1© 2007 gambro lundia ab 306175553 rev c profiling ultrafiltration
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1 © 2007 Gambro Lundia AB 306175553 Rev C
Profiling Profiling Ultrafiltration Ultrafiltration
2 © 2007 Gambro Lundia AB 306175553 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
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BONE, MUSCLE, FAT
VASCULAR SPACE4 LITERS WATER, 5%
INTERSTITIAL SPACE11 LITERS WATER, 15%
INTRACELLULARSPACE
27 LITERS WATER
40%
60% of Total Body Weight
is 42 liters
ofwater
70 kg or 154 lbs.
Extracellular
Fluid Spaces in the BodyAverage weight Male
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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
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Symptom EtiologyWith 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
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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
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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
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• 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
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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
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• 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 Step
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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
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Case Studies
How to select a UF profile for a patient
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Carl Kramper weight gains typically of 3-4 kg and
experiences moderate to severe leg cramps during
the last 30 minutes of treatment
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220
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60
40 30 60 90 120 150 180 210 240
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 B
P
Time in Minutes
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ystolic BP
220
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1.8 Kg/h
1.0 0.7
0.3
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 306175553 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
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Time in Minutes
Systolic B
P
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
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150 180 210 240
Time in Minutes
Systolic B
P
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 306175553 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
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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
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220
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Time in Minutes
Sys
tolic
BP
Arrows indicate
plasma refill times
Utilize a Conductivity
profile to support solute removal
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Sys
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BP
Time in Minutes
UF and Conductivity Profiling can be used simultaneously
with similar step curves
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UF and Conductivity Profiling can be used simultaneously
with similar progressive curves
Time in Minutes
Systolic B
P
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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
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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 34-36.
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; 18:251-254
Oliver, M.J., Edwards, L.J., Churchill, Impact of Sodium and Ultrafiltration Profiling on Hemodialysis Related Symptoms, J Am Soc Nephrol 12: 151-156 2000
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.
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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, 596-599.
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) 13:404-416
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:pp115-123
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. 337-347
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/pp716-721