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An in-depth analysis of the functions of dialysis, focusing on uremic solute removal and excess ECF volume removal. It discusses the methods of dialysis, how adequacy is measured, and the consequences of fluid overload. The document also explores the relationship between fluid overload and hypertension, as well as the causes and consequences of fluid overload in dialysis patients.
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©2017 MFMER | slide-
Excess ECF volume removal Main Process^ Diffusion
Ultrafiltration How is adequacyClearance of surrogatemeasured?solute - urea
BP control, Dry weight Quantification ofspKt/V, Std Kt/V, URRadequacy
No objective measure to quantifyadequacy of fluid removal. Trial &Error method to achieve DW Debate^ Small versus middlemolecular clearance(diffusive versusConvective clearance)
What is the best method toquantify ECF volume removal.Clinical versus Non-clinicalmethods
Dry Weight ECF volume LBM Initiation of HD^
High^
Low Adequate Maintenance HD^
Euvolemic^
Improves Acute illness^
Increases^
Decreases
25,291 pts of 176,790^ Others
% of 41,699 episodes 1008680 60 40 209 5 0 InpatientED^ Observationcare Average cost per episode
Total cost $6, $266 million
^ Arterial stiffness,so^ Sytemic VascResistance
^ LV dilatation
CHF, Compensatory neurohormonal activation^ ^ Arterial stiffness70 – 80% of hypertension in dialysis is from volume excess, 20 -30% other causes
Control groupPrescribed DW unchanged
^ PreloadLVH Afterload
Arrthymia, SCDCHF Ischemia Proof that volume control by dialysis regresses LVH No long term trails showing equivocally that volume control leads toconsistent reduction in LVMI translating into improved outcomes
20018016014012010080 60 40 20 0 FHN Daily Trial^ FHN Nocturnal Trial
Canadian Trial Effect of Intensive versus Conventional HD on LV Mass Mean Left Ventricular Mass (g)
ConventionalbaselineConventionalStudy endIntensivebaselineIntensive Studyend Treatment Effects:^ -13.8 g^
-10.9 g^ -15.3 g
1.941.621.51^ OverhydratedMen: FO/ECF ≥ 15%Women: FO/ECF ≥ 13%1.51p < 0.0011.301.25*^
Mortality rates 2015, USRDSCardiacarrhthmia/OthersSCD49%40% CHF3%AMI/ASHDCVA5%3% ECF volume excessCKD-MBD, FGF-23Reduced vascular compliance,increased PW velocity and PPLVHSilent ischemia, decreasedcoronary flow reserve,impaired microcirculationmyocardial stunningIDHHigher prevalence of CAD, DMIneffective vasoregulation