From the Guidelines
Fluid overload due to missed dialysis is called uremic volume overload or hypervolemia. This condition occurs when a patient with kidney failure misses their scheduled dialysis treatment, causing excess fluid to accumulate in the body. According to the 2013 ACCF/AHA guideline for the management of heart failure 1, patients with significant fluid overload should be promptly treated with intravenous loop diuretics to reduce morbidity.
Key Management Strategies
- Fluid restriction (typically 1-1.5 liters per day)
- Sodium restriction (less than 2 grams daily)
- Urgent dialysis arrangement
- Loop diuretics like furosemide (40-80mg IV) may provide temporary relief in patients with residual kidney function, as the initial intravenous dose should equal or exceed their chronic oral daily dose and should be given as either intermittent boluses or continuous infusion 1.
Symptoms and Complications
- Shortness of breath
- Swelling in the legs and ankles
- Weight gain
- Elevated blood pressure
- Distended neck veins The excess fluid can cause pulmonary edema, heart failure, and hypertensive crisis, emphasizing the need for prompt treatment to reduce morbidity and mortality. Patients should monitor daily weights, track fluid intake, recognize early symptoms, and never skip scheduled dialysis sessions to prevent this potentially life-threatening condition.
From the Research
Overload due to Missing Dialysis
- Overload due to missing dialysis is a critical issue in patients with end-stage renal disease (ESRD) as it can lead to various complications such as resistant hypertension, cardiac hypertrophy, congestive heart failure, and arterial stiffness 2.
- Volume overload is a major risk factor for all-cause and cardiovascular mortality in ESRD patients, and its diagnosis is largely based on clinical criteria, which has poor diagnostic accuracy 3.
- Fluid overload is a common complication in hemodialysis patients, causing unpleasant symptoms, increased hospitalization, and mortality 4.
- Both baseline fluid overload and fluid depletion are associated with increased mortality risk and cardiovascular complications in hemodialysis patients 5.
Diagnosis and Management
- The diagnosis of volume excess and estimation of dry weight is challenging, and various methods such as biomarkers, inferior vena cava assessment, lung ultrasonography, bioimpedance analysis, and blood volume monitoring have been used to assess volume status 2.
- Bioimpedance spectroscopy is a widely used method to quantify fluid distributions over body compartments and produces reliable and reproducible results 3.
- Lung ultrasound provides reliable estimates of extravascular water in the lung, a critical parameter of the central circulation that reflects the left ventricular end-diastolic pressure 3.
- Fluid removal in volume-expanded hemodialysis patients should be gradual and distributed over a sufficiently long time window to maximize cardiovascular tolerance 3.
Complications and Mortality
- Fluid overload is associated with increased risk of all-cause and cardiovascular mortality in hemodialysis patients, and the risk is higher for patients with severe fluid overload 5.
- Fluid depletion is also associated with increased mortality risk, and the risk is higher for patients with moderate to severe fluid depletion 5.
- Greater fluid status variability is independently associated with higher mortality in hemodialysis patients 5.