Haemodialysis techniques and adequacy 2 mp 387 monitoring of fluid overload in a dialysis network

Introduction and Aims: The fluid status of hemodialysis patients has been well established as major factor influencing both clinical outcome and treatment costs. So that headway can be made in defining the thresholds for fluid overload, identifying patients at greater risk of fluid overload and the design of optimal treatment strategies, an objective measurement of fluid overload (FO) is necessary. Consequently, a fluid management program (FMP) is being rolled out within NephroCare (Fresenius Medical Care) which operates dialysis services in over 750 clinics in the regions of Europe, Middle East, Africa and Latin America. A hydration status score (HSS) has been incorporated within a NephroCare Balanced ScoreCard (BSC) system to assess treatment quality. Methods: The basis of the FMP is the BCM_Body Composition Monitor. The BCM allows an objective estimation of fluid overload (FO) and each clinic in the NephroCare network performs a measurement on a monthly basis. A patient card allows data to be transferred to a clinical information system. The HSS requires a measure of the relative fluid overload (RelFO) which is determined by dividing the FO by the extracellular water (ECW). This procedure normalises the patient’s fluid status compensating for patients of different body weight. It has been shown previously that there is a survival improvement in those patients where RelFO is maintained below 15%. [Wizemann et al. NDT 2009]. Three ranges for the HSS apply namely less than 15% RelFO, 15% to 20% RelFO and above 15% RelFO. These ranges score the points 1, 0.5 and 0 respectively. We monitored growth of the FMP over the last 2 years and the assessed the recent distribution of FO in those patients measured in the network. Data were interpreted in terms of median and 25th to 75th percentiles. Results: At the time of the August 2013 analysis, with the step rise due to data reported from Latin America the FMP was measuring 32,484 patients with BCM per month, equivalent to >1000 patients/day. See Fig 1. In August 2013, the median, 25th and 75th percentiles of FO were found to be 1.74 L (0.85 L to 2.71 L) as shown in Fig 2. RelFO were 10.74% (5.44% to 15.95%) respectively. Regarding the HSS in August 2013, 71% of patients were <15% RelFO. Conclusions: The FMP is active in a majority of the NephroCare clinics. RelFO < 15% by sensitive new tool (BCM) is achieved in most patients. The 30% of patients with RelFO >15% provides some basis to challenge clinical judgement. The HSS component of the BSC allows patients with high FO to be identified and corrective treatment to be planned through a peer review process.