Dry weight management mansoura 2017

1. DR. Aly Elkhodiry
Medical Consultant
CME provider
Hypertension in Dialysis patients and
Dry Weight Management

2. Topics to discuss
1.Cardiovascular risk 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
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3. 0.01
0.1
1
10
100
25 – 34 35 – 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)
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4. Traditional risk factors in CKD
Daugirdas et al., Handbook of dialysis, 4th edition
• Hypertension
• Diabetes
• Smoking
• Dyslipidaemia
• Left ventricular hypertrophy
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5. Non-traditional risk factors in 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.
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6. The clinical problem
Abboud 2010, 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
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7. Causes of emergency admission of dialysis patients
Senturanh MJA 2008

8. Halle NDT 2011
102 dialysis patients with Acute Pulmonary
Oedema
68%

9. Japan Europe USA
Congestive HF 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 physiopathology or the
mechanisms of fluid overload and
hypertension in CKD

11. Effect of salt loading on advanced CRF dogs (from Guyton…)

12. CKD1 CKD2 CKD3
Essig NDT 2008
Fluid excess starts early in CKD

13. CKD, the original sin in sodium balance

14. Summary
Sodium is the culprit 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
•Sodium and 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. https://www2.kidney.org/professionals/kdoqi/guidelines_cvd/guide12.htm
Management of Hypertension in Dialysis Patients

17. Removal of antihypertensive drugs by dialysis

18. Dry weight in Haemodialysis 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 for dry 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.’’
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1967; 120:153–167
Kidney Int 17: 571–576, 1980
Handbook of Dialysis 2007
1996; 11(Suppl 2):16–19

20. Hydration Status and Dry Weight Management
EC Fluid
Management
Blood
Pressure
Control
Dry
Weight
Fluid Management
& BP Control

21. Definitions
• Overhydration defined as excess extracellular water
• Normohydration weight (NH-weight)
NH-weight = body weight - actual overhydration
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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
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Keeping the Balance is a Challenge
Hypotensive episodes,
dizziness, fatigue
cramps …
Hypertension,
overhydration,
congestive heart failure…

23. How to assess hydration 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
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24. How to assess hydration 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
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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 assess hydration 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
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Volumestatus
Days
IDWG
overhydration
normovolemia
dialysis
treatments
Patient 1 Patient 2

27. EC Fluid Status and 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 assess hydration 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
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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 Reduction by 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 Chronic Fluid 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 Overload Is Associated With Poorer
Survival
Chazot Ch et al, Nephrol Dial Transplant 2012; 0: 1–11 ePub December 9, 2012

33. Ultrafiltration Rate and CV 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 and CV 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 of the 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,
• Correction of 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 to do with intradialytic hypertension?

38. Chazot, Nephron Clin Pract 2010

39. Intradialytic Hypertension

40. Summary:
• Patients with intradialytic 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.