Donna Bednarski,

1
Give Fluid The BOOT!

• Donna Bednarski,
• MSN, RN, ANP-BC, CNN

2
What do we know?

• Kidneys play a critical role in maintaining the
  effective circulating volume and plasma
  osmolality of the body within narrow limits
• Under normal circumstances, kidneys can adjust to
  variations in dietary intake by appropriate
  variations in water and electrolyte excretion

3
What do we know?

• Hypervolemia is the most common cause of
  hypertension (htn), LV hypertrophy, and CVD
  effecting the mortality rate
• Hypovolemia can cause intradialytic morbidities,
  ischemia, loss of residual kidney function, and
  increased mortality rate

4
What do we know?

• Body water represents approx 55 60 of total
  body weight in young, lean adults.
• Water content of fat is less than that of lean
  body mass
• Body water is divided into two major
  compartments
• Extracellular accounts for 1/3 total body water
• Intracellular accounts for 2/3 total body water
• Interstitial fluid (fluid in between cells)
• Intravascular fluid
• Lymph
• Transcellular fluid (fluid in joints, peritoneal,
  pleural cavities, etc)
• Fluid shifts occurs often between compartments
  through the semipermeable membranes that separate
  them depending on both fluid and electrolyte
  status

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Assessment Parameters

• If a patient is volume overloaded consider
• Too much sodium intake
• Too much fluid intake
• Too little sodium or water removal
• New or exacerbated co-morbid condition

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Identification of Patients at Risk for Fluid
Overload

• Change in body mass
• Non-adherence to prescribed treatment regimen
• Barriers to self management
• Hypertension
• Ischemic heart disease
• Acute myocarditis or infective endocarditis
• Valvular heart disease
• Acute arrhythmias

7
Identification of Patients at Risk for Fluid
Overload

• High output failure from shunting via vascular
  access
• Pulmonary embolism
• Infections and/or fever
• Autonomic neuropathy
• Anemia
• Carnitine deficiency
• Amyloidosis
• Thyrotoxicosis

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Assessment Subjective

• Past and current medical history
• Family history of CV disease
• Life style habits cigarette smoking, alcohol
  consumption, exercise frequency

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Assessment Subjective

• Prescribed medication regimen
• Adherence?
• OTC medication utilization
• Practice patterns?
• Taking antihypertensives before or after dialysis

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Assessment Subjective

• Change in medication that may be nephrotoxic?
• Assess for medications that may stimulate thirst
  or fluid retention
• Calcium channel blockers, clinidine, other
  vasodilator meds, e.g. narcotics, analgesics,
  beta blockers

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Assessment Subjective

• Recent hospitalizations?
• Intake and output
• Decrease in urine volume?
• Change in intake?
• Adherence?
• Other S S Dyspnea, SOB, fatigue, edema, chest
  pain, palpitations

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Assess Knowledge

• Diet and fluid management
• Fluid intake
• Sodium restrictions
• Glucose management
• Intradialytic weight gains
• S S of hyper and hypovolemia
• Medication regimen

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Assessment Objective

• VS
• Temperature febrile/afebrile?
• BP hypertensive, hypotensive, orthostatic
  hypotension?
• Htn
• exacerbation of htn can depress ventricular
  function
• Primary cause of HF in many patients
• Increases hemodynamic load on the failing
  ventricle in pts with established HF

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Assessment Objective

• VS
• HR Apical and peripheral pulses for quality,
  rate, rhythm
• RR Rate and quality
• Pulse Ox, is needed

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Assessment Objective

• Wt
• Trends
• Intradialytic weight gains?
• Evidence of body mass change?

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Assessment Objective

• Cardiovascular (CV)
• JVD / neck vein distention
• Skin Turgor
• Mucous membranes

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Assessment Objective

• Cardiovascular (CV)
• Presence of edema
• Palpable swelling produced by expansion of the
  interstitial fluid volume
• Can be associated with HF, cirrhosis, nephrotic
  syndrome, venous and lymphatic disease

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Assessment Objective

• Presence of Edema - Location
• Peripheral only related to kidney disease, local
  venous disease, or heart failure (HF)
• Left sided HF present with pulmonary congestion
• Right sided HF present with peripheral edema
• Cardiomyopathy usually have equivalent
  involvement of both right and left ventricles
• Remember bed bound patients!

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Assessment Objective

• Cardiovascular (CV)
• Heart Sounds
• S1
• S2
• Murmurs / change in murmurs

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Assessment Objective

• Heart Sounds
• S3 related to early ventricular filling, low
  pitched, heard best with the bell at apex.
• Normal in children/young adults
• gt35 may indicate LV failure or volume overload
• First clinical sign of CHF
• S4 related to late ventricular filling, Low
  pitched, head best with bell at apex.
• Reflects atrial contraction into a noncompliant
  ventricle
• Can be heard in AS, hypertension, hypertrophic
  cardiomyopathy and CAD

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Assessment Objective

• Respiratory
• Lung Sounds
• Can reveal subtle physiologic changes
• Listen for crackles not cleared by coughing
• Often heard in the right and left lung base and
  correlate well with early left sided HR

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Assessment Hemodialysis

• Delivered dose of hemodialysis falls below target
  level evaluate for
• Laboratory or blood sampling errors
• Sampling methods
• Timing of sampling
• Laboratory error

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Assessment Hemodialysis

• 2. Compromised urea clearances
• Vascular access
• Blood flow rate inadequate
• Access recirculation
• Incorrect needle placement
• Reversal of blood lines
• Inappropriate dialyzer size or clearance
• Inadequate dialyzer reprocessing
• Excessive dialyzer clotting during dialysis
• Inadequate dialysate flow rate
• Dialyzer leaks

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Assessment Hemodialysis

• 3. Reduction in treatment times
• A. Inaccurate assessment of effective treatment
  time
• B. Uncompensated interruptions in actual
  treatment time
• Clinical complications (hypotension)
• Equipment alarms
• Manipulation of needles
• Dialysate bypass situations

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Assessment Hemodialysis

• 3. Reduction in treatment times (cont.)
• C. Shortened treatment time
• Premature d/c of dialysis due to
• Patient request/demand
• Dialysis unit issues
• Clinical complications
• Delay in initiation of dialysis
• Missed dialysis treatments

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Assessment Peritoneal Dialysis

• Delivered dose of peritoneal dialysis falls below
  target level evaluate for
• 1. External clamps, kinks or pressure on the
  catheter
• 2. Gravity driven systems
• Height of solution bags
• Distance from lowest point of peritoneal cavity
  to drain bag

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Assessment Peritoneal Dialysis

• Delivered dose of peritoneal dialysis falls below
  target level evaluate for
• 3. Drainage problems related to pt position
• 4. Peritoneal membrane failure

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Assessment Lab

• Laboratory data used to identify
• Failure of dialysis prescription
• Loss of residual kidney function
• Co-Morbid Conditions
• Hypoalbuminemia potential causes
• Identify a new CV event or worsening of
  underlying heart disease (HD)
• Other impacting factors

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Kick it up a Notch What Is the Evidence?

• Residual Renal Function
• How often should it be assessed?
• What does the assessment include?

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Assessment Lab

• Electrolytes
• BUN / Cr
• Ca and Mg
• Glucose
• Liver function tests
• Nutrition albumin, transferrin, prealbumin

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Assessment Lab

• CBC
• Anemia is associated with both kidney failure and
  HF
• The presence of anemia is associated with higher
  mortality risk in patients with HF

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Assessment Lab

• Fasting Lipid Profile
• Primary finding in CKD and dialysis is
  hypertriglyceridemia
• May contribute to accelerated atherosclerosis
• Total cholesterol is sometimes normal or low
• Troponin testing

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C-Reactive Protein (CRP)

• Acute phase protein produced by the liver
• Thought to enhance macrophage phagocytosis and
  complement binding to foreign and damaged cells
• Only recently studied as a marker of vascular
  inflammation associated with CVD
• Other factors that may increase CRP
• Hormone replacement therapy
• ASA

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Kick it up a Notch What Is the Evidence?

• AHA issued a statement about CRP 2007
• Pts with low CV risk scores immediate testing is
  not warranted
• Pts risk score is intermediate than CRP may
  assist in predicting CV event or stroke and
  direct evaluation and therapy
• CRP testing based on this strategy is unclear

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Homocysteine

• Amino acid (AA) which cannot be obtained in the
  diet
• Utilized by changing into other useful AAs
• A lack of transformation into useful AAs leads to
  hyperhomocysteinema
• Elevated levels have been linked to increased CVD
  incidences
• Homocysteine also has prothrombotic properties -
  increased likelihood of clot formation
• Combines with LDL particles to produce foam cells
  and form the necrotic centers for luminal plaques

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Kick it up a Notch What Is the Evidence?

• Treatment of Hyperhomocysteinema
• Folic acid supplementation
• 1 mg/day can decrease homocysteine levels up to
  72
• The evidence to support reducing homocysteine
  levels to decrease heart disease is not yet clear

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Carnitine

• An important intermediary in fat metabolism
• Crucial for energy production in tissues
  dependent upon fatty acid oxidation cardiac and
  skeletal muscle
• Carnitine is derived from red meat and dairy
  products in the diet
• Biosyntheses in the liver, kidney, and brain is
  needed to meet normal requirements

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Carnitine

• Carnitine deficiency may be a significant problem
  in kidney disease
• Normal acylcarnitine free carnitine ratio is
  approx 0.16
• Ratio gt 0.4 is abnormal
• In hemodialysis pts it is increased to 0.76

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Brain Natriuretic Peptide (BNP)

• The natriuretic peptide system impacts salt and
  water handling and pressure regulation and may
  influence myocardial structure and function
• NP is a natriuretic hormone initially identified
  in the brain but released primarily from the
  heart, particularly the ventricles
• The release of BNP is increased in heart failure

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What about BNP?

• Research shows BNP is markedly higher in patients
  with clinically diagnosed HF compared to those
  without
• BNPgt100 pg/mL diagnosed HF with a sensitivity,
  specificity, and predictive accuracy of 76 - 90
• BNP concentrations fall after effective treatment
  of HF so it may be useful in titrating therapy
  but not an established practice

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Kick it up a Notch What Is the Evidence?What
about BNP and Kidney Failure?

• BNP is elevated with kidney failure
• BNP can not be used for the diagnosis or
  management of HF in pts with kidney failure with
  or without dialysis
• A low BNP would exclude LV dysfunction
• There is some evidence BNP can be used as a
  marker for mortality - independent from the
  dialysis modality

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Assessment Echocardiography

• Evaluates left ventricle size, valvular
  function, wall thickness and pumping function or
  ejection fraction (EF)
• EF indicates the of blood ejected from the
  ventricle with each heartbeat
• Normal 50 - 65
• LV systolic dysfunction EF lt 40

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Assessment ECG

• Shows cardiac rhythm /conduction and QRS duration
• Can detect
• myocardial ischemia
• previous MI
• LV hypertrophy
• ACS
• Acute arrhythmias

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Assessment Radiology

• CXR
• Lateral and posterior lateral may assist in
  identifying
• cardiomegaly
• pleural effusions
• pulmonary congestion
• Abdominal X-Ray
• Flat plate and lateral views to determine
  position of PD catheter and identification of
  internal kinks

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Complications of Fluid Overload

• Hyponatremia (Na lt135mmol/L)
• S S confusion, lethargy and disorientation,

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Complications of Fluid Overload

• Hypertension (htn)
• Increased fluid volume increases pressure exerted
  by the fluid on the vessel walls
• Antihypertensive therapy

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Antihypertensive Agents

• 3 Categories
• Sympatholytics
• Central acting agents (Clonidine, Methyldopa)
• Beta adrenergic agents (Atenolol, Metoprolol,
  Nadolol)
• Alpha-1 adrenergic blockers (Prazosin, Terazosin,
  Doxazosin)
• Mixed adrenergic blockers (Labetalol, Carvedilol)
• Vasodilators
• Direct (Diazoxide, Hydralazine, Minoxidil,
  Nitroprusside)
• Calcium channel blockers (Amlodipine,
  Nicardipine, Nifedipine)
• Renin-angiotensin-aldosterone system antagonists
• Angiotensin-converting enzyme (ACE) inhibitors
  (Captopril, Enalapril, Fosinopril, Lisinopril)
• Angiotensin II receptor blockers (ARBs)
  (Candesartan, Losartan Valsartan)

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Complications of Fluid Overload

• Pulmonary Edema
• Life threatening
• S S SOB, orthopnea, tachypneic, wet crackles
  and possible heart murmurs and gallop rhythms
• Confirmed by CXR

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Complications of Fluid Overload

• Pulmonary Edema
• Treatment fluid control
• Increase ultrafiltration
• Increase frequency of dialysis
• Diuretics in those with residual renal function
• Loop diuretics are most potent and remain
  effective when GFR lt25mL/min

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Complications of Fluid Overload

• CHF
• S S cough, dyspnea, fatigue, tachycardia, may
  or may not have chest discomfort, crackles and
  may have S3 /or S4, elevated JVD, may or may not
  have peripheral edema
• Can occur in the absence of heart disease fluid
  overload, severe hypertension

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Complications of Fluid Overload

• Precipitating factors
• Cardiac
• MI
• Atrial fibrillation and other arrhythmias
• Underlying cardiac dysfunction
• Synchrony with right ventricular pacing
• Non Cardiac
• Severe hypertension
• Misc factors anemia, hypo/hyperthyroidism,
  toxins (cocaine/alcohol), fever, infection
  (pneumonia), uncontrolled Db
• Significant drug interactions negative inotropic
  drugs (verapamil, nifedipine, diltiazem, beta
  blockers) or NSAID
• Pulmonary emboli

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Complications of Fluid Overload

• Confirmed by CXR can range from mild pulmonary
  vascular redistribution to marked cardiomegaly
  and extensive bilateral interstitial markings and
  bilateral perihilar alveolar edema give a typical
  butterfly appearance.
• Echo identify systolic dysfunction vs diastolic
  dysfunction or valvular disease

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CHF in Stage 5 Kidney Disease

• Treatment for general population does not
  necessarily apply
• Identify/manage associated conditions
• Htn
• Ischemic HD
• Valvular HD
• High output failure from vascular access
• Anemia
• Carnitine deficiency
• Amyloidosisis
• Volume Control
• Pharmacologic

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Kick it up a Notch What does the evidence say?
ACE Inhibitors

• Used to treat LV systolic HF or asymptomatic LV
  dysfunction
• Have been shown in multiple randomized
  prospective trials to improve survival in pts
  with normal or near normal kidney function with
  all degrees of severity of LVSD

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Kick it up a Notch What does the evidence say?
ACE Inhibitors

• There are very limited prospective controlled
  studies performed in dialysis patients for use of
  ACE inhibitors
• Use in the dialysis pts is used based on the
  benefits observed with HF with normal or near
  normal kidney function

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ACE/ARBs Things to Remember

• Can decrease protein excretion and may be
  beneficial in slowing the progression of kidney
  disease
• Useful for pts with LV hypertrophy or ischemic HD
  with LVSD
• Adverse reactions
• Angioedema
• Orthostatic hypotension
• Hyperkalemia
• Chronic cough (ARBs produce less cough)
• Many ACE inhibitors are removed with hemodialysis

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Kick it up a Notch What does the evidence say?
Beta Blockers

• A single prospective randomized trial showed beta
  blockers reduced the risk of death in dialysis
  pts with severe dilated cardiomyopathy (LVEF
  lt35)
• Based on the trial, K/DOQI guidelines suggest
  carvedilol as the preferred beta blocker

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Beta Blockers Things to Remember

• They all produce sedation, bradycardia,
  hypotension and HF
• All require HR and BP monitoring
• All can mask the S S of hypoglycemia
• Can precipitate or worsen depression
• Need dose tapered before D/C to prevent rebound
  htn
• Most do not require a dosage adjustment in CKD
• Most are not dialyzable

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Kick it up a Notch What does the evidence say?
Angiotensin Type II Receptor Blockers (ARBs)

• In pts with normal or near normal kidney function
  ARBs for the treatment of HF appear to be as or
  possibly slightly less effective than ACE
  inhibitors
• There are very limited studies addressing the use
  of ARBs in dialysis patient with HF
• Use of ARBs in ACE intolerant dialysis pts with
  HF based on the utilization in the general HF
  population

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Kick it up a Notch What does the evidence say?

• Digoxin
• Challenging in the dialysis population with the
  narrow therapeutic to toxic ratio
• Major indication ventricular rate control for
  those in atrial fibrillation
• Aldosterone Receptor Antagonists
• Significantly decreases the rate of sudden
  cardiac death in selected HF pts without ESRD
• Use in dialysis pts is controversial due to risk
  for hyperkalemia
• Currently not recommended in dialysis pts with HF

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Treatment of Diastolic HF

• Pts with preserved LVSF - little data is
  available
• The following factors need to be addressed
• Htn
• HR control
• Blood volume control
• Myocardial ischemia

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Kick it up a Notch What does the evidence say?

• AHA
• Recommends early recognition and treatment of
  CAD, hypertension, DM and other CV risk factors
• Include staging of HF and treatment for each
  stage

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Barriers to Fluid Removal

• Hypoalbuminemia
• Blood Glucose Level
• Effect upon osmosis and fluid shifts

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Barriers to Fluid Removal

• Intradialytic Hypotension
• Common in patients with myocardial dysfunction
• Other causes
• Rapid fluid removal
• Rapid reduction in plasma osmolality
• Autonomic neuropathy
• Diminished cardiac reserve
• Antihypertensive medications
• Ingestion of a meal immediately before or during
  dialysis
• Arrhythmias or pericardial effusion with
  tamponade
• Other
• Monitor response to treatment plan

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Barriers to Fluid Removal

• Intradialytic Hypotension
• Treatment
• Accurate dry weight
• Steady, constant ultrafiltration
• Sodium modeling
• Temperature control
• Improve CV performance
• Midodrine
• Carnitine
• Avoidance of food
• Vasopressin infusion

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Barriers to Fluid Removal

• Venous insufficiency
• Incidence increases with age, obesity, history of
  phlebitis or venous thrombosis, leg trauma
• Differential Dx
• limited to lower extremities - can be unilateral
• Often subsides with recumbency
• Often accompanied by varicosities,
  hyperpigmentation, other signs of venous disease

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Goals

• Relieve symptoms
• Adherence to the prescribed treatment regimen
• Meet educational deficits
• Maintain optimal fluid volume status
• Identify underlying causes and precipitating
  factors
• Achieve/maintain BP in targeted range
• Reduction in modifiable risk for CVD

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Interventions

• Encourage adherence to therapeutic lifestyle
  changes
• Diet and weight management
• Increased physical activity
• Moderation in alcohol consumption
• Smoking cessation
• Encourage adherence to medication therapy
• Assess patient response to therapy and adjust UF
  and meds as ordered
• Identify resources to assist in adherence to
  prescribed regimen

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Fluid Control Adherence

• Dialysis Staff Encouragement and Fluid Control
  Adherence in Patients on Hemodialysis
• Yokoyama, et al
• Nephrology Nursing Journal, May-June 2009
• Looked at fluid control in 77 patients on
  dialysis and dialysis staff encouragement
• Measured
• Dialysis staff support
• Self-efficacy
• Health Locus of Control
• Psychological burden
• Diet therapy burden
• Conclusion Dialysis staff encouragement is
  important in improving fluid control adherence

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Interventions

• Adjust target dry weight, as needed
• How do we determine dry weight?
• No standard measurement
• Set at the weight below which unacceptable
  symptoms occur
• The weigh when fluid volume is optimal
  (euvolemic, normotensive)

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Interventions

• Individualize dialysis prescription
• Target hemoglobin levels
• Modifiable risk factors for CVD
• Control Hypertension
• Control of bone metabolism
• Treatment of anemia
• Immunize influenza and pneumococcal pneumonia

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Interventions HD

• Review dialysis prescription
• Dialysate sodium concentration
• Use of isolated ultrafiltration
• Dialysate temperature
• Treatment time vs. ultrafiltration requirement
• Take measures to correct any issues that could
  result in compromised clearances during dialysis
• Monitor vascular access function

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Ultrafiltration

• Determine degree of UF for each dialysis
  treatment and feasibility of reaching UF goal
• Monitor and adjust UF based on pts response
• Achieving dry weight through UF should be
  accomplished gradually
• Blood volume monitoring

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Blood Volume Monitoring

• Goal Monitoring blood volume and the changes
  that occur over the course of a treatment
• As fluid is removed from the intravascular
  compartment at a greater rate than capillary
  refilling, RBCs become more concentrated
  resulting in increased Hct
• If fluid is shifting at roughly the same rate as
  UF, a steady profile will be displayed
• BVM may present an opportunity to increase the UF
  rate until an increased Hct or decreased blood
  volume
• BVM should be used in conjunction with other
  objective assessment tools

75
Sodium Modeling

• May diminish hypotensive episodes
• Shifting fluid from intracellular fluid to
  extracellular fluid to improve efficiency of UF
  with increased dialysate sodium
• Results in a rapid refilling of the vascular space

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Interventions PD

• Adjust height of dialysate to enhance drain/fill
  rates
• Change pts position to enhance dialysate drain
  rates or obtain complete drain
• Treat constipation
• PET testing with adjustment of dialysis
  prescription accordingly

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Education, Education, Education

• Based on initial assessment and treatment plan
• Diet and fluid management
• Fluid intake
• Sodium restrictions
• Glucose management
• Intradialytic weight gains
• S S of hyper and hypovolemia
• Medication regimen
• Understanding of co-morbid conditions

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Case Studies