In a patient with End-Stage Renal Disease (ESRD) and pulmonary edema, what is adjusted during dialysis to remove excess fluid?

From the Guidelines

To help remove excess fluid from the lungs in an ESRD patient during dialysis, healthcare providers should adjust the ultrafiltration rate (UFR) and target dry weight, with the goal of achieving optimal "dry" weight without inducing hypotension, as recommended by the clinical practice guidelines for hemodialysis adequacy 1. When adjusting the ultrafiltration rate, it is essential to consider the patient's hemodynamic stability and tolerance of ultrafiltration, as excessive fluid removal can lead to hypotension and muscle cramping 1.

• The ultrafiltration rate is typically increased to remove more fluid, usually set between 0.5-1.0 kg/hour depending on the patient's hemodynamic stability.
• The target dry weight is reassessed and often lowered temporarily to account for the excess fluid accumulation.
• Additionally, dialysate sodium concentration may be adjusted to maintain plasma osmolality and prevent rapid fluid shifts that could cause hemodynamic instability.
• The dialysis session duration might be extended beyond the standard 3-4 hours to allow for more gradual fluid removal while minimizing hypotension risk.
• Dialysate temperature may be lowered slightly (35-36°C) to improve cardiovascular stability during increased ultrafiltration. These adjustments work by creating a pressure gradient that pulls excess fluid from the patient's bloodstream into the dialyzer, effectively reducing volume overload that causes pulmonary edema, and are supported by guidelines for the diagnosis and management of heart failure in adults, which suggest that ultrafiltration or hemofiltration may be needed to achieve adequate control of fluid retention in patients with diuretic-resistant heart failure 1. The healthcare team carefully monitors blood pressure, heart rate, and symptoms during treatment to ensure the patient tolerates the increased fluid removal.

From the Research

Adjusting Dialysis for ESRD Patients with Fluid in Lungs

• To help get extra fluid off in ESRD patients with fluid in lungs during dialysis, the key adjustment is in the ultrafiltration rate.
• According to 2, lung congestion is reduced but not abolished by ultrafiltration dialysis, indicating that adjusting the ultrafiltration rate can help manage fluid overload.
• The goal is to remove excess fluid without causing hypotension or other complications, which requires careful monitoring and adjustment of the ultrafiltration rate.
• While the provided studies do not specify exact protocols for adjusting ultrafiltration rates, they emphasize the importance of managing fluid overload in ESRD patients, particularly those with lung congestion.
• Other studies, such as 3, 4, and 5, discuss fluid management in ESRD patients but do not provide direct guidance on adjusting dialysis parameters for patients with fluid in the lungs.
• Overall, the adjustment of ultrafiltration rate during dialysis is crucial for managing fluid overload in ESRD patients with lung congestion, and should be tailored to the individual patient's needs and response to treatment.