Dry Weight Assessment in

Haemodialysis Patients
Maimun Syukri

Division of Nephrology and

Hypertension,
Syiah Kuala University/dr.Zainoel
Abidin Centre Hospital ,
Banda Aceh - Indonesia
WHAT
IS DRY
WEIGHT?
“The weight at which the dialysis patient has neither
edema nor hypertension with no
BP medication”
DW is the lowest weight at which patient does not
develop intra dialytic hypotension & cramps
Thomson GE, et al. Arch Intern Med 1967;120:153-167
Dry Weight Terminology

Clinical terminology
 Two Main Risk Factors Faced by
Dialysis Patients

Risk Factors

Cardiovascular Risk factors Nutritional Risk Factors

Salt intake Inflammation

Sodium overload  intake of nutrient
Fluid intake Loss of appetite
Failure to diagnose hypervolemia  protein catabolism
Failure achieve normovolemia Hyperparathyroidism
Antihypertensive medications Insulin resistance
etc.. etc

Volume Overload  Hypertension  LVH Malnutrition

 CVD ( fat/muscle mass   ECV)

 Mortality Risk of Dialysis Patients

 Associations of Posthemodialysis Weights above and below Target Weight with All-Cause and
Cardiovascular Mortality
Jennifer E. Flythe,*† Abhijit V. Kshirsagar,* Ronald J. Falk,* and Steven M. Brunelli†‡
Abstract
Background and objectives
Fluid removal via ultrafiltration is a primary function of hemodialysis, and inadequate volume control is associated
with significant morbidity and mortality among chronic dialysis patients. Treatment-to-treatment fluid removal goals
are typically calculated on the basis of interdialytic weight gain and prescribed target weight. The clinical effect of
frequent missed target weights is unclear. This study was designed to evaluate the associations of postdialysis
weights above and below the prescribed target weight (separately) and outcomes.
Design, setting, participants, & measurements
Data were taken from a national cohort of 10,785 prevalent, thriceweekly, in-center hemodialysis patients dialyzing
from 2005 to 2008 (median time at risk, 2.1 [25th percentile, 75th percentile] years) at a single dialysis organization.
Patients were characterized as having an above target weight miss if their postdialysis weight was > 2 kg above
target weight in at least 30% of baseline treatments (14.6% of cohort), or they were characterized as control
otherwise. Below target weight miss characterization was analogous for patients with postdialysis weight .2 kg
below target weight (6.6% of cohort). Coprimary endpoints were all-cause and cardiovascular mortality.
Results
Above target weight miss in at least 30% of treatments (versus not) was associated with greater all-cause mortality
(adjusted hazard ratio, 1.28; 95% confidence interval, 1.15 to 1.43); and below target weight miss in at least 30% of
treatments (versus not) was associated with greater all-cause mortality (adjusted hazard ratio, 1.22; 95% confidence
interval, 1.05 to 1.40). Both above and below target weight misses were also significantly associated with greater
cardiovascular mortality. Secondary analyses demonstrated dose-response relationships between target weight
misses and mortality. Results from sensitivity analyses considering the difference in postdialysis and target weights
as a proportion of body weight were analogous to the primary results. Conclusions Postdialysis weights > 2 kg
above and below target weight are associated with higher all-cause and cardiovascular mortality. Consistent target
weight achievement is a viable target for improving fluid management. Clin J Am Soc Nephrol 10: 808–816, 2015.
doi: 10.2215/CJN.10201014
 Managing IDFG in the ESRD Patient: Reaching for the Target
Weight

How is fluid overload managed in the CKD patient?

• The primary goal in dialysis (either HD or PD) is to

remove enough fluid to get the patient to what is
called their “target weight” or “dry weight” *

• Dry Weight is defined as the lowest weight a patient can tolerate without the development of
symptoms or hypotension*

The Question is, how to accurately determine this

‘Dry Weight’?

*Henderson, LW Kidney Int 17: 571-576, 1980

 Pathophysiology of dry weight
• normal kidney functions 24 hrs/day
• HD is discontinuous, a few hours every 2 or
3 days: to a peak-and-valley situation.
• The patient gains one to several liters of ECV
during the interdialytic period.
 Pathophysiology of dry weight
If this weight has If it has been found
been found to be too to be too low, the
high, the planned planned UF must be
ultrafiltration (UF) decreased.
must be increased.
• IDWG = 3 kg
• Set UF = 3.2 kg
– allow about 200 ml
IDWG = 1kg
extra for blood return
Set UF =1.2 kg
+ fluid & food taken during HD
Pathophysiology of dry weight

He needs to lose the

At the initiation of each HD
weight gained during
session: the patient is saline
the interdialytic period
overloaded, or "wet." to return to the last
postdialysis weight.
Pathophysiology of dry weight

The water
Refilling and
from salt subtraction
interstitial from the plasma
(and intracellular) spacesvolume
has
createsbut
started a disequilibrium situation between the plasma
is not yet completed
and
(it interstitial
takes about 4spaces.
hours).
 Pathophysiology of dry weight
• At the end of the HD session, plasma volume
reaches a nadir.
• At disconnection the patient is hypovolemic,
or "dry," and may have a postural BP drop that
will disappear within a few hours.
Assessment of
Dry Weight
Dry weight Assessment: Clinical

 Blood pressure
 JVP
 Oedema/ascites
 Lungs
examinations
 Weighing scale.
Dry weight Assessment: non-clinical

 Inferior vena cava

diameter
 Atrial natriuretic peptide
(ANP)
 Bioimpedance
 Blood volume monitoring
INFERIOR VENA CAVAL DIAMETER

Overhydration: VCD > 11, CI < 40%

Ideally measured 2hrs post dialysis
Limitations: Operator variability, heart failure
Timing of measurements is of pivotal importance for VCD, reference value of 8mm/m2
obtained 2 h after dialysis.
 Natriuretic peptides and the dialysis patient

BNP correlates well with cardiac function, and is a

good prognosticator for risk stratification

ANP is sensitive to volume changes during dialysis, but

changes in concentration do not predict achievement of
euvolemia.

Suresh et al. Seminars in Dialysis 2005

Challenges in Assessing Dry Weight

How can I manage Fluid

Overload if I can’t measure it?
Determination of Dry Weight

• In most cases, a patient’s dry weight or target weight is an

‘estimate’ determined by the physician based on:
• Normal blood pressure
• Absence of edema or swelling
• Neck veins that are not distended
• Absence of lung sounds related to fluid overload
• No shortness of breath or congestive heart failure
• Normal size heart shadow on X-ray
 “Failure” of Dry Weight
• A large proportion of patients are reported to
be hypertensive in spite of being at their "dry
weight.“
• This is, in almost all cases, due to:
1. the DW has been overestimated
2.the correctly estimated DW could not be
achieved.
 Failure” of Dry Weight
Clinical Scenario
• If a normotensive patient has edema, shortness
of breath or a high venous pressure (or full
jugular veins), or an enlarged heart on chest
x ray, -> suspected of being saline overloaded.
• Studies have shown that a proportion of
normotensive patients have an increased ECV
(fluid overloaded) according to bioimpedance.
• BP is the target of ECV control, it is important
to assess ECV.
 Failure” of Dry Weight
Clinical Scenario
• One of the main potential problems in achieving
DW is insufficient dialysis time:
insufficient time allocated for UF.
• A shorter HD session leads to more
hypertension, and at the same time hypotension
• When session time is shortened, UF rate is
increased and hypotension occur.
 “Failure” of Dry Weight
Clinical Scenario
• This has several bad effects:
• The patient has a poor perception and acceptance of
HD and asks for a shorter session.
• The nurse has to cut down the UF rate or give saline, so
prescribed DW is not achieved.
• The physician wrongly re-evaluates DW. Often the
prescribes a higher dialysate sodium (Na profiling).
• This, reduces the diffusive sodium drag from
the patient and leads to increased osmolality,
thirst, and interdialytic weight gain.
• Consequence: the patient does not achieve DW
 “Failure” of Dry Weight
Clinical Scenario
• Another potential factor in achieving an
adequate ECV is the existence of so-called
hypotension-prone patients
• Risk factors:
– left ventricular hypertrophy (LVH) and
impaired diastolic relaxation
– Poor LV function impaired cardiac output
 Management of Dry Weight
• Which is more important?
restricting fluid Versus restricting sodium
on weight gain between dialyses
• Sodium intake must be reduced to the lowest
level .
• A low sodium diet of 2-3 gram.
• A multidisciplinary approach is needed to educate the
patient and caregivers
• Daily fluid restriction
• Accurate pre- and post-dialysis weights, to measure the
weight gain in between dialysis treatments is essential
 Fluid Management-Volume Control
Current Practices in Fluid Assessment
Parameter Frequency Comments
Blood pressure Daily  Advantages:
 cheap
• JVP Monthly  immediate
• Oedema  universally available at
the patient's bedside
• Ascites
• Disadvantages:
• Lungs /
 Unreliable & inaccurate
• Heart sound
 Depends on clinical skills

• Chest X-ray ? 6 monthly • Advantages:

– Heart size  accurate
Cardiothoracic ratio • Disadvantages:
• Ultrasound ?  scheduling time
– Inferior vena cava  requires expertise
diameter (IVCD)  radiation exposure
 Cost $$$
 Limitations of Estimating
a Patient’s Dry Weight

• The inexact determination of dry weight can result in

substantial errors, such that patients often leave the
dialysis center (after treatment) in hypervolemic or
hypovolemic states

• Hypervolemic patients are at risk for developing volume-

related hypertension, left ventricular hypertrophy (LVH)
and congestive heart failure

• Hypovolemic patients may suffer from symptoms of

volume depletion and inter-dialytic hypotension
 OCM® - Online Clearance Monitoring
Features that available in Hemodialysis Machine for Dry weight

 Non Invasive, automatic

 Does not require laboratory
examination
 No additional cost
 Effective guarantees the quality of
dialysis dosing
 Can perform monitoring every HD
session
 Easy  patients & family can help
monitoring HD quality

EARLY DETECTION & EARLY CORRECTION

Available as standard Fresenius Medical Care 4008S NG Machine
 Impact of Inaccurate Fluid Assessment
•Diagnostic failure
– What’s the euvolemic “dry weight”
– What’s my “target”
• Therapeutic failure
– How much diuretic?
– What and how much
antihypertensive?
– How much ultrafiltration?

This is where
BCM helps

It’s difficult to know what to

prescribe without a target
 The BCM: A Key Tool in Fluid Management and Volume Control

BCM Overview The BCM - Body Composition Monitor allows

. the assessment of over/under hydration by
accurately determining the amount of fluid in
the body

Dramatically shortens the initial trial-and-

error phase of finding the optimal dry weight
in PD patients

Extremely useful in the long-term monitoring

of patients=trending
Take Home Messages

 Dry Weight is an
essential part of
dialysis adequacy

Thank you
 Measuring fluid volumes
and guiding dry weight
targets is essential to
avoid both fluid depletion
and fluid overload
 Clinical assessment of DW
is feasible and reliable in
dialysis patients