1© 2007 gambro lundia ab 306175553 rev c profiling ultrafiltration

1 © 2007 Gambro Lundia AB 306175553 Rev C

Profiling Profiling Ultrafiltration Ultrafiltration


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


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


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


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


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


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


• 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


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


• 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


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


Case Studies

How to select a UF profile for a patient


Carl Kramper weight gains typically of 3-4 kg and

experiences moderate to severe leg cramps during

the last 30 minutes of treatment


220

200

180

160

140

120

100

80

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

15 © 2007 Gambro Lundia AB 306175553 Rev CS

ystolic BP

220

200

180

160

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120

100

80

60

40 30 60 90 120 150 180 210 240

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


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


220

200

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160

140

120

100

80

60

40 30 60 90 120 150 180 210 240

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


220

200

180

160

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120

100

80

60

40 30 60 90 120

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


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


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


220

200

180

160

140

120

100

80

60

40 30 60 90 120 150 180 210 240

Time in Minutes

Sys

tolic

BP

Arrows indicate

plasma refill times

Utilize a Conductivity

profile to support solute removal


220

200

180

160

140

120

100

80

60

40 30 60 90 120 150 180 210 240

Sys

tolic

BP

Time in Minutes

UF and Conductivity Profiling can be used simultaneously

with similar step curves


220

200

180

160

140

120

100

80

60

40 30 60 90 120 150 180 210 240

UF and Conductivity Profiling can be used simultaneously

with similar progressive curves

Time in Minutes

Systolic B

P


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


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.


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

1© 2007 gambro lundia ab 306175553 rev c profiling ultrafiltration

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