UF & SODIUM PROFILING

SABU ABRAHAM B.Sc. CCNT

Clinically Certified Nephrology Technologist from
National Nephrology Certification Organization (USA)
SR.FACULTY IN DIALYSIS
ST.GREEGORIOS COLLEGE OF DIALYSIS
PARUMALA
 Why we do Profiling
 Managing fluid removal and blood pressure
during the hemodialysis treatment
 Allowing the patient to reach their dry weight

with a minimum of symptoms (hypotension,

cramping etc.)
 To ultrafiltrate, fluid from the patient, we

must enhance plasma refill rate (PRR) to

correlate with the UF rate needed to reach our
goal.
Distribution of Na+ in the body
 10 mEq/L intracellular
 140 mEq/L interstitial
 140 mEq/L intravascular
 Normal dialysate Na+ does not promote fluid

shifts-intended to maintain homeostasis

 A very small portion of the body water in the

vascular space-need to refill at the rate equal

to UF rate or patient will experience
intravascular hypovolemia
 How ultrafiltration achieved during
dialysis
 Body water shifts are caused by change in
osmotic pressure
 When intravascular Na+ increased, the body

water contained in the intracellular and

interstitial compartments shifts in to the
intravascular compartments
 This shifts, water from the cells and tissues,

in to blood
 Sodium Modeling
 Sodium modeling increases the osmotic
gradient in the intravascular compartment. By
increasing the osmolarity of blood, we
encourage fluid shifts from the extravascular
(interstitial and intracellular) space in to the
intravascular space, making it available for
ultrafiltration.
Utilizing Na Modeling Effectively

 Namodeling programs start

with a high sodium in the
dialysate, which generally
decreases as treatment time
progresses
Some Points to keep in mind with the
Adjustment of Sodium
 Cramping early in the treatment (or when we
know that the patient is not dry yet) is an
indicator that sodium modeling is needed.
 A low BP in conjunction with low pre-dialysis

BUN, albumin or hematocrit (Osmotics in the

early period of ultrafiltration) is another
indicator.
 Sodium modeling helps to maintain BP post

dialysis
 Na modeling can increase the plasma sodium

post dialysis which can cause thirst in patients

Contra indications of Na Modeling
 Severe hypertension (180/100) prior to the
treatment
 Remember, by increasing the sodium, we are
inviting a movement of fluid in to the vascular
space which will further increase the blood
pressure
 Some patients may have hypertensive response
to low intravascular volume. As the vascular
space “drys out”, there is a response of ADH and
catecholamines which results in vasoconstriction
in an attempt to maintain the BP
Contra indications of Na Modeling
 Symptoms of congestive heart failure( very low
Blood pressure, low pulse rate and high weight
gains)
There is a general tendency among staff to use Na
profile with a low pre dialysis blood pressure. But
in this scenario, Na could further drop the BP.
The reason for low BP in this case is actually an
overload of fluid in the circulation. In this patient
when we remove the fluid from the system, the BP
will rise to a safer level.
If one applies Na modeling early in the treatment,
the response will be further increase in
intravascular volume.
LINEAR
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TIME
STEP-WISE
EXPONENTIAL
 Ultrafiltration Profiles
 Ultrafiltration profiles are variable programs
of the application of negative pressure in a
manner that allows individualized periods of
intravascular plasma refilling between periods
of ultrafiltration
Rules of individual fluid
removal plan
 All patients do not need modeling and/or profiling.
some use a combination of both,others may use
only UF or only Na+ modeling.
To evaluate a patients individual needs assess
the following factors
 BP
 Intradialytic symptoms
 Methods of relief
 Laboratory values
 A patients profile or modeling need can change as
their overall health picture changes.
UF PROFILE-0
UF profile 1
 Provides a relatively high level UF for almost half the
run,then begins gradually decreasing until the end of
the run.
UF PROFILE-1
UF profile 2
 Gives a gradual decline in the fluid removal ,but
again, starting with aggressive UF in the early part of
dialysis. These would work well with a patient with
high weight gains,possibly symptomatic
(SOB,HTN)and with a tolerance for rapid fluid
removal(cardiovascular stability).
UF PROFILE-2
UF profile 3
 Provides moderate UF throughout 2/3rd of the
treatment, followed by a more dramatic decrease in
the last portion of dialysis moving to a minimum UF
in the last segment.This would work well with the
patient who becomes hypotensive in the last hour or
comes off the machine with a low BP.(one might also
initiate a STEP Na+ model to help maintain the blood
pressure throughout the run).
UF PROFILE-3
UF profile 4
Starts with a low UF and moves into a series of
decreasing peaks and valleys for the first 2/3rd of the
treatment followed by a plateau of moderate UF to
completion.This profile would facilitate the patient
with poor vascular response who drops B/P early and
needs time for plasma refill .This type of patient
would probably benefit from Na+ modeling in
conjunction with UF profile
UF PROFILE-4
UF profile 5
 This program begins with a moderate UF for the
first segment,then jumps to a more aggressive UF
in the next, continuing to step down for two
segments to a minimum UF. This pattern
continues for 3 hours,with the last segment ending
in a minimum UF prior to completion. The
program allows progressive periods for plasma
refill, followed by aggressive UF for short periods
at a time.
UF PROFILE-5
Last notes on sodium Modeling and
UF profiling

 Monitor B/P’s frequently,especially when initiating

a new program.
 Do not allow a patient to become hypotensive for

the sake of trialing a program.Hypotensive

episodes are very dangerous to the patient and
should always be a priority.
 You can select the program individually or both together
 Take into account current factors that may affect outcomes

(ie:sepsis,post hospitalization,changes in dry weight,etc.)

 Sodium Modeling and UF profiiling require a physician

order or a written protocol .

 In Summery
 Na + modelling helps to move fluid from the
tissues in to the vascular space, while UF
profiling allows us to move fluid from the
vascular space in to the dialysate, resulting in
ultrafiltration
Dialysate calcium modeling
 The use of low- calcium dialysate leads to decreased
LV contractility and a decrease in blood pressure
 Have been associated with the changes when

dialysate calcium concentration is <_2.5 mEq/L

 A dialysate Ca of 3.5 mEq/L may lead to

hypercalcemia and decreased bone turnover

 Iimited studies have shown only marginal benefit on

the frequency of IDH episodes with the use of

dialysate Ca >3.0mEq/L
Systemic Evaluation
 Identify focus patient
• Gather Data
• Evaluate trends
• Involve patient
• Apply Na+and/or UF trial
• Evaluate weekly
THANK YOU