1. What is sodium modeling in hemodialysis patients?

3. Causes of Intradialytic hypotension(IDH)
Excessive fluid removal
Ultrafiltration rate > 0.35 ml/min/kg
Decrease in plasma vol. > 20%
Patient-related factors
Autonomic neuropathy (e.g. DM, Uremia)
Antihypertensive medications
Sympathetic failure (적절한 plasma NE↑가 無)
RAS and arginine-vasopressin syst. sensitivity↓
Food ingestion(splanchnic vasodilation)
Tissue ischemia(adenosine mediated)
Bacterial sepsis
Intradialytic venous pooling
Core body temp.↑
Anemia.
Reduced plasma refilling rate
Reduced ECV
Impaired Vasoconstriction
Hemorrhage
Intradialytic
Hypotension n
Dialysis-related factors
Acetate dalysate (adenosine-mediated)
Low dialysate Na &/or ionized Ca conc.
Complemant activation (C3a and C5a-mediated)
Cytokine generation(IL-1 and NO-mediated)
Heart problems
Myocardial Infarction
Structural heart dis.
Arrythmias
Pericardial tamponade
Hemolysis
Dialyzer Rxn
Air embolism

4. Water movement during standard hemodialysis
Intracellular fluid
Extracellular fluid
Dialyzer
step3
Water movement
step1
280
Loss of urea and water
Osmolality
320 mosm/kg
Falling to 290mosm/kg
as diffusion occurs
Osmolality
320 mosm/kg n
step2
Compensatory refilling

5. Fluid removal
Plasma refilling

6. Increased risk of hypotension Fluid removal Fluid removal Low Na
meq/l Na

7. Historically the dialysate Na was maintained at hyponatremic level, 130-135:
To prevent:
Intradialytic hypertension
Thirsty
Interdialytic weight gain

8. Disadvantages of dialysates with low sodium concentration:
Increased risk of hypotension
Increased risk of intradialytic cramps
Increased risk of dialysis disequilibrium syndrome

9. Increased intracellular
urea removed
by dialyzer
urea sequestration
in tissue
fluid
Effluent
Dialysate
Increased intracellular
osmolarity
Inffluent
Dialysate
fluid Na

10. High dialysate sodium:
Advantages:
Decreased risk of hypotension
Decreased risk of intradialytic cramps
Decreased risk of dialysis disequilibrium syndrome
Disadvantages:
Increased rate of hypertension
Interdialytic weight gain
Polydipsia

11. Fluid removal Plasma refillingNa
Low Na >145 meq/l Na

13. Different patterns of sodium modeling
meq/lit
Na concentration
meq/lit
Hours after dialysis initiation

18. Dialysate Na should be regulated based on serum Na:
hyponatremia:
If Na > 130: Dialysate Na: 140-(140-predialysis Na)
If Na<130: Dialysate Na: Predialysis Na
Hypernatremia:
Dialysate Na: Predialysis Na-2 mmol

19. 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

20. Fluid Spaces in the Body
Average weight Male
70 kg or 154 lbs.
BONE, MUSCLE, FAT
60% of Total Body Weight is
42 liters
of water
VASCULAR SPACE 4 LITERS WATER, 5%
Extracellular
INTERSTITIAL SPACE 11 LITERS WATER, 15%
INTRACELLULAR SPACE 27 LITERS WATER
40%

21. 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
Only fluid in the vascular space is available during dialysis for ultrafiltration. This amounts to less than 4L in the average patient

22. Symptom Etiology With Constant Ultrafiltration
Symptoms of Volume loss:
Hypotension
Cramping
Dizziness
Nausea
Vomiting
Shock
Ultrafiltration (UF) removes water volume from the blood into the dialysate, causing hypovolemia

23. 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

24. 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

25. Things to Consider for Ultrafiltration Profiling
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?
Read the slide

26. 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

27. Choosing the Right UF Profiles
Linear
Progressive
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
Step
Step
I would need an explanation or a for instance for the 1.5 times hourly UF rate I don’t understand what you mean.

28. 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

29. How to select a UF profile for a patient
Case Studies
How to select a UF profile for a patient

30. A patient weight gains typically of 3-4 kg and experiences moderate to severe leg cramps during the last 30 minutes of treatment
Read the slide.

31. Symptoms are relieved at the end of treatment with a lower UF
Patient tolerates fluid removal (higher UF) at the beginning of treatment
220
200
180
160
140
120
100 80 60 40 30 90
150
210
240
Symptoms are relieved at the end of treatment with a lower UF
Systolic BP
UF Profile
Time in Minutes

32. 220
200
180
160
140
120
100 80 60 40 30 90
150
210
240
Fluid overloaded patients benefit from aggressive UF at the beginning of the treatment
1.8 Kg/h
1.0
0.7
0.3
Systolic BP
Step profiles allow for dramatic decreases in UF. Lower UF at the middle and end of treatment will reduce the patient’s symptoms
UF Profile
Time in Minutes

33. Second patient arrives with a systolic blood pressure of 85 and a weight gain of 3 Kg. If her SBP falls below 75 she becomes symptomatic

34. 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
220
200
180
160
140
120
100 80 60 40 30 90
150
210
240
Decrease the UF toward the end of treatment as the patient approaches her dry weight to prevent symptoms
Systolic BP
Time in Minutes

35. 220
200
180
160
140
120
100 80 60 40 30 90
150
210
240
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
Systolic BP
Time in Minutes

36. A woman patient is hypertensive and diabetic
A woman patient 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

37. Assessment and Plan Assessment: Plan 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

38. 220
200
180
160
140
120
100 80 60 40 30 90
150
210
240
Utilize a Conductivity profile to support solute removal
Systolic BP
Arrows indicate plasma refill times
Time in Minutes

39. 220
200
180
160
140
120
100 80 60 40 30 90
150
210
240
UF and Conductivity Profiling can be used simultaneously with similar step curves
Systolic BP
Time in Minutes

40. 220
200
180
160
140
120
100 80 60 40 30 90
150
210
240
Systolic BP
UF and Conductivity Profiling can be used simultaneously with similar progressive curves
Time in Minutes

41. 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
Read the slide.

42. 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
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:
Oliver, M.J., Edwards, L.J., Churchill, Impact of Sodium and Ultrafiltration Profiling on Hemodialysis Related Symptoms, J Am Soc Nephrol 12:
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.

43. 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,
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:
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:pp
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
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/pp