Bringing the problem of fluid overload under control among dialysis patients has been central to discussions by clinicians and policy makers over the past two to three years. It has been discussed as a new quality measure for the End Stage Renal Disease Program Quality Incentive Program; policy makers see it as a major cause of expensive hospitalizations among dialysis patients, which consume half of the ESRD Program’s annual expenditures. It creates headaches for dialysis staff who must be aggressive about trying to find the ideal dry weight for dialysis patients. It also reduces the effectiveness of drugs aimed at treating other kidney disease-related problems, like anemia.

Teaching dialysis patients about salt restriction
Teaching patients about salt restrictions, which leads to fluid retention, is difficult; patients do not want to be reminded of their disease, and a renal diet can be bland without salt. But results from a quality initiative presented at ASN’s Kidney Week 2012 suggest that monitoring and a good education program for professionals and patients can make a difference in controlling extracellular volume (ECV) between dialysis sessions. While the study was small – less than 20 clinics involved about 1,200 patients in a study and control group –– the testing of the methods suggests that fluid overload in dialysis patients can be managed.
Study: Extracellular volume control in dialysis patients to reduce hospitalizations
The results of the initiative, outlined in the poster, “Extracellular volume control in dialysis patients to reduce hospitalizations,” and presented by Thomas F. Parker, MD, involved patients from three dialysis providers: Renal Ventures Management, Fresenius Medical Care, and DaVita Inc. Patients in 15 facilities were randomly selected for either education only about fluid control or education + ECV monitoring. Ultrafiltration monitoring and assessment of normalized ECV  dry weight was accomplished with a monitoring device. In the education-only group, clinical assessment used an ultrafiltration algorithm to achieve dry weight.

The results between the two groups were striking. Before the education and education + monitoring efforts began, all cause and ECV-related hospital rates were similar between the two study groups. After a six-month review of the hospital data, those patients who received education about the dangers of ECV and were monitored showed a 50% drop in ECV-related hospitalizations. No drop was seen in dialysis patients who were provided with education only. In fact, after education was implemented in the education-only group of dialysis patients, there was an actual increase in ECV-related hospitalizations and the number of hospitalized days.

“I think the era where we see the Kt/V as the end all” for measuring dialysis adequacy is over, said Parker. “We need to look at volume control.”

The abstract is available online