volume reduction
• Achieve dry weight
• Low sodium bath
• Ultrafiltration
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.
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
Anemia:
Achieving & Sustaining Hgb/Hct
Predialysis hypertension
•
Hypervolemia dilutes
Hgb AND Hct
•
Current ESA therapy
does not account for
volume
•
Hypervolemia
increases
inflammation
•
Inflammation contributes to ESA resistance
Interdialytic weight gain
Dry weight never achieved
Minimal weight loss
LVH on ECHO?
Antihypertensive drugs
33%
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.
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.
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Increased Hospitalizations
14.3% of Medicare
patients hospitalized are
for fluid-related
diagnosis
Costs
• Heart failure was the primary diagnosis in 83% of episodes, fluid
overload in 11%, and pulmonary edema in 6%
¾ of deaths and hospitalizations
in dialysis patients can be linked
to sudden death or CHF, which
• 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
are left ventricular in origin
Arneson, TJ, Liu, J, Qiu, Y, Gilbertson, DT, Foley, RN, Collins, AJ. Hospital treatment for fluid
overload in the medicare hemodialysis population. Clin J Am Soc Nephrol. 2010 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
Physiological Effects of Fluid Deficit
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
Causes of Death in Prevalent
Dialysis Patients, 2008-2010
• 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.
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
USRDS 2012 Annual Data Report, Figure 4.1 (Volume 2)
Loss of Residual Renal Function
hypovolemia
↑ BP & ↑ pulse
renin
Intradialytic Hypotension
(20-30% occurrence)
vasoconstriction
angiotensin I
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
aldosterone
A.C.E.
angiotensin II
Guyton & Hall, Textbook of Medical Physiology, 10th ed, 2000.
McIntyre, CW. (2009). Effects of hemodialysis on cardiac function. Kidney Int. 76(4):371-375
Brewster & Perazella: Cardiorenal Effects of the Renin-Angiotensin-Aldosterone System,Hospital
Physician, June 2004, pp. 11-20.
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4/26/2013
“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.”
Dallas QI, 2012 – Goals of Therapy
• ECV control using assistive technology
• Normalized ECV
• Prevent intradialytic hypotension and cardiac
stunning through controlled ultrafiltration
Shemin D, Bostom AG, Laliberty P,
Dworkin LD. (2001). Residual Renal
Function and mortality risk in
hemodialysis patients. Am J kidney Dis.
Jul;38(1):85-90.
Tools to Improve Safe Fluid Removal
• Reduce volume-related hospitalizations
Parker, T.F. et al. A quality initiative: Reducing rates of hospitalizations by objectively
monitoring volume removal. Nephrology News and Issues. 2013 Mar;27(3): 30-36
Quality Initiative Protocol:
Assess Two Techniques to Control ECV
Education Only Group
• Education
• 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
• Assistive
Technology
• Clinical assessment of dry
weight
Sinha, AD (2011). Why assistive Technology is needed for probing of dry weight. Blood Purification,
31: 197-202. DOI: 10.1159/000321840
• Establishment of normalized
ECV using assistive technology
Parker, T.F. et al. A quality initiative: Reducing rates of hospitalizations by objectively monitoring
volume removal. Nephrology News and Issues. 2013 Mar;27(3): 30-36
Implications of current trend toward
prescribing high dialysate sodium in HD
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
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
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4/26/2013
Dialysate Sodium & Sodium
Gradient
Thirst
• 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
• Post-HD thirst directly correlated with sodium gradient
• Mean post-HD Na+ 141.3 (+/- 2.5mEq/L)
Mendoza JM, Sun S, Chertow GM, Moran J, Doss S, Schiller B:
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?
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
Nephrol Dial Transplant (2011) 26: 1281-1287 doi: 10.1093/ndt/gfq807
Sodium Burden
Education + Assistive Technology
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?
•
< 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
Nephrol Dial Transplant (2011) 26: 1281-1287 doi: 10.1093/ndt/gfq807
Blood Pressure
Mosaic Octagon of 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 199.
Sinha AD, Agarwal R: The Pitfalls of the Clinical Examination in Assessing Volume Status. Seminars in
Dialysis-2009 DOI: 10.1111/j/1525-139X/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.
Adapted from Page, I.H., Circ Res 34:133, 1974
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4/26/2013
Hypoxia Definition
Interventions to Prevent Hypotension
Non Dialysisbased
Dialysis-based
Daily HD
Thermoregulation
O2
Therapy/Hypoxia
Avoidance
Dialysate Na of
138 mEq/L
pH/Bicarb
Slower UFR
“An inadequate supply of oxygen to tissues is called
tissue hypoxia”
Dietary Na
Reduction
Diabetes Control
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
McIntyre, CW. (2009). Effects of hemodialysis
on cardiac function. Kidney Int. 76(4):371375
Ahmad, S. (1999). Complications of
hemodialysis. In M. Knowles (Ed.), Manual of
clinical dialysis (p. 35). London: Science Press
Ltd.
Incidence
Hypoxia Causes
• Hypoxemia occurs in nearly 90% of patients during
hemodialysis, may contribute to intradialytic hypotension,
nausea, and muscle cramps
HYPOXIC
• Pulmonary
• Hypoventilation
• Pleural effusion present in 28% of pre-dialysis chest
radiographs
ANEMIC
• ↓ Hemoglobin = hypoxemia
• Dilutional d/t hypervolemia
• Soft tissue calcification was identified in 79% of patients
on hemodialysis – heart, lungs, stomach
CIRCULATORY
• ↓ Cardiac Output
• Hypovolemia
HISTOTOXIC
• Sepsis
• Toxic Substances
• 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.
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.
Case Study
Hypoxia
Anemia
Vasodilation
CP
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.
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%
-7.3%
93%
4:00
HD ended
Diroll, DD (2013). Oxygen as an adjunct to treat intra-dialytic hypotension during hemodialysis.
Manuscript submitted for publication.
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4/26/2013
Fluid-Related Hospitalizations
Hospitalized
days
(per 1000
treatments)
All-Cause Hospitalizations
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, T.F. et al. A quality initiative: Reducing rates of hospitalizations by objectively monitoring
volume removal. Nephrology News and Issues. 2013 Mar;27(3): 30-36
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, T.F. et al. A quality initiative: Reducing rates of hospitalizations by objectively monitoring
volume removal. Nephrology News and Issues. 2013 Mar;27(3): 30-36
Conclusion
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, T.F. et al. A quality initiative: Reducing rates of hospitalizations by objectively monitoring
volume removal. Nephrology News and Issues. 2013 Mar;27(3): 30-36
Adequacy: Include Blood Volume Reduction
URR =
pre BUN – post BUN
post BUN
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, T.F. et al. A quality initiative: Reducing rates of hospitalizations by objectively monitoring
volume removal. Nephrology News and Issues. 2013 Mar;27(3): 30-36
Jaeger & Mehta: Assessment of dry weight in hemodialysis. JASN, 10:392-403, 1999
Ahmad, S. (1999). Dose of hemodialysis. In M. Knowles (Ed.), Manual of clinical dialysis (p. 52).
London: Science Press Ltd.
Target BVR
1Steep
BVR =
post Hct
3-hour run, total BVR = 4.8 to 10.8%
4-hour run, total BVR = 6.4 to 14.4%
Improvements:
Target ≥ 65%
post Hct – pre Hct
slope = BVR 1.6% to 3.6% per hour
Examples:
x 100
2BP
reduction
1higher
albumin level
1higher
Hgb
x 100
1Flat
Target ≥ ???
Leypoldt, JK, Cheung, AK, Steuer, RR, Harris, DH, & Conis, JM. Determination of circulating blood
volume by continuously monitoring hematocrit during hemodialysis. JASN. 1995; 6:214-219.
Boyle, A & Sobotka, PA. Redefining the therapeutic objective in decompensated heart failure:
hemoconcentration as a surrogate for plasma refill rate. Journal of Cardiac Failure. 2006; 12(4) 247-249.
slope = BVR 0.3% to 1.1% per hour
1.72 higher hazard of mortality
1Agarwal,
R. Hypervolemia is associated with increased mortality among hemodialysis patients.
Hypertension. 2010 Jul; DOI: 10.1161/HYPERTENSIONAHA.110.154815
2Sinha, AD, Light, RP, & Agarwal, R. Relative plasma volume monitoring during hemodialysis aids the
assessment of dry weight. Hypertension. 2009 Dec. DOI:10.1161/HYPERTENSIONAHA.109.143974
7