Fluid and hemodynamic management in hemodialysis patients: challenges and opportunities

Abstract

Fluid volume and hemodynamic management in hemodialysis patients is an essential component of dialysis adequacy. Restoring salt and water homeostasis in hemodialysis patients has been a permanent quest by nephrologists summarized by the ‘dry weight’ probing approach. Although this clinical approach has been associated with benefits on cardiovascular outcome, it is now challenged by recent studies showing that intensity or aggressiveness to remove fluid during intermittent dialysis is associated with cardiovascular stress and potential organ damage. A more precise approach is required to improve cardiovascular outcome in this high-risk population. Fluid status assessment and monitoring rely on four components: clinical assessment, non-invasive instrumental tools (e.g., US, bioimpedance, blood volume monitoring), cardiac biomarkers (e.g. natriuretic peptides), and algorithm and sodium modeling to estimate mass transfer. Optimal management of fluid and sodium imbalance in dialysis patients consist in adjusting salt and fluid removal by dialysis (ultrafiltration, dialysate sodium) and by restricting salt intake and fluid gain between dialysis sessions. Modern technology using biosensors and feedback control tools embarked on dialysis machine, with sophisticated analytics will provide direct handling of sodium and water in a more precise and personalized way. It is envisaged in the near future that these tools will support physician decision making with high potential of improving cardiovascular outcome.

Predialysis Hyponatremia and Positive Change of Natremia Within Hemodialysis Sessions Are Strong Indicators of Poor Cardiovascular Outcome in Hemodialysis Patients

“…As a first step, a precise assessment of extracellular fluid volume status should be performed to quantify degree of fluid overload. 6 This relies on a stepwise approach consisting of searching for clinical symptoms (i.e., dyspnea, edema, hypertension, lung crackles) that may be complemented by instrumental measures (e.g., vascular refilling capacity and ultrafiltration tolerance, multifrequency bioimpedance, lung ultrasound, inferior vena cava diameter) and dosing cardiac biomarkers (i.e., brain natriuretic protein, N-terminal pro-brain natriuretic protein).…”

Dialysis-Induced Cardiovascular and Multiorgan Morbidity

“…[74][75][76] Furthermore, this response may be modulated by additional factors (e.g., age, gender, comorbidity, and medication) that may explain individual or temporal variations in hemodynamic adaptation. 77,78 Whatever the reason, the hemodynamic stress of dialysis must be considered as a potent disease modifier in an already highly vulnerable population. 79 This presents an important therapeutic dilemma, as insufficient fluid removal contributes to chronic fluid overload, which is an important risk factor for mortality in dialysis patients.…”

Effect of Hemodialysis on Diabetic Retinopathy

“…Гемодиализ Гемодиализ -метод внепочечного очищения крови при остром и хроническом нарушении функции почек. Процедура гемодиализа обеспечивает удаление из организма токсических продуктов обмена веществ и нормализацию нарушений водно-электролитного баланса [28].…”