2016 Annual Dialysis Conference Michelle Hofmann RN, BSN, CNN Renal Clinical Educator - Home

Transcription

1 Fluid Management 2016 Annual Dialysis Conference Michelle Hofmann RN, BSN, CNN Renal Clinical Educator - Home

2 Objectives Define euvolemia Determine factors which contribute to fluid imbalance Discuss strategies to improve fluid overload USMP/MG1/ /16 2

3 Fluid Management Pre USMP/MG1/ /16 3

4 Fluid Management Post 2006 Maintain euvolemia with the lowest dextrose concentration 1 1 National Kidney Foundation: DOQI Clinical Practice Guidelines for Peritoneal Dialysis Adequacy. Am J Kidney Dis 48:S122-S143, 2006 (suppl 1) USMP/MG1/ /16 4

5 Changes in Transport Properties with Time Adapted from Davies SJ, Bryan J, Phillips L, et al. Longitudinal changes in peritoneal kinetics: the effects of peritoneal dialysis and peritonitis. Nephrol Dial Transplant 1996;11: USMP/MG1/ /16 5

6 Glucose Exposure and Transport Characteristics Davies SJ, Phillips L, Naish PF, Russell GI. Peritoneal glucose exposure and changes in membrane solute transport with time on peritoneal dialysis. J Am Soc Nephrol 2001;12: USMP/MG1/ /16 6

7 Euvolemia Euvolemia is the normalization of extracellular volume. In dialysis this may be referred to as ideal body weight target weight, estimated dry weight or true dry weight 2 3 Guest S. Volume management in PD therapy.. In: Handbook of Peritoneal Dialysis. 2nd ed. San Bernardino, California. 2014: Mujais S, Nolph K, et al. Evaluation and management of ultrafiltration problems in peritoneal dialysis. PDI 2000;Vol 20, Supp 4: S6 USMP/MG1/ /16 7

8 Strategies Fluid Assessments Dietary Management Diuretics Maintenance of Residual Renal Function Prescription Adaptation to Peritoneal Equilibration Test (PET) Blood Sugar Control Hypertonic or alternative osmotic solution 5 Mujais S, Nolph K, etal. Evaluation and management of ultrafiltration problems in peritoneal dialysis. PDI 2000;Vol 20, Supp 4: S7 USMP/MG1/ /16 8

9 Fluid Assessment Weight Blood Pressure Pulse Edema Breath Sounds Co Core Curriculum for Nephrology Nursing 5 th Ediition. American Neohrology Nurses Association 2008, pg 692 USMP/MG1/ /16 9

10 Fluid Assessment Strategies Clearly define euvolemic weight Consider defining weight ranges Determine normal blood pressure ranges Educate on self assessment of edema Jdaugirdas, PBlake, Ting, In: Handbook of Dialysis Fourth Edition Philadelphia USMP/MG1/ /16 10

11 Dietary Management Salt Restriction 3 Most patients on PD therapy will require a sodium restriction to maintain euvolemia 6 grams/day Fluid Allotment 3 Guest S. Volume management in PD therapy.. In: Handbook of Peritoneal Dialysis. 2nd ed. San Bernardino, California. 2014: 176 USMP/MG1/ /16 11

12 Dietary Management Strategies Dietitian Diet History Ongoing Education Fluid Allotment Quarterly UF/Urine output numbers to dietitian Reinforcing education National Kidney Foundation Clinical Practice Guidelines for nutrition in Chronic Renal Failure 2000 Appendice C. Appendix IV. USMP/MG1/ /16 12

13 Diuretics In patients with RKF, to achieve dry weight, diuretics may be preferred to increasing dialysate dextrose concentration 1 1 National Kidney Foundation: DOQI Clinical Practice Guidelines for Peritoneal Dialysis Adequacy. Am J Kidney Dis 48:S122-S143, 2006 (suppl 1) USMP/MG1/ /16 13

14 Diuretics KDOQI Guideline States: A small randomized controlled trial showed that volume status can be improved with the use of highdose loop diuretics 1 1 National Kidney Foundation: DOQI Clinical Practice Guidelines for Peritoneal Dialysis Adequacy. Am J Kidney Dis 48:S123,, 2006 (suppl 1) USMP/MG1/ /16 14

15 Diuretic Strategies In patients with RKF, to achieve dry weight, diuretics may be preferred to increasing dialysate dextrose concentration 1 What percentage of your patients with RKF are on a diuretic? 1 National Kidney Foundation: DOQI Clinical Practice Guidelines for Peritoneal Dialysis Adequacy. Am J Kidney Dis 48:S143, 2006 (suppl 1) USMP/MG1/ /16 15

16 Maintenance of Residual Renal Function 4 Consequences of the loss of RRF Reduced survival Worsened blood pressure control Increased risk of volume expansion with edema formation Worsened cardiac hypertrophy Reduced middle molecule clearance Erythropoietin resistance Lower serum albumin levels Elevated calcium-phosphorus product Endothelial dysfunction 4 Guest S. Residual kidney function in PD. In: Handbook of Peritoneal Dialysis. Lexington, 2nd ed. San Bernardino, California. 2014: 44 USMP/MG1/ /16 16

17 Maintenance of RRF Strategies 4 Avoidance or cautious use of: Aminoglycosides Non-steroidal anti-inflammatory agents Contrast agents Antagonism of the renin-angiotension system Diuretics Hypertension control Avoidance of: Intravascular volume depletion Urinary tract obstruction 4 Guest S. Residual kidney function in PD. In: Handbook of Peritoneal Dialysis. 2nd ed. San Bernardino, California. 2014: 47 USMP/MG1/ /16 17

18 Prescription Management 3 Peritoneal membrane transport characteristics predict the response to an osmotic stimulus. An understanding of the underlying peritoneal membrane characteristics allows for optimization of the PD prescription 3 Guest S. Volume management in PD therapy. In: Handbook of Peritoneal Dialysis. 2nd ed. San Bernardino, California. 2014: 177 USMP/MG1/ /16 18

19 Ultrafiltration Profiles with Transport Type Net UF (ml) L LA HA H Time (hr) Adapted from: Mujais S, Vonesh E. Profiling of peritoneal ultrafiltration. Kidney Int 2002;62[Suppl 81]:S17 S21. USMP/MG1/ /16 19

20 Dwell Time and Consequence Transport Solute Clearance UF Prescription High Short dwell High A CAPD/CCPD Low A CAPD/CCPD Low Long dwell *Always try to maximize instilled volumes Adapted from: Daugirdas J, Blake P, Ing T. Handbook of Dialysis Fifth Edition, Wolters Kluwer 2015: USMP/MG1/ /16 20

21 Prescription Management Strategies 3 Adjust dwell times to match membrane characteristics High/High Average greatest UF in the first hours of the dwell so can tolerate shorter dwells Low/Low Average maintain the osmotic gradient longer and should have longer dwells to optimize the therapy Manage the long dwell Careful review of flow sheets Monitor for changes in membrane characteristics 3 Guest S. Volume management in PD therapy. In: Handbook of Peritoneal Dialysis. 2nd ed. San Bernardino, California. 2014: USMP/MG1/ /16 21

22 Blood Sugar Control Systemic hyperglycemia can interfere with fluid removal by reducing the gradient. Mujais S, Nolph K, etal. Evaluation and management of ultrafiltration problems in peritoneal dialysis. PDI 2000;Vol 20, Supp 4: S7 USMP/MG1/ /16 22

23 Blood Sugar Control Strategies Communication with Endocrinology team Use of lowest dextrose solution Mujais S, Nolph K, etal. Evaluation and management of ultrafiltration problems in peritoneal dialysis. PDI 2000;Vol 20, Supp 4: S16 USMP/MG1/ /16 23

24 Strategies Fluid Assessments Dietary Management Diuretics Maintenance of Residual Renal Function Prescription Adaptation to PET Blood Sugar Control Hypertonic or alternative osmotic solution 5 Mujais S, Nolph K, etal. Evaluation and management of ultrafiltration problems in peritoneal dialysis. PDI 2000;Vol 20, Supp 4: S7 USMP/MG1/ /16 24

25 Solution Strategies 3 Educate on importance of limiting hypertonic usage Root cause analysis for cause of fluid imbalance Rule out technical problem-constipation/catheter mal-placement Compliance with therapy/diet Short term use of hypertonic solution Use of alternative osmotic solution 3 Guest S. Volume management in PD therapy. In: Handbook of Peritoneal Dialysis 2nd ed. San Bernardino, California. 2014: 175. USMP/MG1/ /16 25

26 Fluid Management Overview Emphasis on managing fluid balance has changed Clearly define dry/target weight Diet Diuretics Maintaining residual renal function Prescription to maximize ultrafiltration Alternative osmotic solutions USMP/MG1/ /16 26

27 Thank You! Baxter is a registered trademark of Baxter International Inc. USMP/MG1/ /16