uu.seUppsala University Publications
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf
Fluid Management in Haemodialysis: Studies on current practices and new methods
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Renal Medicine.ORCID iD: 0000-0003-2408-0087
2020 (English)Doctoral thesis, comprehensive summary (Other academic)
Description
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 [en]
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: urn:nbn:se:uu:diva-407956ISBN: 978-91-513-0935-4 (print)OAI: oai:DiVA.org:uu-407956DiVA, id: diva2:1421455
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
List of papers
1. Clinical praxis for assessment of dry weight in Sweden and Denmark: A mixed-methods study
Open this publication in new window or tab >>Clinical praxis for assessment of dry weight in Sweden and Denmark: A mixed-methods study
2016 (English)In: Hemodialysis International, ISSN 1492-7535, E-ISSN 1542-4758, Vol. 20, no 1, p. 111-119Article in journal (Refereed) Published
Abstract [en]

Overhydration is an independent predictor of mortality in hemodialysis (HD) patients. More than 30% of HD patients are overhydrated, motivating the development of new methods for assessing hydration status. This study surveyed clinical praxis and local guidelines for dry weight (DW) assessment in Swedish and Danish HD units, and examined if differences in routines and utilization of bioimpedance spectroscopy (BIS) and other assistive technology affected frequency of DW adjustments and blood pressure (BP) levels. Cross-sectional information on praxis, guidelines and routines, plus treatment-related data from 99 stratified patients were collected. Qualitative data were analyzed with content analysis and interpreted in convergence with statistical analysis of quantitative data in a mixed-methods design. Local guidelines concerning DW existed in 54% of the units. A BIS device was present in 52%, but only half of those units used it regularly, and no correlations to frequency of DW adjustments or BP were found. HD nurses were authorized to adjust DW in 60% of the units; in these units, the frequency of DW adjustments was 1.6 times higher and systolic BP pre-HD 8 mmHg lower. There is a wide variation in routines for DW determination, and there are indications that authorization of HD nurses to adjust DW may improve DW assessment. BIS is sparsely used; its implementation may have been delayed by uncertainty over how to manage the device and interpret measurements. Hence, better methods and guidelines for assessing DW and using BIS need to be developed.

Keywords
Hemodialysis, dry weight, bioimpedance spectroscopy, guidelines, blood pressure, mixed-methods design
National Category
Medical and Health Sciences
Research subject
Medical Science
Identifiers
urn:nbn:se:uu:diva-264132 (URN)10.1111/hdi.12336 (DOI)000369304400022 ()26264888 (PubMedID)
Available from: 2015-10-06 Created: 2015-10-06 Last updated: 2020-04-03Bibliographically approved
2. Perspectives on clinical use of bioimpedance in hemodialysis: focus group interviews with renal care professionals
Open this publication in new window or tab >>Perspectives on clinical use of bioimpedance in hemodialysis: focus group interviews with renal care professionals
2018 (English)In: BMC Nephrology, ISSN 1471-2369, E-ISSN 1471-2369, Vol. 19, article id 121Article in journal (Refereed) Published
Abstract [en]

Background

Inadequate volume control may be a main contributor to poor survival and high mortality in hemodialysis patients. Bioimpedance measurement has the potential to improve fluid management, but several dialysis centers lack an agreed fluid management policy, and the method has not yet been implemented. Our aim was to identify renal care professionals’ perceived barriers and facilitators for use of bioimpedance in clinical practice.

Methods

Qualitative data were collected through four focus group interviews with 24 renal care professionals: dieticians, nephrologists and nurses, recruited voluntarily from a nation-wide selection of hemodialysis centers, having access to a bioimpedance-device. The participants were connected to each other and a moderator via equipment for telemedicine and the sessions were recorded. The interviews were semi-structured, focusing on the participants’ perceptions of use of bioimpedance in clinical practice. Thematic content analysis was performed in consecutive steps, and data were extracted by employing an inductive, interactive, comparative process.

Results

Several barriers and facilitators to the use of bioimpedance in clinical practice were identified, and a multilevel approach to examining barriers and incentives for change was found to be applicable to the ideas and categories that arose from the data. The determinants were categorized on five levels, and the different themes of the levels illustrated with quotations from the focus groups participants.

Conclusions

Determinants for use of bioimpedance were identified on five levels: 1) the innovation itself, 2) the individual professional, 3) the patient, 4) the social context and 5) the organizational context. Barriers were identified in the areas of credibility, awareness, knowledge, self-efficacy, care processes, organizational structures and regulations. Facilitators were identified in the areas of the innovation’s attractiveness, advantages in practice, and collaboration. Motivation, team processes and organizational capacities appeared as both barriers and facilitators.

Place, publisher, year, edition, pages
Springer, 2018
Keywords
Barriers, Bioimpedance, Dry weight, Facilitators, Focus groups, Renal dialysis
National Category
Urology and Nephrology
Research subject
Medical Science
Identifiers
urn:nbn:se:uu:diva-351359 (URN)10.1186/s12882-018-0907-4 (DOI)000433236500004 ()29792174 (PubMedID)
Available from: 2018-05-24 Created: 2018-05-24 Last updated: 2020-04-03Bibliographically approved
3. Brain natriuretic peptide reflects individual variation in hydration status in hemodialysis patients
Open this publication in new window or tab >>Brain natriuretic peptide reflects individual variation in hydration status in hemodialysis patients
2019 (English)In: Hemodialysis International, ISSN 1492-7535, E-ISSN 1542-4758, Vol. 23, no 3, p. 402-413Article in journal (Refereed) Published
Abstract [en]

Introduction: Fluid management in hemodialysis patients is a controversial topic. Brain natriuretic peptide (BNP) is secreted from the heart in response to volume overload, and may be a marker of overhydration in hemodialysis patients. Our aim was to investigate the correlation between BNP and overhydration in a cohort of hemodialysis patients, and to find out whether BNP and overhydration correlate in repeated measurements within individuals with elevated BNP.

Methods: The study was prospective, observational, and had a cross-sectional part and a longitudinal follow-up. The distribution of BNP was investigated in a cohort of 64 hemodialysis patients. Blood samples and bioimpedance spectroscopy measurements were performed before midweek dialysis. Subsequently, 11 study participants with elevated BNP concentrations (>500 pg/mL) were assessed in another nine dialysis sessions each. These individuals also had their cardiac function and heart rate variability (HRV) examined.

Findings: BNP was above 500 pg/mL in 38% of the participants, and correlated positively with overhydration (r(s) = 0.381), inflammation and malnutrition, but not with systolic blood pressure. In comparison to participants with BNP below 500 pg/mL, participants with elevated BNP were older, had lower muscle strength, lower bodyweight and lower levels of hemoglobin and albumin. Echocardiography revealed cardiac anomalies in all 11 participants in the longitudinal follow-up, and HRV, as measured by SDNN, was pathologically low. In repeated measurements, the between-individuals variation of BNP in relation to overhydration was greater (SD = 0.581) than the within-person variation (SD = 0.285).

Discussion: BNP correlates positively to overhydration, malnutrition, and inflammation. In a subgroup of patients with elevated BNP, who are mainly elderly and frail, BNP reflects individual variation in hydration status, and hence seems to be a modifiable marker of overhydration. These data suggest that BNP is best applied for measuring changes in hydration status within an individual over time.

Place, publisher, year, edition, pages
WILEY, 2019
Keywords
Fluid overload, brain natriuretic peptide (BNP), bioimpedance, hemodialysis, repeated measurements
National Category
Urology and Nephrology
Identifiers
urn:nbn:se:uu:diva-391030 (URN)10.1111/hdi.12751 (DOI)000475503700025 ()30848066 (PubMedID)
Available from: 2019-08-19 Created: 2019-08-19 Last updated: 2020-04-03Bibliographically approved
4. Systematic fluid assessment in haemodialysis: Development and validation of a decision aid
Open this publication in new window or tab >>Systematic fluid assessment in haemodialysis: Development and validation of a decision aid
2020 (English)In: Journal of Renal Care, ISSN 1755-6678, E-ISSN 1755-6686, Vol. 46, no 1, p. 52-61Article in journal (Refereed) Published
Abstract [en]

Background

About a third of patients undergoing haemodialysis have poorly controlled fluid status, which may affectsurvival. Clinical assessment is subjective and imprecise, which has led to the increasing use of devices based on bioimpedancespectroscopy (BIS). However, BIS cannot provide a simple target applicable to all patients. Our aim was to developand validate a decision aid combining clinical assessment of fluid status with information from BIS in target weightdetermination.

Methods

The decision aid was based on empirical experience and a literature review identifying physiological parametersalready used in the clinical assessment of fluid status. Content validity was established by patient representatives, interdisciplinarystakeholders and external experts, who assessed item relevance and comprehensiveness. Reliability was assessedby inter‐rater agreement analysis between nurses assessing typical patient cases.

Results

The decision aid for Recognition and Correction of Volume Alterations (RECOVA) consists of three parts (1) a scoringsystem; (2) thresholds and triggers; (3) a decision aid algorithm. Agreement between raters in the assessment of symptomswas almost perfect, with Intraclass Correlation Coefficient > 0.90. Agreement in clinical response was only fair, but increasedto moderate, with training and self‐reported confidence.

Conclusion

RECOVA may enable systematic clinical assessment of fluid status, facilitating early recognition of fluid alterations,and incorporation of bioimpedance into target weight management. However, implementation into clinicalpractice will require training of staff. Clinical intervention studies are required to evaluate if RECOVA facilitates response toand correction of recognised fluid alterations.

Keywords
Bioimpedance, Fluid management, Haemodialysis, Overhydration, Validation
National Category
Urology and Nephrology
Research subject
Medical Science
Identifiers
urn:nbn:se:uu:diva-396814 (URN)10.1111/jorc.12304 (DOI)000493824500001 ()31682083 (PubMedID)
Available from: 2019-11-11 Created: 2019-11-11 Last updated: 2020-04-09Bibliographically approved
5. Implementation of a decision aid for Recognition and Correction of Volume Alterations (Recova®) in haemodialysis
Open this publication in new window or tab >>Implementation of a decision aid for Recognition and Correction of Volume Alterations (Recova®) in haemodialysis
(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:nbn:se:uu:diva-407955 (URN)
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

Open Access in DiVA

fulltext(857 kB)33 downloads
File information
File name FULLTEXT01.pdfFile size 857 kBChecksum SHA-512
f8c22c3c90d22a302ca189fb84e883e05554016f670a7f8ab104732717ee8b43759aee07dee2040050718c3335fe08a064af9f61f102382fb05d5135de31d8f8
Type fulltextMimetype application/pdf

Other links

Online Defence. Meeting ID: 103370

Authority records BETA

Stenberg, Jenny

Search in DiVA

By author/editor
Stenberg, Jenny
By organisation
Renal Medicine
Urology and Nephrology

Search outside of DiVA

GoogleGoogle Scholar
Total: 33 downloads
The number of downloads is the sum of all downloads of full texts. It may include eg previous versions that are now no longer available

isbn
urn-nbn

Altmetric score

isbn
urn-nbn
Total: 141 hits
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf