#209 Dialysis and Fluid Management: 5 Pearls Segment

[SPEAKER_04]: my recommendation is the follow-in two words. [SPEAKER_04]: Go in. [SPEAKER_04]: Like everyone's stop at the Dallas as unit of the door and they turn around. [SPEAKER_04]: They do the rounds and the cell will come back and they don't ever go into the Dallas tune. [SPEAKER_04]: So just go inside and I think that really the cool thing about Dallas is it's really not complicated but it's pretty darn life-saving.

[SPEAKER_03]: That's Dr. John Danzinger, and a phylogist at Beth Israel Deknism Medical Center. [SPEAKER_03]: Welcome to the core. [SPEAKER_03]: I am Thyah Pearl's podcast, bringing you high-yields Evan Space Pearls. [SPEAKER_03]: I'm Dr. Schrecher, ready and I'm joined by. [SPEAKER_01]: Hi, I'm Dr. Nathan Kulapore, an internal medicine resident at Beth Israel Deknism Medical Center.

[SPEAKER_01]: Today, we're talking about fluid management and end-stage kidney disease patients on human dialysis. [SPEAKER_01]: And we'll be using the no-manclature of ESKD instead of ESRD. [SPEAKER_03]: Uh-huh, I did not know that. [SPEAKER_03]: And Nathan, why did you say N-stage kidney disease and not N-stage renal disease? [SPEAKER_03]: Why are we saying ESKD now? [SPEAKER_03]: Not ESRD?

[SPEAKER_01]: Yes, so there's actually this movement in the nephrologic community to use nomenclature of ESKD over ESRD. [SPEAKER_01]: Because most people outside of medicine don't know what the term renal means. [SPEAKER_03]: Yeah, I definitely didn't know that. [SPEAKER_03]: But let's get into it. [SPEAKER_03]: I am so excited for this episode. [SPEAKER_03]: There's so much good teaching here. [SPEAKER_03]: And so many things I wish I'd known earlier on. [SPEAKER_01]: Exactly.

[SPEAKER_01]: So let's get into it and run through the five pearls for today's episode. [SPEAKER_03]: Yes, and remember the more you test yourself, the deeper you're learning gains. [SPEAKER_01]: Pearl 1. [SPEAKER_01]: Foundations of dialysis. [SPEAKER_03]: What does dialysis do compare to a normal kidney? [SPEAKER_03]: And how does that explain why your patient's creatine is sitting at seven? [SPEAKER_01]: Earl II, Distinct Physiology.

[SPEAKER_03]: What can autopsy's of patients who have end stage kidney disease tell us and teach us about what physiology differences there are? [SPEAKER_01]: Earl III, the importance of fluid management. [SPEAKER_03]: Why is fluid management the number one priority in end-stage kidney disease patients? [SPEAKER_01]: Earl 4, fluid management, pro tips. [SPEAKER_03]: How should we cancel our patients in terms of helping them manage their volume set us?

[SPEAKER_01]: Pearl 5, residual kidney function. [SPEAKER_03]: All right, what patients who still make a urine do on non dials days to optimize fluid?

[SPEAKER_03]: Let's start simple. [SPEAKER_03]: What is dialysis actually trying to do? [SPEAKER_01]: At its core, dialysis does two things. [SPEAKER_01]: One clearance, which is removing toxic particles like eeriea, and two ultra-filtration, removing excess salt and water. [SPEAKER_01]: I love Dr. Danziger's analogy of fish tank. [SPEAKER_04]: I like to think about us just as like a large tank. [SPEAKER_04]: almost like a fish tank. [SPEAKER_04]: And inside that tank of fluid, there are cells.

[SPEAKER_04]: And the cells are constantly making byproducts, which have toxic potential, right? [SPEAKER_04]: But if you talk about your tank and you talk about the leaders that are clear completely of the particles inside. [SPEAKER_04]: So now you have that same amount of fluid, but there's no particles. [SPEAKER_04]: That's clear. [SPEAKER_04]: And so clear is the concept of particle removal. [SPEAKER_04]: And then the other one is is actually just through the removal.

[SPEAKER_04]: Like how do we get rid of the salt and water in the tank? [SPEAKER_04]: It's really these two concepts that are so fundamental. [SPEAKER_04]: How do we talk about clearance, which is a mirror image of removing toxins, leaders clear particles, but clearance refers to particle removal, and then the other concept is this idea of ultra filtration, which is the removal of fluid, which is essentially salt and water. [SPEAKER_04]: And so dialysis has to really achieve both of those.

[SPEAKER_03]: Now, with that, how does the dialysis machine actually do its two jobs? [SPEAKER_01]: So we're talking about hemadiosis, not per tenial, and in this case, the machine is taking the blood from your body, running it into the machine one way, and then you have a separate fluid called the dialysis that runs in the opposite direction, and these two fluids are separated by a dialysis membrane. [SPEAKER_01]: And the concentration gradient between these is what helps with clearance.

[SPEAKER_03]: And then, if the fluid removal has a bit simpler. [SPEAKER_04]: So the food removal is very easy. [SPEAKER_04]: Essentially, if these filters, the nurses can basically change the pressure across the blood supply. [SPEAKER_04]: And by increasing the pressure across the blood supply as it's in the stiles of the filter, they can squeeze out protein and cell-free fluid. [SPEAKER_04]: And essentially what they're squeezing out is basically a syrup.

[SPEAKER_04]: So you'll get everything that's in your blood, your sodium, your urea, your potassium, [SPEAKER_04]: Wilkes, we will come out with the water. [SPEAKER_04]: So they're putting pressure, there's ultra filtration, and they can move salt water and everything else out into the dial, and that's essentially how they affect fluid removal. [SPEAKER_03]: Okay, so it's hydrostatic pressure that pushes protein free fluids, so plasma water and the dissolved solids across the dials is membrane.

[SPEAKER_04]: And so the prescribing to phrologist really has two things as well, how much clearance I'm going to give them and how much fluid I'm going to take off and those are two components of a prescription so most patients depend on their body size need three and a half to four hours to reach the clearance that we set as a goal, which is cleaning the total body water four times per week.

[SPEAKER_03]: Now let's get to some math and I have to say once I understood the math a bit, it really clicked for me why our patient's labs look so different. [SPEAKER_01]: We'll detail the full calculations in the show notes, prepare to be mindful. [SPEAKER_03]: It really is.

[SPEAKER_01]: Yes, so based on a normal GFR of 120 milliliters per minute, an average weight of 60 kilograms, which equates to 40 to 50 liters of water, the frequency, this total body water ends up being filtered, is 30 times per week. [SPEAKER_01]: But a standard dials ascession, that equates to the total body water being [SPEAKER_03]: Yeah. [SPEAKER_03]: And so just to say it again, if we compare a patient who's on dialysis, they get their total body of water cleared four times a week.

[SPEAKER_03]: But someone with normal kidneys will get their total body of water cleared of toxins, diarrhea, creatinine 30 times a week. [SPEAKER_03]: So for versus 30, that ratio is about one seventh. [SPEAKER_03]: And that's exactly why patients labs look the way they do. [SPEAKER_04]: break down products as a normal individual. [SPEAKER_04]: So what's a typical free adenine analysis around service? [SPEAKER_04]: right, a normal creatinine for most of us is around one.

[SPEAKER_04]: If we're getting one seventh that clearance, a typical creatinine on dialysis is around seven. [SPEAKER_04]: Now, of course, if you're a tiny woman and you have a small body mass, you will have one seventh of your normal weight. [SPEAKER_04]: And so there's a variability in this, but I think it's, you know, does at least give some ideas to what a typical electrolyte panel looks like in hemod dialysis. [SPEAKER_03]: Alright, so that's a bit of a mind shift here, right?

[SPEAKER_03]: Like when we see that creatinine of seven on a BMP, that's actually a well-dialized patient. [SPEAKER_03]: And then a practical point that can save us from some panic and some pages for critical lab results. [SPEAKER_04]: the other thing I would say is please don't check labs after dialysis. [SPEAKER_04]: They are uninterpretable. [SPEAKER_04]: And so the potassium is going to be very low. [SPEAKER_04]: The phosphorus is going to be very low.

[SPEAKER_04]: And you're going to want to repeat it. [SPEAKER_04]: And then you're going to give them potassium. [SPEAKER_04]: And six hours later, the potassium is going to be really high. [SPEAKER_04]: And then a phrology team is going to be really upset with you. [SPEAKER_04]: So don't check the labs for at least six hours after dialysis to let them equilibrate and to be more reflective of their truth [SPEAKER_03]: All right, so do not check the BMP right after a dialysis session, right?

[SPEAKER_03]: And I think understanding what's actually happening with dialysis helps me at least appreciate why we should wait at least a few hours for a equilibrium to happen. [SPEAKER_01]: A very practical takeaway. [SPEAKER_01]: All right, let's recap per one. [SPEAKER_01]: Dialysis is accomplishing two things. [SPEAKER_01]: The clearance of toxins and ultra filtration of volume.

[SPEAKER_01]: Next, a well-dialized patient gets one-seventh the clearance of normal kidneys, which is why the creatinine number of seven is expected. [SPEAKER_01]: Finally, don't check labs until at least a few hours after dialysis to allow for a collaboration.

[SPEAKER_01]: And it is that ESKD patients are physiologically distinct, as kind of like a tide pool at the ocean's edge. [SPEAKER_01]: Born of the same sea, but governed by different horses. [SPEAKER_03]: Thanks. [SPEAKER_03]: OK, so to translate one, Nathan is saying, into English, he just loves nephrology that much.

[SPEAKER_03]: But I think he's trying to pay is the picture that we can't assume that the medicine we know for all or other patient automatically maps out to our patients who are on dialysis. [SPEAKER_04]: Dallas's patient, we very rarely see in acute myocardone function. [SPEAKER_04]: Most patients are dying of cardiovascular disease, but that's not a scheme of cardiovascular disease.

[SPEAKER_04]: That's a type of unique type of cardiovascular disease defined by Monkerberg's arterial sporesis, the medial calcification. [SPEAKER_04]: And if you ever get the opportunity to go to an autopsy of a dialysis patient, do it, because it's incredibly informative. [SPEAKER_04]: And you don't actually watch an autopsy of a dialysis patient, you listen to it. [SPEAKER_04]: Because when they pull out the A order, it sounds like this. [SPEAKER_04]: It's incredible.

[SPEAKER_04]: their vessels are like lead pipes. [SPEAKER_04]: And so they're dying from hemodynamic complications of these lead pipes. [SPEAKER_04]: They're not dying from acute plugs and acute myocardial infarctions. [SPEAKER_04]: They're dying from LDH, from ventricular hypertrophy, from abnormal myocardial remodeling. [SPEAKER_04]: A hard one dialysis is fibrotic, and it's demobal fibrotic. [SPEAKER_04]: So the physiology is so different from these individuals.

[SPEAKER_04]: And so the things that you accept as normal in general medicine often doesn't apply. [SPEAKER_04]: Basic questions, any calculation in atrial fibrillation? [SPEAKER_03]: Okay, that is such a humbling reminder. [SPEAKER_03]: Lead pipe vessels, global cardiac fibrosis. [SPEAKER_03]: These are not our standard patients with hypertension.

[SPEAKER_03]: And that helps explain as we'll see in the following pearls and in the next episode why our typical blood pressure holes don't often apply to these patients.

[SPEAKER_01]: Now the stage is set, we can let the play begin. [SPEAKER_01]: Here's what Dr. Danziger highlighted as one of the biggest takeaways in caring for these patients. [SPEAKER_04]: Please, just figure out fluid management. [SPEAKER_04]: Because that's really how you're going to help your patients in the Dallas's, it's fluid management. [SPEAKER_04]: Nothing else is more important. [SPEAKER_01]: Okay, nothing more important.

[SPEAKER_01]: I also sat down with Dr. Erica Drewary, an aphrologist at University of Rochester, who helped break down very practically how she approaches fluid management, and it starts with thinking critically about the dry weight. [SPEAKER_02]: The dry weight is defined as the weighted which a patient has no volume overload. [SPEAKER_02]: And this is a weight that is determined clinically. [SPEAKER_02]: And dry weight is going to a change during a patient's lifetime.

[SPEAKER_02]: So if someone gains nutritional body weight like they've gained muscle mass or fat mass, [SPEAKER_02]: their dry weight is also going to go up or if they've lost muscle, mass, fat, mass, kind of other body weight, their dry weight is going to go down. [SPEAKER_02]: So it's something that we cannot just set it and forget it. [SPEAKER_02]: We have to continually reassess as this appropriate target dry weight for a patient.

[SPEAKER_03]: Man, that point of changes in muscle and fat mass over time really hits home. [SPEAKER_03]: I recently had this patient who said she used to weigh 220 pounds. [SPEAKER_03]: And then, unfortunately, had a whole year of being in and out of the hospital, being mostly bedbound and losing muscle. [SPEAKER_03]: And in front of me was 190 pounds in her AM standing weights.

[SPEAKER_03]: And, [SPEAKER_03]: In one sentence on paper, yeah, it looked like she was well below her dry weight, but actually there was a lot of that redistribution and she was quite overloaded. [SPEAKER_03]: And so that was just so memorable to me. [SPEAKER_03]: And it really helped the hammer home the idea that if we're just trending the weight number alone without context, we can really be misled. [SPEAKER_01]: Yeah, things were sharing that story, Shreya.

[SPEAKER_01]: I think it really pains the dilemma in my mind. [SPEAKER_03]: Yeah. [SPEAKER_01]: So it makes me wonder when should we be pushing that dry weight lower or just questioning it? [SPEAKER_02]: I would argue that we should always be trying to push someone's dry weight down or always at least think about pushing it down because a lot of dialysis patients do have volume overload when it's not quite obvious. [SPEAKER_02]: You walk by the patient and you look at them and examine them.

[SPEAKER_02]: They don't have peripheral edema or lungs sound pretty clear, but that's the limit of your exam. [SPEAKER_02]: But they might have true volume overload, maybe you can call it subclinical. [SPEAKER_02]: So I think it's always important to try and consider how to put this patient's dry weight a little bit lower. [SPEAKER_02]: Could I challenge their dry weight? [SPEAKER_03]: All good points to bring up. [SPEAKER_03]: So let's talk about the elephant in the room.

[SPEAKER_03]: Why do we care so much about this? [SPEAKER_03]: Why does fluid management matter so much? [SPEAKER_02]: In most dialysis patients, hypertension is often related to volume overload. [SPEAKER_02]: So the first way to address hypertension is not by adding a blood pressure medication, but by trying to make sure that we are achieving an appropriate dry weight. [SPEAKER_03]: So this is the real mindset or a mantra that we all need to take away.

[SPEAKER_03]: It's gonna be volume first and then blood pressure second, right? [SPEAKER_01]: We do, there's this study, the drip trial that showed that just reducing dry weight alone without any adjustments to medications made a significant impact on patients' blood pressure. [SPEAKER_03]: Yeah, so I think that was surprising to me was that the people enrolled in this trial did not look volume overloaded. [SPEAKER_03]: No over edema, lungs were clear.

[SPEAKER_03]: Yet the sub-clinical volume overload was enough to drive up blood pressure. [SPEAKER_03]: And so you don't have to be so overtly overloaded to raise pressures. [SPEAKER_01]: Exactly. [SPEAKER_01]: The moon. [UNKNOWN]: Yes. [SPEAKER_03]: And maybe we can just sit with this idea. [SPEAKER_03]: Like, why is it that extra volume can lead to elevations in blood pressure? [SPEAKER_03]: And I think it goes back to the idea we talked about in Pearl 2 about these patients on dialysis.

[SPEAKER_03]: They have these relatively rigid lead pipe vessels. [SPEAKER_01]: Right, if we think what normally happens when intravascular volume increases and blood pressure is rising, a normal patient's blood vessels will respond by relaxing to relieve that pressure. [SPEAKER_01]: So in these ESKD patients that have these stiff, lead-pipe vessels, they can't relax as well. [SPEAKER_01]: So even a mild increase in volume leads to a significant increase in blood pressure.

[SPEAKER_03]: Yeah, it kind of sucks, right? [SPEAKER_03]: Like these patients are indelibined. [SPEAKER_03]: You know, their volume comes in, right? [SPEAKER_03]: They need to drink. [SPEAKER_03]: They can't excrete it, and then at the same time, their vessels can't easily adapt. [SPEAKER_04]: What happens if you've had long-standing hypertension and long-standing chronic kidney disease, like all of the dialysis patients have? [SPEAKER_04]: Well, that ventricle begins to thicken.

[SPEAKER_04]: And so for each, you know, milliliter of blood that fills the pressure within the ventricle is higher. [SPEAKER_04]: And so there's a very steep part of the diastolic fully curved during the fill cycle of diastolic fill in for most dials as patients and why that's important is because they can get into pulmonary flash into pulmonary dima very, very quickly.

[SPEAKER_03]: Ah, so steep dystallic filling curve means extra volume can shoot ventricular pressures up and before we know it, patients can be in Florida, pulmonary edema. [SPEAKER_02]: I have a patient. [SPEAKER_02]: I think that's a great example of this. [SPEAKER_02]: So dialysis patient that had been new to me several years ago because he had switched dialysis clinics.

[SPEAKER_02]: And in reviewing his history, he had frequent hospitalizations for severe hypertension that was relatively acute onset, pulmonary edema, acute hypoxia respiratory failure,

[SPEAKER_02]: He would sometimes end up on bypass and require IV anti-hypertensive, and then we would do an ultra-filtration session or two, and we'd get his blood pressure down, and then maybe a blood pressure medication would be added in the hospital, and then upon discharge, the same thing we happen to get in months later, and after a lot of education with him on reducing his sodium intake,

[SPEAKER_02]: which was actually quite high and really pushing his dry weight down, even when he did not seem to look very valuable, overloaded when we saw him, but his blood pressure's pre-dialysis were always quite high. [SPEAKER_02]: We were able to get him to a point where I was able to take him off of all of his blood pressure medications, and he had beautiful blood pressures.

[SPEAKER_02]: We were taking off only a few years of fluid with dials and sessions, and he had not gone to the hospital. [SPEAKER_02]: in a couple years, because we were able to achieve a really nice dry weight for him, which subsequently managed his blood pressure. [SPEAKER_02]: I think we got it down like a good 10 kilos. [SPEAKER_03]: 10 kilos?

[SPEAKER_03]: Wow. [SPEAKER_03]: Someone carrying around 10 kilos of extra fluid and just being hospitalized, repeatedly being discharged on different blood pressure meds and the answer was really in the dry weight, [SPEAKER_01]: I know what a powerful story, Shreya. [SPEAKER_01]: So to recap, estimated dry weight is the cornerstone of the house's care.

[SPEAKER_01]: It's clinically determined, changes over time, especially when someone's muscle mass might be changing, like the story you shared Shreya. [SPEAKER_01]: And we should always be asking if we can push it lower, especially when blood pressure is elevated.

[SPEAKER_03]: Yeah, and then I think for me, the next time I see someone's blood pressure, flagged as a red in a patient who is on dialysis, I'll think a little bit more about, can we push that dry weight down a little bit and is it volume that's contributing, right? [SPEAKER_03]: We have evidence from that drip trial that even modest dry weight reductions can improve blood pressure, even in people who don't have overt edema.

[SPEAKER_01]: So what happens when we're not staying on top of that dry weight? [SPEAKER_01]: We end up in what Dr. Dan Ziggler calls a seesaw pattern. [SPEAKER_04]: Right now, you think about Monday when they fired a dialysis. [SPEAKER_04]: They gain fluid, we take it off. [SPEAKER_04]: They gain fluid, we take it off a seesaw pattern. [SPEAKER_04]: And if you could kind of blunt that to more of a gentle sine wave so that their intake was less.

[SPEAKER_04]: I think that would help our dialysis procedure because they wouldn't have to take off as much. [SPEAKER_03]: Seth fluid built up, we pull it off, fluid built up, we pull it off over and over. [SPEAKER_01]: And that seesaw isn't just a number as problem. [SPEAKER_01]: I had a chance to sit down with David Rush, a patient on human analysis since his 20s. [SPEAKER_01]: He described what this is actually like. [SPEAKER_00]: taking off three kilos at a time or four kilos.

[SPEAKER_00]: Some people, I remember back in the days, five, six when I didn't understand what that meant is very texting on the body. [SPEAKER_00]: When I'm done with treatment, honestly, most honest effect that I can tell you what I feel like a little bit is like a lava lamp. [SPEAKER_00]: I'm just kind of just moving around. [SPEAKER_00]: Everything, the washing, my vision's a little blurry, bright light, it's a really bright vision in my eyes a little bit.

[SPEAKER_00]: And those are just my personal effects. [SPEAKER_03]: a lava lamp, man. [SPEAKER_03]: That's what aggressive fluid removal feels like, and even much worse when we let our patients get too far behind. [SPEAKER_01]: And one of our reviewers, the wonderful Dr. Jeff William, pointed out that sometimes, fluid removal is tricky in the real world. [SPEAKER_01]: People can get symptomatic hypotension, like cramping, nausea, or headaches, with even modest, fluid removal.

[SPEAKER_01]: So the less fluid that has to come off, the better the session goes. [SPEAKER_03]: Yes, so then how do we stay on top of it? [SPEAKER_03]: Like, Nathan, you talked to so many nephrologists and curious, what did you take away from talking to them and what have you changed in your practice to help with fluid management? [SPEAKER_01]: Yes, fortunately, we're in luck. [SPEAKER_01]: And it starts with simple counseling.

[SPEAKER_01]: We love talking about fluid restriction, but the real money is in the salt. [SPEAKER_04]: It's not about drinking the water. [SPEAKER_04]: That's secondary. [SPEAKER_04]: The primary issue is a low salt diet, because if they eat salty food, they're going to be incredibly thirsty, and they're going to drink water, right? [SPEAKER_04]: You can't extinguish the thirst mechanism.

[SPEAKER_04]: Oh, you really have to counsel all your CKD patients, all your patients with hypertension, and definitely all your dialysis patients. [SPEAKER_04]: about salt reduction. [SPEAKER_04]: Process food reduction. [SPEAKER_04]: Reduce dietary sodium. [SPEAKER_04]: It's absolutely critical and might be the most important thing that they can do. [SPEAKER_01]: Ultimately, the reasoning to limit sodium is to limit the subsequent fluid intake because the patients are not peeing.

[SPEAKER_01]: They're literally like a box. [SPEAKER_01]: What comes in doesn't come out until dialysis. [SPEAKER_00]: So I'm holding all this water in and treatment is modulating this spell of this water. [SPEAKER_00]: So if my dry weight, let's say, is a 138.5 and I'm gaining three, four kilos over time.

[SPEAKER_00]: I have to now dry that often be during the treatment, which can be very taxing, camping, all those things that happen, drop on blood pressure, all those things happen during that time, trying to pull off that much fluid. [SPEAKER_01]: And David actually had some really practical tips he learned over the years for managing this day to day. [SPEAKER_01]: fruits.

[SPEAKER_00]: Yeah, they have water in them, but if you eat fruits a little more, it is for fresh as you were wondering about the drinkable bottle. [SPEAKER_00]: And if you do, I would put things in smaller cups or range it in my bottles. [SPEAKER_00]: If you know that if you drink four bottles for the day, you're going to gain 2.2 kilos. [SPEAKER_00]: And that's your max that you can go on treatment. [SPEAKER_00]: And I would just stick with those four all the day and make push fruits.

[SPEAKER_00]: I find that. [SPEAKER_00]: So it's just learning dryweight, understanding dryweight, being proactive in, you know, and your fluid intake and knowing what to put into your [SPEAKER_03]: I love that trick with the fruits and definitely going to suggest that to my patients next time. [SPEAKER_03]: And then David also had this remarkable story about what happened to him when he changed his diet more dramatically.

[SPEAKER_00]: The doctor said, if you can slow your meat and take them, I start eating meat completely from that day. [SPEAKER_00]: And when that happened, and with the help of home balances and doing more dialysis, you know, daily dialysis treatments, my blood pressure subsided. [SPEAKER_00]: And I got off all seven blood pressure medications now, now I'm on and my blood pressure [SPEAKER_00]: and it had to do mostly with the diet, salt intake, meats, and of course, Hondahouse is doing more.

[SPEAKER_00]: The house is a home help to save my blood pressure. [SPEAKER_03]: I love a winning story. [SPEAKER_03]: It is so inspiring. [SPEAKER_03]: I mean, diet changes are hard or said they're done. [SPEAKER_03]: And when I think we all know that, but I think definitely inspires me to still try to do good counseling around salt. [SPEAKER_03]: Maybe tricks around even fruits.

[SPEAKER_03]: And of course, you know, pointing out where there may be hidden salt, right, especially a process me in a gosh, this David was able to get off seven medants. [SPEAKER_01]: Yes, quite incredible. [SPEAKER_01]: So let's recap, Pearl 4 up fluid management, we're trying to avoid the seesaw pattern, where fluid is building up between sessions and then needing aggressive removal during dialysis.

[SPEAKER_01]: And that makes the entire dialysis experience miserable for patients, not to mention the cramps low blood pressure and other side effects that happen with intense fluid removal. [SPEAKER_03]: Definitely, and if for the prevention perspective, the money's in the salt, right? [SPEAKER_03]: Not just the water, and it's really because the salt is going to drive the thirst, and then the thirst, of course, drives fluid gain.

[SPEAKER_03]: Okay, so what if we're patient is still peeing aka still has this residual kidney function? [SPEAKER_03]: That kind of changes things and we have a little bit more options. [SPEAKER_03]: So how do we best minimize the CSA pattern beyond just salt counseling and patients who have residual kidney function?

[SPEAKER_02]: And if I'm starting a CKD patient and dialysis for the first time, and they're already on a daily diuretic, what I'll typically do is I keep them on the diuretic, but I change it to Nadella's days, because when we're dialasing someone, we're often trying to take a little bit of fluid off, and if they take their diuretic on their diola's stay, you'd really don't need both oftentimes. [SPEAKER_02]: So I'll often keep the diuretic going, but just switch it to non dialysis days only.

[SPEAKER_02]: Why do we keep it going? [SPEAKER_02]: If they're still urinating a lot, take advantage of that urine output, to manage their volume status. [SPEAKER_01]: So many patients still make meaningful year and when they first start dialysis, even though it's not enough for adequate clearance on its own. [SPEAKER_01]: Over time, as residual function is lost, achieving dry weight gets harder and harder.

[SPEAKER_01]: So while our patient has residual function, we should definitely try to leverage and preserve it. [SPEAKER_03]: Yeah, speaking of preserving. [SPEAKER_03]: Sometimes I get scared of the doses, just because I'm like, whoa, is that high dose going to hurt this patient? [SPEAKER_02]: You can use pretty high doses of diuretics because these patients have very low GFRs, right? [SPEAKER_02]: You have very low GFRs. [SPEAKER_02]: You need a lot of diuretic to actually have an effect.

[SPEAKER_02]: So pick your loop diuretic of choice and you do not need to be worried about the high doses because that's what they need. [SPEAKER_01]: Another hall is about how much fluid we can actually take off on non-dialysis days, and how we might be undershooting it on non-dialysis days out of unnecessary caution. [SPEAKER_03]: Yeah, they may class of teaching when we really want to get fluid off, is okay. [SPEAKER_03]: Net negative 1 to 2 liters per day.

[SPEAKER_04]: when you give someone a diurect, me pee out, salt and water, and initially it comes from the intervascular space, but very, very quickly, it's refilled from the interstitial space. [SPEAKER_04]: And so, you know, really, I think if you wanted to know what a question was like, how much fluid can you take off a day in a person? [SPEAKER_04]: How quickly does this person move salt and water from the interstitium into the intravascular space?

[SPEAKER_04]: And if you can answer that, I can tell you 100% people can take up way more than one to two years. [SPEAKER_04]: That's not predicated on anything. [SPEAKER_04]: It how do I know that is because we could take the sickles patients in the world. [SPEAKER_04]: We put them on dialysis and we take up one or two liters in four hours and they're fine. [SPEAKER_04]: And so why we, you know, 24 hour basis will be only take off one or two liters.

[SPEAKER_04]: We're doing exponentially higher during their dial, succession, and they can refill those refill rates, the refill rates from the interstitium to the vasculature, have been studied and generally have been defined. [SPEAKER_01]: So let me reiterate this because plasma refill rate was a new concept to me. [SPEAKER_01]: When we remove fluid with a diuretic or dialysis, the interbascular space will refill from the interstitial.

[SPEAKER_01]: The rate at which that refill happens determines how much fluid you can safely remove. [SPEAKER_04]: The biggest determinant of what the rate is is heart function. [SPEAKER_04]: And so if you've got a really crappy heart, then you've got, you know, a sustained ejection fraction of 15 or 20%. [SPEAKER_04]: The refill rate is about 500 cc per hour. [SPEAKER_04]: And if you've got a great heart and your normal, it's probably closer to two liters an hour.

[SPEAKER_03]: Okay, so the patient's cardiac function is when a big is factors with how aggressive we can diaries on non dialysis days. [SPEAKER_03]: But of course, there's more nuance and just ejection fraction. [SPEAKER_01]: Hearing this has certainly helped me move beyond the reflexive one to two liters max mindset when they need more fluid off. [SPEAKER_03]: Yeah, same.

[SPEAKER_03]: And then, I think the other thing to say at loud is, you know, when do we stop the diaretic altogether in a patient who's on dialysis? [SPEAKER_02]: Oh, someone is making less than a cup a year in a day. [SPEAKER_02]: I stopped the loop diuretic. [SPEAKER_03]: OK, less than a cup a day, we can stop. [SPEAKER_03]: Good to know. [SPEAKER_01]: Sort of recap on the clinical side.

[SPEAKER_01]: If we need to be aggressive with FlutterMoval, we can often pull more than one or two liters of non-dialysis days, depending on cardiac function and plasma refold rate. [SPEAKER_01]: For diuretics, switch to use a non-dial stays. [SPEAKER_01]: Use high doses if needed given a low GFR and stop entirely when you're an output dropped below a cup of day. [SPEAKER_03]: Yeah, and with that, that is a wrap for today's episode.

[SPEAKER_03]: If you found it helpful, our ask is to please share it with one other colleague, a team of yours. [SPEAKER_03]: Anyone else who might find this episode helpful. [SPEAKER_01]: Thank you so much for our peer reviewers, Dr. Jeff William, Dr. Jeff Cot, and Dr. Matthew Sparks. [SPEAKER_03]: And as always, we love hearing feedback. [SPEAKER_03]: Please email us at helloacoriumpodcast.com.

[SPEAKER_01]: And a huge thank you to David Rush for sharing his experience and his wisdom so generously throughout these episodes. [SPEAKER_01]: We hope you now have a greater appreciation for the magic of Dallas. [SPEAKER_03]: Mm-hmm. [SPEAKER_03]: Hi, definitely, do. [SPEAKER_03]: And then, last but not least, there's one last practical point that just came up over and over in our conversations. [SPEAKER_03]: We didn't know where to put it, but I thought it'd be a good way to end.

[SPEAKER_02]: A lot of times patients who are on long-term chemo dialysis, all of those records are in a separate medical record system, because a lot of these patients are getting dialysis that large dialysis organizations that aren't directly associated with or connected with your institution. [SPEAKER_02]: And so there's a lot of data there that you might not have access to.

[SPEAKER_02]: But if you have questions about what's going on in dialysis, maybe they came in with chest pain during dialysis, you don't really know what the story was. [SPEAKER_02]: You can certainly just call the dialysis center and talk to one of the nurses that took care of them that day and get a lot of information from them.

[SPEAKER_02]: Their outpatient nephrologist or nephrology team is a really great source of information again because at least they know where I work, a lot of this is hidden from the medical team. [SPEAKER_01]: Nice. [SPEAKER_01]: Let's go. [SPEAKER_01]: How do you feel about one? [SPEAKER_01]: I like it. [SPEAKER_03]: Yeah, I like it. [SPEAKER_03]: I like it. [SPEAKER_03]: Good energy. [SPEAKER_03]: Okay, let's keep it up.