Is Inacurate Dry Weight Assesment Killing Patients?

[Ken Shelmerdine]

I have just been reading the thread  Vcarmody sent about her husbands dialysis problems. I didn't want to put this on that particular thread because it's not going to make her or her husband feel any better for the future but I suppose she may read this anyway, but this is a forum where we've always told it like it is, positive or negative so here goes.

I am convinced that the whole dry weight assessment process is badly and whats more dangerously flawed. Since I have been attending my clinic at least two patients have cramped so badly and suffered  severe BP drops on such a regular basis that eventually the occurrence has lead to them being rushed into hospital where they have subsequently died.

How can anybody have an absolute dry weight? Everyone's body weight can vary from day to day by as much as 1 to 2 kilograms depending on how many calories and fats they've consumed between dialysis sessions. When this happens there is no way of knowing how much is excess fluid and how much is extra bodyweight so the dialysis usually results in not only excess fluid being removed but also some of the body's essential fluid.

I don't know what the answer is maybe some way of measuring body mass and subtracting it from actual weight and also a weight assessment of the clothes you are wearing. Can this be done?

What puzzles me is that the medical profession must realise how absurd this whole dry weight process is and how debilitating it is in the long term causing cardiovascular problems and other morbidities and yet there doesn't seem to be the will or concern to address it.

[tyefly]

I completely agree..... I just started D last week and they were dealing with my dry weight on the first day.......When I went in they wanted to take of 2 kilograms which they say is standard and maybe challenge me at 4 kg.... I told them that I do not need any water taken off as I have no fluid retention right now.   I take water pills and I can manage my water still pretty good.... This was my first D session and they had a hard time believing  me.... by I insisted that they take no water...  they  disagreed  and we compromised and we agree to the minimum (no sure what that was )   and I was hoping that I would not cramp....   I did not take my BP pills that day cause I didn't want to crash and walk in with low BP anyway..... They took of 0.3kg....  according to my weight after I was done.... I did not cramp and everything was good with the BP..... Seems like they have a set standard of what to take off and they don't like to change that ....again the next time I went in  they wanted to take off 2 kg.... my weight was under what I first weighed in on the first day   so I said  why  take of water  when I weigh less than I did the first day....  They told me that its standard protocol....  I told them no.....again....
    I think there are many people who will not say anything and will just let them do what they want....and when they do cramp they say its normal that you will get use to that.....  That is BS...Cramps are not normal and should not be happening every time.... at least I don't think so....  I feel sorry for those people who cant say anything or don't even know what to say or do...  I would hope that there would be a common sense approach to D for every person ....... Dont take a bunch of water off untill you know what that persons weight is...... go slow for the first few weeks..... 

[billybags]

This is one of my husbands bug bears. He lost a lot of weight when he had that e-coli bug and they put his dry weight down from 75kl to 72kl dry and took off accordingly, but no more than 2.3. We went a way for a weekend last week, had a lovely time and he ate and ate and I just didn't know where he was putting it. My husband said it was the sea air. Away he went to the unit on Monday and his weight had gone up to 75kl the nurse went ballistic and told him to cut down on fluids and she would take off the maximum she  could . He had to argue with her and in the end she actually put his dry weight up to 73. How do they know what is body weight and what is fluid. One nurse said that the machine only takes off fluid. I like you do not understand this.

[willowtreewren]

This is one reason I really like doing dialysis at home. We don't have to argue with anyone about how much to pull off. Since my husband still has some kidney function, it is rare that I pull any extra off beyond the rinse back.

Once in a while he says that he feels like he is carrying extra fluid, so we take off some. When he was still in center (even when we were training on NxStage) they wanted to take more off than I thought wise. Now I know to stand up for what is best.

My husband is very slight and a big meal makes a big difference in his dry weight. If we were still in center he would be crashing for sure!

Aleta

[bevvy5]

How do you dispute that?  Hubby started on PD in early August, cycler in mid September and is struggling to get to the weight that I personally think was very arbitrarily set for him based on a huge weight loss when he first started PD.

His blood work is good.  He feels good, no shortness of breath.  A tiny bit of swelling in the ankles by the end of the day but they're very svelte - ha ha - in the mornings.  Blood pressure is stable and good.  And his weight is not fluctuating greatly, but it's about 1 to 1.5 kilos higher than his "goal" weight.  Based on that, they're talking about trying 4.25% solutions every second night, etc.  From what I can tell, that could have detrimental effects on how long he can continue to do PD, couldn't it?

I'm sure this is much more of an issue on hemo but it's frustrating.  I guess the best thing is to try to keep good track of how he's feeling, etc., as well as numbers and use that to suggest that perhaps fluctuation is more of a measure than a hard and fast number?  Or am I missing something here?

Thank you in advance, as always.

[petey]

Ahhh, the dreaded dry weight debate.  My husband and I fought this, argued this, and got two heads full of gray hair over his damned dry weight for all the years he was in-center hemo.

I know several of you have said that dry weight is some arbitrary number that some nurse/doc comes up with for your dry weight.  I agree.  But, I think they've changed the way they determine an individual's dry weight (or, I hope they have!).  When Marvin (my hubby) started in-center hemo in March of 1995, here's how a person's dry weight was determined that first treatment:  (1) Hook him up to the machine; (2) turn the UF high; (3) suck the patient dry until he cramps, screams, cries, and begs; (4) flip his chair so he's almost standing on his head; (5) give him 200-500 ml of saline; (6) weigh him.  TA DA --That's his dry weight!  (As an option, the nurse could skip the saline, weigh him, and then add half a kilo to the weight shown on the scale to determine dry weight -- but it was hard to weigh a cramping, screaming, crying patient who couldn't stand on the scale.)

That first treatment, we knew so very little about the whole process, but Marvin (who was on his head when this was explained to him) said, "There has to be a better way to determine dry weight than this!"  To which, he was told, "Nope.  This is the way we've always done it."

If that's not bad enough, that first dry weight then became written in stone in his chart.  No matter what he told the nurse/tech he ate -- or didn't eat -- no matter if he had been hospitalized between treatments -- no matter if his appetite increased -- no matter if he exercised more between treatments .... his dry weight was (according to the nurses/techs) a never-changing figure.  Marvin hated, absolutely hated going to the clinic for treatments because he knew he'd have to argue about his dry weight.  His nurse/tech would say, "I KNOW what your dry weight is.  It's written in your chart."  And Marvin would say, "And I KNOW what I ate or didn't eat or threw up or pooped out since the last time I was here.  Is that written in your precious chart?"

It was, to say the least, a three-times-a-week fight.  Eventually (and it took about six months of arguing, and my being extremely aggressive), the facility administrator put in Marvin's chart that he could set his dry weight before every treatment.  This worked well.  Marvin knew how his body felt on the inside; he knew the "signs" of too much fluid as opposed to actual weight gain.  But, no one else at Marvin's clinic ever questioned their dry weight.  They crashed, and crashed, and crashed again.  It used to make me so mad. 

When you're in-center, dry weight is the one thing that the nurses/techs become obsessed with.  Even though Marvin could determine before each treatment how much to take off, it was still an argument and still required detailed justification of what Marvin wanted to set the UF on.

Like Aleta, we're so glad those days are over.  On home hemo, I never argue with Marvin about what he says his dry weight is.  Hey, it changes daily -- hourly even.  He knows when we need to up the dry weight, and he knows when we need to challenge it.  He has the "full" or the "dry" feeling.

To those on in-center, I'd suggest that YOU start *suggesting* that YOU know how your body feels on the inside and then *request* that you have input into what the UF is set on before each treatment.  Learn to be so in tune with your body that you know the feeling of having a little too much on or a little too much taken off.  Avoid those situations.  Is it going to be a fight?  Maybe.  But, if it is, it's a fight worth fighting.  It is YOUR body, and you have a right to have some say in your treatment.

[MomInDialysis]

I am so thankful one of you told me about the removal of fluids for my mom.  She is doing so much better after treatment now, I can't believe it.  She goes in and demands no fluids except for .5 for rinse back and it has made a big difference.  I don't know what you are referring to about crashing, but she has landed in the hospital once while in dialysis with cardiac arrest and her Potassium level at 7.4.  WE WILL CONTINUE TO NOT TAKE FLUIDS OFF UNTIL SHE TURNS INTO A BLOW FISH,  The people who are trying to help her are killing her because they treat her like everyone else.  I look around the room and people are sick, hurting, and lost, not knowing what to do.  No one is concerned.  She told them to take .5 last Tuesday and they were taking more.  Her BP was 208/148.  No one was concerned...I nearly dropped my teeth and they are all mine.  We checked the draw and it was 2.5.  I made them stop and lower it to .5.  Only because Tom had told me about the fluids and dry wt. 
KEEP FIGHTING, KEEP DEMANDING, & KEEP LIVING.

[willowtreewren]

Bravo, Petey!

We did not have to put up the fight you did. But Carl was only in center long enough to get the needle size up to 15 gauge so we could switch to NxStage. Now each month when we have our appointment in the clinic they just ask me what we are using as Carl's dry weight. 

They never argue about it, either. I've also learned that I can challenge the heparin dose. I'll be doing that again this month as we are having too much bleeding at the end of the treatment.

Take control! Nobody knows your body like you do!

Aleta

[plugger]

Dry weight, my first hint that things could be a whole lot better in the world of dialysis - a whole nine years ago.  I thought the way they were coming up with dry weight was pretty mickey mouse, so I started asking around on the web.  I'll pass on the information I was given, it still does look to me there is a better way of figuring it: some clinics use these crit line devices (http://hemametrics.com/PressRelease/HemaMetrics%20SalesSheet.pdf).  We had a non-profit clinic about 90 miles from here we got to visit with my daughter, those eons ago, and they swore by the device.  It uses an optical front end that clips on one of the lines and detects values, including fluid if I remember right.

The Fresenius clinic my daughter was at claimed how the crit line was so expensive and how the staff's kids would have to go barefoot if they bought it - it costs 4 or 5 grand back then! (cheap $%^*%!!!).  I imagine as soon as we left for the transplant they probably got rid of the demo.  Years later I did hear from a nephrology nurse I know the doctor did like it and wanted to get it.

But I guess it still might be "experimental" http://www.aetna.com/cpb/medical/data/300_399/0373.html according to the folks who probably think aspirin is "experimental" and a cold is a pre-existing condition.

[Rerun]

Dry weight is definitely a moving target.  I still have problems.  I try and remember to drink a little Tonic Water because it has Quinine in it which helps with cramping.  So, today I challenged my dry weight which means I go .5 below what I usually aim for to make sure I don't have extra fluid on me, and my BP dropped and I felt sick, so I guess I'm right on.

I see people come in with 7 or 8 kilos on over a weekend and then they wonder why they can't get the fluid off.  Dialysis can only do so much in 3 or 4 hours.  It takes time for the fluid to shift from tissue to blood in order to be pulled off.  People have got to restrict their fluid so that the machine has a chance to take off what is needed.

On some of the newer machines there is a crit line which can establish when the blood is replenished with fluid and can have more pulled off, but our Techs don't know how to use it so we don't. 

Some people just rely on the staff to know what to do and that is a huge mistake.  You have got to know how you feel and learn to play with your own dry weight.  There is this one lady that has a BP of like 85/60 and wonders why she feels sick all the time.... she won't stop taking her BP medication because her "doctor" didn't tell her to.  Come on! 

                                                           

[plugger]

On some of the newer machines there is a crit line which can establish when the blood is replenished with fluid and can have more pulled off, but our Techs don't know how to use it so we don't. 

   Yep, another reason I've heard they don't get used - why use it if you can just flip a coin or throw darts.    Anyway, just noticed Home Dialysis Central was having an interesting discussion on critlines:
http://forums.homedialysis.org/showthread.php?t=117

[RichardMEL]

I see people come in with 7 or 8 kilos on over a weekend and then they wonder why they can't get the fluid off.  Dialysis can only do so much in 3 or 4 hours.  It takes time for the fluid to shift from tissue to blood in order to be pulled off.  People have got to restrict their fluid so that the machine has a chance to take off what is needed.

This is the number 1 reason that helps give me the willpower to restrict my fluids to around 2kg between sesssions. I do NOT want to be the guy who is way over, gasping for breath and doing serious damage to heart and lungs for a few extra drinkies (and then probably crash/cramp as they try to take it all off)... not crashing or cramping is a massive incentive to me to be good with my fluids.. when it happens there's nothing worse(well obviously there is, but those who have been there know what I mean) and I will do anything to avoid that stuff!

Those that just don't give a stuff about themselves and don't follow any fluid or diet resitrictions.. well I feel sad for them because they're only doing themselves a disservice for short term pleasure.

On some of the newer machines there is a crit line which can establish when the blood is replenished with fluid and can have more pulled off, but our Techs don't know how to use it so we don't. 

I believe this is what we refer to as a BVM (blood volume monotoring- or something like that). We have I think they are 2008S's (or maybe K's) with the screen on them, and they show the "refill" graph during a session. I've had a few recently due to problems and they are pretty good at showing how your fluid volume "refills" from the other parts of the body back to the blood. It gives apparently a reasonable indication of if you are too dry or wet. We do it in conjunction with a UF profile so you can see the fluid refill during a "rest" in the UF profile cycle. I like them

Some people just rely on the staff to know what to do and that is a huge mistake.  You have got to know how you feel and learn to play with your own dry weight.  There is this one lady that has a BP of like 85/60 and wonders why she feels sick all the time.... she won't stop taking her BP medication because her "doctor" didn't tell her to.  Come on! 

yes yes yes!!!!!!

I totally agree with you! This is all about YOu being the best part of your own treatment team. I tend to think of it this way - who cares about my body more than me? Nobody!! Plus *I* know how I feel and when things are going wrong.

These days I take proactive action based on where I am at. I set my UF goal and if I want to use a profile or not, and if I'm having problems (sadly this is every session lately ) I will either turn the UF off for a bit, or down the pump speed, or temp, or whatever. Now I do consult with the nurse who is looking after me so she knows, and so there's approval, but usually they are OK with me making changes and if they disagree we discuss it and they explain why and either compromise or come to a joint decision.

I'm certainly not willing to lie there and suffer because others are making decisions for me without my input. Now the other day they decided to raise my dry weight by .5 and then another .5 because I've been having trouble with high BP during sessions, and horrible sweating and feeling like crap (not a crash exactly, sort of the opposite) and I did not think that was right and it would not help.. and sure enough it hasn't, but I talked it through with them, and we will go back down slowly to my original dry weight, and work on some other things to try and sort it out. At least it's something that I am dealing with in consultation with the team - they are experienced professionals in this area and I need to be guided by them because they know way more than I do - BUT *I* know *MY* body and know when things are going wrong or have a fair idea if I have increased real body weight or not. So together we work on it I think. At least they treat me with respect and we discuss things rationally and they don't treat me like an idiot and are willing for me to manage myself pretty well.

Except yesterday when they quipped that my "hot flushes" meant I must be going through male menopause!!!  It was pretty funny though we had a laugh.. even the old lady next to me had a go "Well sonny I had that one decades ago!" :p

lol
                                                         

[effinxmandy]

At Fresenius, we had something called a "Crit Line".

You would connect a special piece to the dialyzer, and put a clamp onto the piece that was connected to the crit line, a kind of small machine?. (Forgive my poor explanation).  Ultimatley, it determines hemocrite and oxygen saturation. The hemocrite changes with the changing blood volume, which determines the fluid status.

I LOVED using these because you could determine the patients goal (increase/decrease) throughout treatment. On the monitor it shows a type of graph of fluid being removed. If it showed the graph making a sharp decline, you were taking off too much. If it stayed steady, there was still fluid to be removed. If it made a sharp incline, the patient was fluid over-loaded.

I hope I'm making sense!

We only used them occassionally, but I sincerely wished we would use them every treatment to determine the patients dryweight treatment by treatment to prevent crashing, cramping, vomitting, ect.

There is a way to help in a great deal to determine patients ever-chaning dry weights, I just don't know why they don't. 

[YLGuy]

My dry weight is set but I can request that less than what it would take to get me back to my dry weight is taken off due to my diet/bowel movement history.  They always ask me how much I want removed. 

[Inara]

At Fresenius, we had something called a "Crit Line".

I work for FMC and LOVE the crit line. In the absence of a crit line, all any nurse needs is some friggin' common sense to know if they are pulling off too much/too little fluid!!!

What the hell is wrong with everyone's staff???!!??  Honestly I find this whole topic very disturbing!!!!!!!

There is NO REASON dry weight should be a continuing issue beyond a couple of weeks.  I change at least three dry weights/week, minimum, based on crit line and response to treatment!!!!! 

Find out if your unit has a crit line....if so, DEMAND you get to use it if you think you're dry weight's wrong.  If it doesn't have one, start a petition to get one.  Hell, PM me and I'll write it up for you and e-mail it!  If you get enough people to sign it, they'll get one for you!!

[Zach]

Here's a study about another way to figure out dry weight:
Guided optimization of fluid status in haemodialysis patients

"Fluid status was assessed frequently (at least monthly) in haemodialysis patients (n = 52) with the body composition monitor (BCM), which is based on whole body bioimpedance spectroscopy. The BCM provides the clinician with an objective target for normohydration."

"Conclusion. The BCM provides an objective assessment of normohydration that is clinically applicable. Guiding the patients towards this target of normohydration leads to better control of hypertension in hyperhydrated patients, less intradialytic adverse events and improved cardiac function."

http://ndt.oxfordjournals.org/cgi/content/full/gfp487

 

[thegrammalady]

i can gain weight just thinking about baking a cake. i keep a list on my phone of what i weigh going into each session, and what i weigh going out. i tell them exactly what to take off every time. i know i'm repeating myself, but we have new people. since i'm doing nocturnal i always have the same nurse. i've known her for 3 years so we don't have any problems. if i visit a center where they don't know me, i just stand firm. i always get my way. i'll argue with anyone. i very rarely if ever crash anymore.

if the staff argues with you, just remember it's your life, they do it your way or not at all. stand firm, you controll the situation. knowledge is power.

[Ken Shelmerdine]

It was, to say the least, a three-times-a-week fight.  Eventually (and it took about six months of arguing, and my being extremely aggressive), the facility administrator put in Marvin's chart that he could set his dry weight before every treatment.  This worked well.  Marvin knew how his body felt on the inside; he knew the "signs" of too much fluid as opposed to actual weight gain.  But, no one else at Marvin's clinic ever questioned their dry weight.  They crashed, and crashed, and crashed again.  It used to make me so mad. 

Petey this was almost exactly my experience. I had to argue for months with the techs about it. My dry weight was set just a couple of weeks into recovery from pertinonitis. I had lost over seven kilos through the illness and loss of appetite. Fortunately because I have been a member of this fantastic forum for quite some time even though I was doing PD I kept myself clued up about Haemo. I was sure that in spite of only 6% GFR that I still had full urine output and was not retaining any extra fluid. I even did my own 24 hour output Test and it totaled 2.7 litres. That as far as I am concerned is full output so why the hell should I have ANY fluid removed?!

After a long discussion with the clinic doctor it was agreed that I have no UF removal just toxin removal only 3 times a week 3 hours not 4. I thought this would be put in my records but a couple of weeks later when I got a regular haemo slot at a different hospital it was a different story. By then I'd put on a couple of kilos and as soon as they saw my weight it was 'Right 2 litres above your target weight. We take 2 litres off plus .5 for washback and you'll have to do 4 hours for that amount of fluid to be safely removed.' I was totally gobsmacked, there appeared to be no record of my discussion/argument with the doctor.

So I refused treatment until they would agree to no UF removal. I told them I do over 2 1/2 litres per 24 hours but all they kept harping on about was this 2 kilo over dry weight. They just wouldn't listen putting forward the argument that anyone with only 6% GFR must be retaining fluid to some degree. In the end they agreed but not before I'd had a stern lecture off the doctor with warnings such as my none compliance could lead to 'Crisis Management'

So ever since I've been dialysing with no UF removal and I've never felt better, it hasn't led to crisis management and I'm so glad I put up a fight about it. But even so I had to persuade whoever was setting me up for weeks afterwards. Even now they always ask me 'How much are we taking off today?' to which I always reply 'ZERO!'

Its the patients who are not educated about their illness that I feel sorry for. Patients who cramp regularly or crash and haven't the courage to say THIS IS NOT GOOD ENOUGH!!

I read the links about the Crit-line but our NHS is probably a million years away from getting them. We haven't even got nextage machines.

But after reading these posts I'm glad there are other people who are as angry as I am about this often brutal dialysis protocol of fluid removal and I think  if the various Kidney Patient Associations throughout the world aren't kicking up a stink about it, if not, why not!   

[mikey07840]

I feel blessed. At my clinic, the nurses always discuss the dry weight goal for the treatment. It is a discussion. She always asks me if the goal sounds right. I sometimes adjust it up or down depending on my situation. If I am thirsty, I have some cold water and add the amount to my goal. If I have been crampy or the weight gain is due to eating a lot, I do a lesser amount. The nurses don't just do an amount, they discuss it and we come to an agreement on the amount. I have seen them to this with many patients in the unit.

[murf]

Ask them to do a BVM to work out  how much fluid you are carrying. I kept having extreme low BP"s at the end (85/65) so a BVM determined that I was very dry. The staff put my dry weight up a fair bit (almost 5 Kg over time) and the problem of low BP's disappeared.

[RichardMEL]

Ask them to do a BVM to work out  how much fluid you are carrying. I kept having extreme low BP"s at the end (85/65) so a BVM determined that I was very dry. The staff put my dry weight up a fair bit (almost 5 Kg over time) and the problem of low BP's disappeared.

wow 5kg is a lot!

As I posted earlier I am a big fan of the BVM and think it can really help. Glad your problems have been sorted out, mate!

[Ken Shelmerdine]

I've just viewed the link which Zach posted. It is a study of the use of a Body Composition Monitoride provide a more accurate dry weight assessment. I can't beleive why they are not widely used in dialysis wards. Hell you can buy one for your bathroom for about fifty quid!

Murf you mentioned a BVM which I take means Body Volume Monitor. Are these the same thing as a BCM?

[RichardMEL]

I've just viewed the link which Zach posted. It is a study of the use of a Body Composition Monitoride provide a more accurate dry weight assessment. I can't beleive why they are not widely used in dialysis wards. Hell you can buy one for your bathroom for about fifty quid!

Murf you mentioned a BVM which I take means Body Volume Monitor. Are these the same thing as a BCM?

No they are different. Reading Zach's link that talks about sticking electrodes on hands and stuff.

a BVM is something within the machine. Doing some research it seems to be a module only on the fresnius machines.

this link discusses it a bit more in relation to pediatric patients:

http://www.springerlink.com/content/177g8151276p2863/fulltext.html

Basically the BVM module is within the machine and it displays as a graph on the screen the "refill rate" of fluid into the blood measured as some sort of percentage. I've always been told if you refill to around 90% by the end of the session that you're usually around your goal dry weight - if you refill to more, then you're carrying fluid, and if you're under that, then you're dry.

It's a useful device I've done quite a few of them. We have a couple of nurses with specific interest in the BVM and its use, so they like to use us to test their theories