Fluid Removal during Hemodialysis: An Interview with Dr. Jennifer Flythe, Part II

For this second blog post, I continued my sit-down with Dr. Jennifer Flythe, an expert on hemodialytic fluid removal, to further our discussion on where we, the renal community, are today with fluid removal and where we are headed.

Dr. Brunelli: What do you anticipate will be the consequences of the new ultrafiltration (UF) rate metric?

Dr. Flythe: As I mentioned earlier, the UF rate metric will be incorporated into the Centers for Medicare & Medicaid Services (CMS) End Stage Renal Disease (ESRD) Quality Incentive Program (QIP) in 2020. The measure will likely have, and, in some ways already has had, the intended impact of focusing attention on fluid management—specifically UF rates.

Increased attention on UF rates—and, by extension, interdialytic weight gains, treatment times and volume status—by nephrologists has a trickle-down effect in dialysis clinics. Nurses, care technicians, social workers and dietitians—the people really on the frontlines—are increasingly thinking about fluid and how they can help their patients lower their UF rates. This is a great thing and should absolutely be encouraged. Beyond just getting people talking about fluid and UF rates, the measure may potentially lead to a reduction in UF rates over time as providers learn how to more effectively talk to their patients about the potential harms of high weight gains, short treatment times and associated rapid fluid removal. This would be another great effect.

Dr. Brunelli: Any foreseeable pitfalls or unintended consequences?

Dr. Flythe: The measure does have a couple of potential unintended consequences. If clinics decide to limit UF rates to a maximum of 13 mL/h/kg (or any other value) and patients do not lower their weight gains or extend their treatment times, patients will accumulate extra fluid over time, which would put them at high risk for bad outcomes.

Second, in cases where patients are willing to extend their treatment times to keep UF rates low, clinics will have to operationalize longer treatment times. Longer and potentially fluctuating treatment times can have implications not only for clinic staff and facility resources, but more importantly, for later-scheduled patients who may have set transportation times and other constraints. In the current dialysis environment, fluctuating start and end times for treatments are extremely difficult to operationalize. These unintended potential clinic and patient consequences should be considered.

Dr. Brunelli: What is your advice for health care providers as they seek to incorporate the new UF rate metric into clinical practice?

Dr. Flythe: It is imperative that we not get so focused on reducing UF rates that we lose sight of the equally important goal of getting patients to an appropriate fluid status (i.e., euvolemia) by the end of dialysis. In nephrology, dialysis in particular, it is important not to develop tunnel vision on clinical benchmarks—especially quantifiable measures such as Kt/V, hemoglobin, ferritin, phosphorus and PTH—and not to de-emphasize harder-to-quantify aspects of care such as fluid management or even quality of life. Yes, it is important to lower UF rates, but we cannot lower UF rates at the expense of fluid accumulation just because we can easily quantify a UF rate and cannot easily quantify volume status. Also, we have to keep perspective. The UF rate measure is just one of a growing number of ESRD QIP measures. Allowing a few clinic patients to continue to have high UF rates in the name of achieving euvolemia is not going to ruin a clinic from a quality or financial perspective. We have to treat the patient, not the quality measure.

From a practical perspective, we should try to be less rigid in dialysis prescriptions. Consider the following actions:

• Prescribe longer treatments after the long break and shorter treatments later in the week. Patients may be willing to dialyze longer on Monday if they know they have scheduled shorter treatments on Wednesday and Friday.
• Sit down with patients and show them the UF rate calculation—show them how much weight they can gain while keeping their UF rates < 13 mL/h/kg. Understanding the calculation and knowing that lower weight gains may allow them to have shorter treatment times may be an incentive for them to keep interdialytic weight gains down.
• Add fourth treatments—and when you can, keep the fourth treatment shorter than the other three, again, to make it more appealing to the patient.
• Implement time-limited trials of treatment extension. For example, ask a patient to try four-hour treatments instead of 3 ½-hour treatments for a two-week period and then reassess. Some patients may find that they feel better after longer treatments and be willing to keep with the longer time. Others may not and choose to go back to the shorter time and perhaps focus more on their weight gains via more attention to salt and fluid restriction.

Again—it gets back to flexibility and tailoring decisions to individual patient needs and preferences. A rigid, one-size-fits-all, thrice-weekly approach to dialysis is likely not optimal for fluid management or for the overall well-being of our patients.

Read Fluid Removal During Hemodialysis: An interview with Dr. Jennifer Flythe, Part I.

Jennifer Flythe, MD, MPH, is a medical director at the University of North Carolina Hospitals Dialysis Services, an assistant professor of medicine at the University of North Carolina at Chapel Hill and a research fellow at Cecil G. Sheps Center for Health Services Research.