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1© 2007 Gambro Lundia AB Rev C Profiling Ultrafiltration
2© 2007 Gambro Lundia AB Rev C Goals of UF Profiling Provide adequate ultrafiltration (UF) Minimize symptoms related to hypovolemia Enhance plasma refill Allow the patient to reach estimated dry weight (EDW) Hypovolemia: Decreased blood volume leads to decreased cardiac output which can cause hypotension Plasma refill: Refilling of the blood compartment, or vascular space from the surrounding tissue spaces
3© 2007 Gambro Lundia AB Rev C BONE, MUSCLE, FAT VASCULAR SPACE 4 LITERS WATER, 5% INTERSTITIAL SPACE 11 LITERS WATER, 15% INTRACELLULAR SPACE 27 LITERS WATER 40% 60% of Total Body Weight is 42 liters of water 70 kg or 154 lbs. Extracellular Fluid Spaces in the Body Average weight Male
4© 2007 Gambro Lundia AB Rev C Two Basic Reasons That Patients End up With Dialysis Symptoms During Treatment The loss of circulating volume in the vascular space The loss of osmolarity as the urea is removed during dialysis (see section - conductivity profiling) Only fluid in the vascular space is available during dialysis for ultrafiltration. This amounts to less than 4L in the average patient
5© 2007 Gambro Lundia AB Rev C Symptom Etiology With Constant Ultrafiltration Ultrafiltration (UF) removes water volume from the blood into the dialysate, causing hypovolemia Symptoms of Volume loss: Hypotension Cramping Dizziness Nausea Vomiting Shock
6© 2007 Gambro Lundia AB Rev C Profiling Ultrafiltration: Allows the patient to reach their estimated dry weight (EDW) Helps prevent symptoms Allows refilling of vascular fluid volume from the interstitial space (plasma refill) Allows higher volume fluid removal at times when fluid is more readily available Prevents hypotension
7© 2007 Gambro Lundia AB Rev C How to Do UF Profiling Identify patients with dialysis related symptoms Analyze patient’s treatment records Decide if the patient will benefit from a profile Choose a profile that matches your analysis
8© 2007 Gambro Lundia AB Rev C Does the patient have difficulty with fluid removal? Have the MD answer these questions: –What UF rates can the patient tolerate? –Will the patient require periods of minimum UF? –How will patient co-morbidities affect fluid removal? –What type of profile would be best suited for the patient? Things to Consider for Ultrafiltration Profiling
9© 2007 Gambro Lundia AB Rev C Individualize the Prescription Based Upon the Patient’s Treatment History Determine when the patient typically demonstrates symptoms. Beginning – mid – end of treatment? Does the patient need minimum UF to complete the treatment? Evaluate the pre treatment systolic blood pressure (SBP) Evaluate the patient’s weight gains between treatments
10© 2007 Gambro Lundia AB Rev C A profile that begins with the highest UF that can be tolerated by the patient which then decreases to a minimum will work for patients: With large weight gains between treatments Who become hypotensive late in treatment Who cramp late or at the end of treatment With large weight gains between treatments and present with an elevated BP Choosing the Right UF Profiles Linear Progressive Step
11© 2007 Gambro Lundia AB Rev C Choosing the Right UF Profiles Consider a profile with varying steps for patients who: Need a gradual increase in UF at the beginning of the treatment to support low BP or cardiac output Need short intervals of minimum UF to allow for plasma refill Have difficulty shifting fluid into the vascular space (elderly, diabetic or unstable) Cramp or are hypotensive randomly during treatment
12© 2007 Gambro Lundia AB Rev C Case Studies How to select a UF profile for a patient
13© 2007 Gambro Lundia AB Rev C Carl Kramper weight gains typically of 3-4 kg and experiences moderate to severe leg cramps during the last 30 minutes of treatment
14© 2007 Gambro Lundia AB Rev C Patient tolerates fluid removal (higher UF) at the beginning of treatment Symptoms are relieved at the end of treatment with a lower UF UF Profile Systolic BP Time in Minutes
15© 2007 Gambro Lundia AB Rev C Systolic BP Kg/h Step profiles allow for dramatic decreases in UF. Lower UF at the middle and end of treatment will reduce the patient’s symptoms Fluid overloaded patients benefit from aggressive UF at the beginning of the treatment UF Profile Time in Minutes
16© 2007 Gambro Lundia AB Rev C Harriet Hart arrives with a systolic blood pressure of 85 and a weight gain of 3 Kg. If her SBP falls below 75 she becomes symptomatic
17© 2007 Gambro Lundia AB Rev C Time in Minutes Systolic BP Less UF should be used at the beginning of treatment while the SBP is low. Increase the UF during periods when the SBP is higher Decrease the UF toward the end of treatment as the patient approaches her dry weight to prevent symptoms
18© 2007 Gambro Lundia AB Rev C Time in Minutes Systolic BP Using a Step Profile, you can create multiple minimum UF periods which will allow plasma refill to occur. Decrease the UF toward the end of treatment as the patient approaches her dry weight to prevent symptoms
19© 2007 Gambro Lundia AB Rev C Katy Glycemia is hypertensive and diabetic. She has large fluid gains of 4-6 Kg between treatments and has symptoms of hypotension about 45 minutes into the treatment as well as mid and late treatment
20© 2007 Gambro Lundia AB Rev C Assessment and Plan Assessment: –Large fluid gains –Severe hypotensive episodes –Poor plasma refill Plan –Support plasma refill, especially during the first part of the treatment –Prevent hypovolemia –Consider conductivity profiling in addition to UF profiling
21© 2007 Gambro Lundia AB Rev C Time in Minutes Systolic BP Arrows indicate plasma refill times Utilize a Conductivity profile to support solute removal
22© 2007 Gambro Lundia AB Rev C Systolic BP Time in Minutes UF and Conductivity Profiling can be used simultaneously with similar step curves
23© 2007 Gambro Lundia AB Rev C UF and Conductivity Profiling can be used simultaneously with similar progressive curves Time in Minutes Systolic BP
24© 2007 Gambro Lundia AB Rev C Summary of UF Profiling Allows unlimited variation of ultrafiltration rates so that fluid can be removed from the vascular space while preventing symptoms Allows periods of automatic plasma refilling to allow adequate fluid removal Decreases the patient’s symptoms May be used simultaneously with conductivity profiling
25© 2007 Gambro Lundia AB Rev C References Heinrich, W.L. & Victor, R.G., “Autonomic Neuropathy and Hemodynamic Stability in End- Stage Renal Disease Patients”, Principles and Practice in Dialysis, Williams and Wilkins, Baltimore, Wilson, S., Alvarez, D., A Primer on Ultrafiltration Profiling and Sodium Modeling for Dialysis Patients, Contemporary Dialysis and Nephrology, April 2000, pp Bonomini, V., Coli, L., Scolari, M.P., Profiling Dialysis: A New Approach to Dialysis Intolerance, Nephron 1997; 75:1-6 Leunissen, K.M.L., Kooman, J.P., van der Sande, F.M., van Kuijk, W.H.M., Hypotension and Ultrafiltration Physiology in Dialysis, Blood Purif 2000; 18: Oliver, M.J., Edwards, L.J., Churchill, Impact of Sodium and Ultrafiltration Profiling on Hemodialysis Related Symptoms, J Am Soc Nephrol 12: Jensen, B.M., Dobbe, S. A., Squillace, D.P., McCarthy, J.T., (April 1994) Clinical Benefits of High and Variable Sodium Concentration Dialysate in Hemodialysis Patients, ANNA Journal, Vol. 21, No. 2.
26© 2007 Gambro Lundia AB Rev C References Gambro Basics 1 Gambro Education 1994 Petitclerc, T. and Jacobs, C. Dialysis sodium concentration: what is optimal and can it be individualized?, Nephrol Dial Transplant Editorial Comments1995, Coli, L., Ursino, M., Dalmastri, V., Volpe, F., LaManna, G., Avanzolini, G., Stefoni, S., Bonomini, V., A simple mathematical model applied to selection of the sodium profile during profiled haemdialysis, Nephrol Dial Transplant (1998) 13: Donauer,J., Kolblin, D., Bek, M., Krause, A., Bohler, J., Ultrafiltration Profiling and Measurement of Reletive Blood Volume as Strategies to Reduce Hemodialysis-Related Side Effects, AJKD, Vol 36, No 1 (July), 2000:pp Stiller, S., Bonnie-Schorn, E., Grassmann, A., Uhlenbusch-Korwer, Mann, A Critical Review of Sodium Profiling for Hemodialysis, Seminars in Dialysis, Vol 14, No 5 (September-October) 2001 pp Locatelli, F., DiFilippo, S., Manzoni, C., Corti, M., Andrulli, S., Pontoriero, G., Monitoring sodium removal and delivered dialysis by conductivity, The International Journal of Artificial Organs/Vol. 18/no. 11, 1995/pp
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