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Dry weight management mansoura 2017
This document discusses hypertension in dialysis patients and dry weight management. It begins by outlining the cardiovascular risk of dialysis patients and defining hypertension and dry weight in this population. It then discusses various methods for assessing hydration status, such as clinical criteria, lab tests, medical devices, and blood pressure monitoring. Maintaining the proper dry weight is key to controlling hypertension and reducing mortality risk from fluid overload in dialysis patients. Intradialytic hypertension is also addressed.
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Dry weight management mansoura 2017
- 1. DR. Aly Elkhodiry MedicalConsultant CME provider Hypertension in Dialysis patients and Dry Weight Management
- 2. Topics to discuss 1.Cardiovascularrisk of dialysis patients 2.Hypertension in Dialysis patients 3.Definition of dry weight 4.Assessment of hydration status 5.Mortality and overhydration 6.Role of sodium Page 2Title, Subject, Author © Copyright, 25/11/2017
- 3. 0.01 0.1 1 10 100 25 – 3435 – 44 45 – 54 55 – 64 65 – 74 75 – 84 > 85 AnnualCVDMortality(%) Age (years) The Challenge - reducing the CV-Risk in ESRD Graph adopted from original publication: Foley 1998, AJKD, 32 (5) Supp3: S112-S119 Dialysis population (male, female, black, white) 500-fold In younger individuals the difference in mortality rate is about 500-fold higher than in general population (stratification for age, race and gender) General population (male, female, black, white) Page 3Title, Subject, Author © Copyright, 25/11/2017
- 4. Traditional risk factorsin CKD Daugirdas et al., Handbook of dialysis, 4th edition • Hypertension • Diabetes • Smoking • Dyslipidaemia • Left ventricular hypertrophy Page 4Title, Subject, Author © Copyright, 25/11/2017
- 5. Non-traditional risk factorsin CKD Daugirdas et al., Handbook of dialysis, 4th edition • Extracellular volume overload • Abnormal mineral and bone metabolism (Ca, P, PTH) • Vitamin D deficiency • Anaemia • Oxidative stress • Inflammation • Malnutrition • Thrombogenic factors • etc. Page 5Title, Subject, Author © Copyright, 25/11/2017
- 6. The clinical problem Abboud2010, N Engl J Med,362:56-65 • CKD a well known risk factor for CVD • e.g. diabetes and hypertension promote development of CKD and, together with proteinuria, are also risk factors for CVD • The risk of each cardiovascular complication in CKD like, e.g. heart failure, stroke, sudden death, increases from early to advanced ESRD. • Less than 2% of patients with CKD require RRT • In part, this low rate is explained by the increased risk of death from cardiovascular causes before reaching ESRD Page 6Title, Subject, Author © Copyright, 25/11/2017
- 7. Causes of emergencyadmission of dialysis patients Senturanh MJA 2008
- 8. Halle NDT 2011 102dialysis patients with Acute Pulmonary Oedema 68%
- 9. Japan Europe USA CongestiveHF 6% 25% 46% Hypertension 56% 73% 83% Coronary HD 19% 29% 50% …adapted from Goodkin, AJKD 2004; 44:S16 Cardio-vascular situation in DOPPS Difficult to imagine that fluid excess does not play an important part in this situation
- 10. Back to physiopathologyor the mechanisms of fluid overload and hypertension in CKD
- 11. Effect of saltloading on advanced CRF dogs (from Guyton…)
- 12. CKD1 CKD2 CKD3 EssigNDT 2008 Fluid excess starts early in CKD
- 13. CKD, the originalsin in sodium balance
- 14. Summary Sodium is theculprit for fluid accumulation and hypertension in CKD, one of the most dangerous uremic toxin Fluid accumulation is the danger #1 (short term) Vascular remodeling is the danger #2 (long term?) Positive sodium balance and vascular remodeling persist beyond fluid excess correction Lag phenomenon Charra AJKD 1998
- 15. Mechanism of HTN •Sodiumand volume overload •Sympathetic nervous system activity •Inappropriate renin secretion •Alteration in endothelinand nitric oxide •Erythropoietin therapy •Hyperparathyroidism •Other: Uremic toxins, Nocturnal hypoxemia and sleep disturbances NephrolDial Transplant. 2004 May; 19(5):1058-68 Achieving Dry Weight will control 60% of cases of HTN
- 16.
- 17. Removal of antihypertensivedrugs by dialysis
- 18. Dry weight inHaemodialysis patients • The “dry weight” is defined as the level below which further fluid removal, during the dialysis treatment, would produce hypotension, muscle cramps, nausea, and vomiting. • However, the occurrence of such symptoms depends on: how quickly fluid is removed the dialysis strategy used the predialysis volume status • concomitant drug treatment (many antihypertensive drugs impair the reflex cardiovascular adjustments to volume removal).
- 19. Different definitions fordry weight • Thomson GE et al. Arch Intern Med. ‘‘Not merely the absence of edema, but the edge of hypovolaemia which should be achieved at the end of the session, to allow the patient to gain some weight up to the next dialysis session without becoming hypertensive… the reduction of BP to hypotensive levels during UF, represented the achievement of a dry weight status.’’ • Henderson L et al. • “The lowest weight a patient can tolerate without the development of symptoms or hypotension.” • Daugirdas JT, Blake PG, Ing TS. • ‘‘The post-dialysis weight at which all or most excess body fluid has been removed, below which the patient, more often than not, will develop symptoms of hypotension.’’ • Charra B, Nephrol Dial Transplant.. ‘‘The post-dialysis weight at which the patient is and remains normotensive until the next dialysis in spite of the interdialytic fluid retention without anti-hypertensive medication.’’ Page 22Title, Subject, Author © Copyright, 25/11/2017 1967; 120:153–167 Kidney Int 17: 571–576, 1980 Handbook of Dialysis 2007 1996; 11(Suppl 2):16–19
- 20. Hydration Status andDry Weight Management EC Fluid Management Blood Pressure Control Dry Weight Fluid Management & BP Control
- 21. Definitions • Overhydration definedas excess extracellular water • Normohydration weight (NH-weight) NH-weight = body weight - actual overhydration Page 24Title, Subject, Author © Copyright, 25/11/2017 TBW - total body water ICV - intracellular volume ECV - extracellular volume OH - overhydration Dialysis Patients Healthy Subjects ICV 67% ECV 33% TBW Excess ECV Normal ICV OH Increased TBW
- 22. Fluid assessment Page 25Title,Subject, Author © Copyright, 25/11/2017 Keeping the Balance is a Challenge Hypotensive episodes, dizziness, fatigue cramps … Hypertension, overhydration, congestive heart failure…
- 23. How to assesshydration status • Clinical Criteria: presence of edema, jugular venous distension, lung râle • Lab test: Brain natriuretic peptide (BNP) • It is obvious that a patient with oedema is overhydrated • But how to quantify amount of overhydration? • Oedema may be missing, although overhydration is present • Overhydration may be overseen due to missing oedema Page 26Title, Subject, Author © Copyright, 25/11/2017
- 24. How to assesshydration status • Benefits: – easy to conduct when x-ray is at site, – excess fluid in lungs easily visible • Limitations: – not always available – radiation exposure – no quantification of overhydration – no definition of treatment target Page 27Title, Subject, Author © Copyright, 25/11/2017 Chest X-ray Charra Haemodialysis Int 2007 (11) 21-31
- 25. • Multifrequencybioimpedance spectroscopy:The Body Composition Monitor (BCM, Fresenius Medical Care, Germany) has been well validated in dialysis patients. The BCM-based treatment policy aimed at minimizing fluid overload is used to control hypertension in a dialysis setting. • Continuous recording of HCT during dialysis:Crit-Line®Monitor • Ultrasonography measurements:Inferior vena cava diameter, left atrium diameter, pulmonary congestion (comets) How to assess hydration status : Medical Devices
- 26. How to assesshydration status • Monitoring pre- and post-dialysis body weight plus interdialytic weight gain IDWG over time • IDWG and overhydration are different! • Removal of IDWG is not sufficient to achieve normohydration in overhydrated patients Page 29Title, Subject, Author © Copyright, 25/11/2017 Volumestatus Days IDWG overhydration normovolemia dialysis treatments Patient 1 Patient 2
- 27. EC Fluid Statusand Blood Pressure in HD Patients Wabel P et al, ERA-EDTA 2012 Poster NephroCare 22 European Centres 1500 Prevalent HD patients ECF HT37% hT 14% ECF nT 9% nECF HT12%
- 28. How to assesshydration status • Modified acc. Sinha and Agarwal, J Nephrol (2009) 22: 587-597 • Blood pressure monitoring: • Hypertension can be dissociated from overhydration • Overhydration might be overseen due to missing hypertension Page 31Title, Subject, Author © Copyright, 25/11/2017 Hypertension/ Dehydration Dissociation (e.g. arterial stiffness) Consider adjustment of BP lowering medication Hypotension/ Dehydration Association likely Correction hydration status increase of BP likely Hypertension/ Overhydration Association likely Correction of hydration status decrease of BP likely Hypotension/ Overhydration Dissociation (e.g. CHF) Careful correction of hyd. status increase of BP likely Hypertension present Hypertension absent Over- hydration No Over- hydration
- 29. Mortality and overhydration(OH) 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 0 12 24 36 48 60 72 CummulativeSurvival Follow-up (months) Survival Curve (Kaplan-Meier) • This study confirmed the association between hyperhydration and higher mortality on the basis of a quantitative method to estimate the hydration status. This association does not necessarily imply a causal relationship: formal clinical trials will be required to confirm the improvement in survival once the dry body weight has been adjusted according to the BCM's indications. • Graph adopted from original publication: Wizemann NDT 2009 (24) 1574-1579 Page 32Title, Subject, Author © Copyright, 25/11/2017 OH < 2.5L OH > 2.5L
- 30. Dry Weight Reductionby Additional UF Improves Blood Pressure Control Agarwall R et al. Hypertension. 2009;53:500-507 RCT hypertensive HD patients: . Additional UF (n 100) . Control medication group ( n 50) Dry-Weight Reduction in Hypertensive Hemodialysis Patients (DRIP)
- 31. Effect of ChronicFluid Overload on Mortality in HD Patients Wizemann V et al. Nephrol Dial Transplant 2009;24: 1574–1579 • Assessment of hydration status and body composition by BCM In 269 prevalent HD patients, follow up of 3.5 years • Result: Hydration status is an important and independent significant predictor of mortality in chronic HD patients
- 32. Chronic Fluid OverloadIs Associated With Poorer Survival Chazot Ch et al, Nephrol Dial Transplant 2012; 0: 1–11 ePub December 9, 2012
- 33. Ultrafiltration Rate andCV Mortality: Hemodialysis Study, an almost-7-year Randomized clinical trial of 1846 patients Flythe JE et a. Kidney Int 2011;79, 250–257
- 34. Ultrafiltration Rate andCV Mortality: UFR>13ml/h/kg is Associated with Increased CV and All-Cause Mortality Flythe JE et a. Kidney Int 2011;79, 250–257 UF rates were divided into 3 categories-less than 10 ml/h/kg, 10-13 ml/h/kg, and more than 13 ml/h/kg The highest UF group was associated with HR (compared to lowest group) of all cause and CV mortality rates of 1.59 and 1.71 respectively The 10-13 group had only a slightly higher mortality than the less than 10 group
- 35. Progressive decrease ofthe target weight by ±300-g steps Anti-hypertensive drugs tapering in several weeks Pushing the patients for low-salt diet Charra NDT 1996 The target is the normalization of high blood pressure (BP) in incident patients or in prevalent patients with BP increase
- 36. In conclusion, • Correctionof fluid volume excess is crucial for controlling hypertension (volume-dependent hypertension in ~80% of dialysis patients) and reducing cardiovascular mortality of haemodialysis patients. • Achieving the optimal dry weight is a key tool in the quest of restoring extracellular fluid balance in haemodialysis patients. • New bedside non-invasive tools such as the bioimpedance spectroscopy monitor used in this study will provide more objective information on volume status and will guide physicians in the quest for dry weight. • However, one should remember that the more sophisticated tool will not replace the clinical assessment and judgement made by an expert physician. Bernard Canaud, Nephrol Dial Transplant (2012) 27: 2140–2143
- 37. And what todo with intradialytic hypertension?
- 38. Chazot, Nephron ClinPract 2010
- 39.
- 40. Summary: • Patients withintradialytic hypertension have been found to be more chronically volume overloaded compared to other hemodialysis patients, although no causal role has been established. • Patients with intradialytic hypertension have intradialytic vascular resistance surges that likely explain the BP increase during dialysis. • Acute intradialytic changes in endothelial cell function have been proposed as etiologies for the increase in vascular resistance, although it is unclear if endothelin-1 or some other vasoconstrictive peptide is responsible. • There is an association between dialysate to serum sodium gradients and BP increase during dialysis in patients with intradialytic hypertension, although it is unclear if this is related to endothelial cell activity or acute osmolar changes • In addition to probing the dry weight of patients with intradialytic hypertension, other management strategies include lowering dialysate sodium and changing antihypertensives to include carvedilol or other poorly dialyzed antihypertensives.