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Profiling Ultrafiltration© 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 © Gambro Lundia AB Rev C
Fluid Spaces in the BodyAverage weight Male 70 kg or 154 lbs. BONE, MUSCLE, FAT 60% of Total Body Weight is 42 liters of water VASCULAR SPACE 4 LITERS WATER, 5% Extracellular INTERSTITIAL SPACE 11 LITERS WATER, 15% INTRACELLULAR SPACE 27 LITERS WATER 40% © Gambro Lundia AB Rev C
Two Basic Reasons That Patients End up With Dialysis Symptoms During TreatmentThe 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 © Gambro Lundia AB Rev C
Symptom Etiology With Constant UltrafiltrationSymptoms of Volume loss: Hypotension Cramping Dizziness Nausea Vomiting Shock Ultrafiltration (UF) removes water volume from the blood into the dialysate, causing hypovolemia © 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 © 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 © Gambro Lundia AB Rev C
Things to Consider for Ultrafiltration ProfilingDoes 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? Read the slide © Gambro Lundia AB Rev C
Individualize the Prescription Based Upon the Patient’s Treatment HistoryDetermine 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 © Gambro Lundia AB Rev C
Choosing the Right UF ProfilesLinear Progressive 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 Step Step I would need an explanation or a for instance for the 1.5 times hourly UF rate I don’t understand what you mean. © Gambro Lundia AB Rev C
Choosing the Right UF ProfilesConsider 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 © Gambro Lundia AB Rev C
How to select a UF profile for a patientCase Studies How to select a UF profile for a patient © 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 Read the slide. © Gambro Lundia AB Rev C
Symptoms are relieved at the end of treatment with a lower UFPatient tolerates fluid removal (higher UF) at the beginning of treatment 220 200 180 160 140 120 100 80 60 40 30 90 150 210 240 Symptoms are relieved at the end of treatment with a lower UF Systolic BP UF Profile Time in Minutes © Gambro Lundia AB Rev C
220 200 180 160 140 120 100 80 60 40 30 90 150 210 240 Fluid overloaded patients benefit from aggressive UF at the beginning of the treatment 1.8 Kg/h 1.0 0.7 0.3 Systolic BP Step profiles allow for dramatic decreases in UF. Lower UF at the middle and end of treatment will reduce the patient’s symptoms UF Profile Time in Minutes © 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 © Gambro Lundia AB Rev C
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 220 200 180 160 140 120 100 80 60 40 30 90 150 210 240 Decrease the UF toward the end of treatment as the patient approaches her dry weight to prevent symptoms Systolic BP Time in Minutes © Gambro Lundia AB Rev C
220 200 180 160 140 120 100 80 60 40 30 90 150 210 240 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 Systolic BP Time in Minutes © Gambro Lundia AB Rev C
Katy Glycemia is hypertensive and diabeticKaty 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 © Gambro Lundia AB Rev C
Assessment and Plan Assessment: Plan Large fluid gainsSevere 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 © Gambro Lundia AB Rev C
220 200 180 160 140 120 100 80 60 40 30 90 150 210 240 Utilize a Conductivity profile to support solute removal Systolic BP Arrows indicate plasma refill times Time in Minutes © Gambro Lundia AB Rev C
220 200 180 160 140 120 100 80 60 40 30 90 150 210 240 UF and Conductivity Profiling can be used simultaneously with similar step curves Systolic BP Time in Minutes © Gambro Lundia AB Rev C
220 200 180 160 140 120 100 80 60 40 30 90 150 210 240 Systolic BP UF and Conductivity Profiling can be used simultaneously with similar progressive curves Time in Minutes © Gambro Lundia AB Rev C
Summary of UF ProfilingAllows 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 Read the slide. © 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, 1994. 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. © Gambro Lundia AB Rev C
References Gambro Basics 1 Gambro Education 1994Petitclerc, 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 © Gambro Lundia AB Rev C
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