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Implementation of a decision aid for Recognition and Correction of Volume Alterations (Recova®) in haemodialysis
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Renal Medicine.ORCID iD: 0000-0003-2408-0087
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Research and Development, Gävleborg. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.ORCID iD: 0000-0003-1289-9896
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Renal Medicine.ORCID iD: 0000-0002-9001-614x
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background

Chronic fluid overload is an independent predictor of mortality in haemodialysis. Clinical assessment of fluid status is subjective and unprecise, and 30% of the patients remain fluid overloaded at target/dry weight. This study evaluates the effects of implementing a decision aid, Recova®, which combines a systematised fluid status procedure with bioimpedance spectroscopy, for individualised dry weight determination in haemodialysis.

Methods

Nurses at two haemodialysis units were instructed to use Recova® every two weeks, assessing the study participants’ fluid status and adjusting their dry weights, as appropriate. The impact of the intervention was measured as proportion of participants at an adequate dry weight at the end of the study, assessed as change in symptoms, hydration status and N-terminal pro-brain natriuretic peptide (NT-proBNP). The process of the intervention was measured as frequencies of fluid status assessments, bioimpedance measurements and dry weight adjustments.

Results

Forty-nine patients were enrolled. In seven out of ten participants with fluid overload symptoms and bioimpedance-measured overhydration, symptoms and overhydration pre dialysis had decreased (2 to 0, p = 0.033 and 3.8 to 2.9 L, p = 0.047), by the end of the study. In 13 out of 20 participants with symptoms of fluid depletion and underhydration, there was a significant increase in dry weight (72.8 to 73.4 kg, p = 0.024), but also in NT-proBNP (6,230 to 9,625, p = 0.018). In groups of participants in which clinical assessments and BIS measurements were in conflict, fluid status was not affected.

Conclusions

Implementation of Recova® increased the monthly frequencies of bioimpedance measurements and dry weight adjustments. At the end of the study, participants with fluid overload had decreased symptoms and decreased OH. Participants with negative OH and fluid depletion symptoms had increased dry weight and reduced negative OH. Recova® may contribute to improved fluid management in haemodialysis.

National Category
Urology and Nephrology
Research subject
Medical Science
Identifiers
URN: urn:nbn:se:uu:diva-407955OAI: oai:DiVA.org:uu-407955DiVA, id: diva2:1421012
Note

This PhD project was financed by the Centre for Research and Development at the Uppsala University Hospital/County Council of Uppsala, the Faculty of Medicine at Uppsala University, the Signe and Olof Wallenius Foundation, and the Swedish Association for Kidney Patients CUWX Foundation.

Available from: 2020-04-01 Created: 2020-04-01 Last updated: 2020-04-03
In thesis
1. Fluid Management in Haemodialysis: Studies on current practices and new methods
Open this publication in new window or tab >>Fluid Management in Haemodialysis: Studies on current practices and new methods
2020 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Chronic fluid overload has been identified as an independent predictor of mortality in haemodialysis patients, and 30% remain fluid overloaded at dry weight. The use of bioimpedance spectroscopy (BIS) in fluid management may improve blood pressure control and cardiovascular status. However, the importance of regular and careful clinical assessment of fluid balance is repeatedly emphasised.

This thesis is based on five papers and the overall aim was to investigate current practices and new methods for fluid management in haemodialysis, and to develop a management tool for dry weight determination, based on multiple complementary methods. The purpose was to contribute to reduced prevalence of fluid overload and intradialytic symptoms in haemodialysis patients, by providing the healthcare team and the patient with a tool, that facilitates communication and enables informed decision-making in dry weight determination.

In the initial, cross-sectional study, clinical praxis for dry weight assessment in Sweden and Denmark was investigated. A wide variation in routines was found. Despite high access, BIS was sparsely used. Instead, nurses’ authorisation to adjust haemodialysis patients’ dry weight was associated with improved fluid status. The second study had a qualitative approach. Focus group interviews, with healthcare professionals, were carried out to achieve a deeper understanding of the factors preventing or facilitating the use of BIS. In the third study, the usefulness of a biomarker, brain natriuretic peptide (BNP), for assessing fluid status in haemodialysis patients, was investigated. An association between BNP and fluid overload was established. The between-individual variation in BNP levels was greater than the within-individual variation over time. Therefore, if BNP is to be used as a marker for fluid overload, repeated measurements are required. In the fourth study, we developed and validated a multifactorial decision aid, Recova®, that incorporates BIS in dry weight determination. Recova® is based on physiological parameters routinely measured in haemodialysis and provides guidance on when and how to respond to recognised fluid alterations. In the fifth study, the decision aid’s effect on volume status was tested in a cohort of haemodialysis patients. Implementation of Recova® had effect on fluid status symptoms, BIS-measured hydration status and NT-proBNP levels.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2020. p. 72
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1664
Keywords
Haemodialysis, Fluid management, Fluid overload, Bioimpedance spectroscopy, Dry weight, Brain natriuretic peptide, Decision aid
National Category
Urology and Nephrology
Research subject
Medical Science
Identifiers
urn:nbn:se:uu:diva-407956 (URN)978-91-513-0935-4 (ISBN)
Public defence
2020-05-27, H:son Holmdahlssalen, Akademiska Sjukhuset, Ingång 100, 2 tr, Uppsala, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2020-05-06 Created: 2020-04-03 Last updated: 2020-05-06

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Stenberg, JennyLindberg, MagnusFuruland, Hans

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