Does Fluid Intake During Dialysis “Count” as Fluid Weight Gain?
I was recently asked the following [edited] question:
“Do you include rinse-back and an on-dialysis drink in working out the amount of fluid to take off? Let’s say I gained 1 litre and thus have 1 litre to remove to reach target weight. But, I then (1) have a drink during dialysis and (2) include the fluid I use for rinse-back. Do I need to take off 1.5 litres? Or, just the 1 litre?”
This is a very good question, and there is no absolutely right answer to it. There are several variables that are hard to be certain about, but let me try to break it down without confusing the situation even more!
In the example, a 1 litre weight gain is pretty minimal for an adult. The heavier someone is, the less a 1kg (1 litre) weight gain is, relative to body weight. As most adults are somewhere between 55-100kg in weight, 1 litre is at most about 2% of body weight. Assuming that a dialysis session will need to be at least 2 hours long (for solute removal, regardless of fluid status), removal of 0.5 litres/hour (i.e., no more than 1% of body weight/hour) would not challenge the blood volume at all. Nor, for that matter, would removal of 1.5 litre over 2 hours (or more).
But, most likely gain more than 1kg (1 litre), and the more fluid there is to remove, the faster it must be removed in any given dialysis treatment. When fluid to remove is a volume greater than about 7-8 ml per kilogram of body weight per hour of dialysis, trouble starts. This is when the vexed issues of (1) fluid consumed during dialysis and (2) rinse-back fluid start to come into play.
Imagine that the amount to remove is 4 litres, and the treatment is a planned 4 hours. This requires removal of 1 litre per hour. This might still be a safe rate if the patient is heavy—but may already be unsafe if the patient is light. Ideally, fluid removal rates should be less than 7-8 ml for every kg of body weight in each hour of dialysis.
See how BODY WEIGHT influences ultrafiltration (UF) RATE. The first example table* uses the same amount to remove and same dialysis duration, but differing target weights.
*Note that ALL of the examples below are made up purely to illustrate points.
|
Target Weight |
Fluid Gain |
Time (Hours) |
UF Rate |
Outcome |
|
Example 1 |
||||
|
150 Kg |
4 Kg (= 4 liters = 4000 mL) |
4 |
(4000 ÷ 150) ÷ 4 =6.6 ml/Kg/hr |
Safe |
|
Example 2 |
||||
|
100 Kg |
4 Kg |
4 |
(4000 ÷ 100) ÷ 4 = 10 ml/Kg/hr |
Getting Dangerous |
|
Example 3 |
||||
|
50 Kg |
4 Kg |
4 |
(4000 ÷ 50) ÷ 4 = 20 ml/Kg/hr |
Downright Lethal |
See how TIME influences the UF rate. The second example table uses the same amount to remove and target weight, but differing dialysis durations.
|
Target Weight |
Fluid Gain |
Time (Hours) |
UF Rate |
Outcome |
|
Example 1 |
||||
|
100 Kg |
4 Kg |
6 |
(4000 ÷ 100) ÷ 6 = 6.6 ml/Kg/hr |
Safe |
|
Example 2 |
||||
|
100 Kg |
4 Kg |
4 |
(4000 ÷ 100) ÷ 4 = 10 ml/Kg/hr |
Getting Dangerous |
|
Example 3 |
||||
|
100 Kg |
4 Kg |
2 |
(4000 ÷ 100) ÷ 2 = 20 ml/Kg/hr |
Downright Lethal |
See how the AMOUNT TO REMOVE influences the UF rate. The last example table uses the same target weight and treatment time, but a differing fluid gain to remove.
|
Target Weight |
Fluid Gain |
Time (Hours) |
UF Rate |
Outcome |
|
Example 1 |
||||
|
100 Kg |
2 Kg |
4 |
(2000 ÷ 100) ÷ 4 = 5 ml/Kg/hr |
Very Safe |
|
Example 2 |
||||
|
100 Kg |
4 Kg |
4 |
(4000 ÷ 100) ÷ 4 = 10 ml/Kg/hr |
Getting Dangerous |
|
Example 3 |
||||
|
100 Kg |
6 Kg |
4 |
(6000 ÷ 100) ÷ 4 = 15 ml/Kg/hr |
Very Unsafe |
So, should fluids taken in during dialysis and rinse-back fluid given afterward “count” when you calculate how much to remove in a given session? Let’s look at both.
- Fluids you drink during dialysis
To a degree, it depends when you drink this fluid. Early on in a treatment, your gut will likely absorb the fluid, so it should technically count. But, we (and many other dialysis services) suggest that you drink no more than a standard cup or tea (or the like) during a treatment, or about 180-200 ml. This is a reasonably small amount, and in the range of normal weighing error. Thus, we don’t count it as extra fluid to remove. If anything, it will add to the fluid gain for the next treatment. Certainly this is the case if you drink fluid at or near the end of a treatment. Then, it is clearly best to regard this as part of the fluid gained between treatments to remove next time.
- Post dialysis rinse-back
This is clearly post-dialysis fluid, and should strictly be counted as the start of the next fluid gain.
In general, then, you would not want to remove the “extra” volume at a treatment. Doing so runs the risk of removing water that is not yet in your bloodstream. Pulling water that is not in your blood can cause your blood pressure to drop—which is not likely to be a good ploy. You would need to add water or even saline (water + salt) to correct the error, or you may have all of the symptoms and effects of volume depletion:
- Nausea
- Vomiting
- Dizziness
- Clouded mental state
- “Flats”
- Organ stunning
The key variable to get right is your predialysis target weight. If target weight is correct, removing more water beyond that can reduce your blood volume. Of course, the real problem is that we really don’t know how to accurately measure a true and ideal target weight (in real time). For all that has been written about bioimpedance techniques, ultrasound to assess the vena cava or lung fluid status, hormone analysis, etc...none are practical at the clinic chair/bedside. And, they are certainly utterly impractical for home patients. Target weight is, in truth, still a clinical guess, though a wise physician and/or a well-trained home patient can get pretty close to it, most of the time.
I don’t think over-drying (i.e. removal of extra volume) is wise. It is better to try to get as close as possible to the assessed target weight and count any post-dialysis fluid return as the first gain for the next treatment. At the end of the day, do we know? Well, no! But, this is the best I can do to explain the inexplicable and advise the unadvisable.
Comments
Jagat
Dec 10, 2024 8:35 AM
After dialysis my dad had bleeding symptoms caused by heparin. So Doctor permanently stopped using it in my dad's case. But when we switched to a different location, we had a new dialysis center. There we were told heparin free but they were using it at the lowest amount for 1 month without our concern and after that I don't know but they put I guess a lot of heparin or maybe less ( around after 1.5 months ). But on the next dialysis session, when we went to see my dad, he was not properly conscious and we thought it might be ok so we let him sleep and dialysis timing which was for 4hrs but after just 1.5 hrs they close dialysis and told us that it's done. We took dad back home and when we got home he started vomiting blood, like 100-200ml and since then he is having difficulty breathing. He couldn't sleep and whenever he goes to sleep he wakes up feeling breathless. It's been 3 months and I am worried. Please guide me. He hasn't slept properly in almost 2 months.
It's all because of heparin.
Jack
Oct 29, 2024 3:32 AM
My dad is getting around 1 kg per day after dialysis. So he is having 3 times dialysis in a week. So in between dialysis, he gain just 1-1.5 kg per day. And sometimes just 0.5kg. he drinks 1l water and urine output is 250ml. Before he was 65kg and now he is 50kg. They were taking 3l everytime.
1.What's the safest UF removal? Is it possible just to clean blood than removing fluid gain?
2.how much liquid he can drink?
He has no swelling. But after dialysis, during night time he can't sleep, he got shortness of breath, his legs are getting cramp, hemoglobin way down, feels like vomiting, cant walk properly because he feels too weak, he bacame skinny and has cough as well as whenever he talks he start to cough.
He has Heparin free dialysis.
Please give me your guidance.
Jennifer Ravert
Oct 29, 2024 6:04 PM
We (Medical Education Institute-- the non-profit behind Home Dialysis Central) have an easy to use tool to figure out if a safe-UFR is being used.
It asks three simple questions:
How much is the fluid removal goal?
How much does the patient weigh?
How long is the treatment?
You can check the tool out here (it is free to use!): https://homedialysis.org/home-dialysis-basics/ufr-calculator
I plugged in your dad's general information that you provided.
A 3L fluid removal goal on a 65 kg patient during a 4 hour treatment gives you a UFR (Ultrafiltration Rate) of 11.5. This is above the point where damage is being done, but not in the red yet.
At 3.5 hours, the UFR is 13.2, which is in the dangerous zone.
At 3 hours, the UFR would be 15.4. This is absolutely within the dangerous zone.
His weight has now been reduced to 50kg. Running those numbers, with a 3L goal and it is:
3 hour treatment: UFR of 20, very dangerous.
3.5 hour treatment: UFR of 17.1, very dangerous.
4 hour treatment: UFR of 15, very dangerous.
A UFR greater than 10 is hard on the body. The safest way to remove fluid is slowly and gently, especially when the patient is smaller and less likely to tolerate aggressive treatment.
If 3L had to be removed on a 50kg patient and the treatment was 8 hours long (nocturnal), the UFR would be 7.5, which is safe.
Plus, he still has residual kidney function and makes some urine on his own. He has symptoms and feels poorly. Is his blood pressure low? It sounds to me like he needs to have his dry-weight re-evaluated and his treatments to pull less water without leaving him volume overloaded-- this can be accomplished by adding treatments, adding time, using diuretics, restricting fluid/sodium-- or a combination of all of the above.
A fluid goal of 2L on a 50kg patient with a 4 hour treatment will give a UFR of 10.
Hope this helps.
Jack
Nov 04, 2024 7:39 AM
Usually he has blood pressure around 120/76 or 133/ 81.
During dylasis he has almost same blood pressure. And he is non diabetic.
His dry weight is 50kg and over fluid is 4L . So total is 54kg. And his pressure during dialysis is 167/103 and they are taking out 4L in 4 hrs.
He has no edema but chest x ray says there's water retention.
When he took allergic medicine, he had no coughing or shortness of breath. But that medicine made me really weak so he didn't continue. And then again he got shortness of breath and cough. Though his oxygen levels was good according to oximeter but he could've breath properly so he stated using oxygen cylinder 3-4 times at night.
Does oxygen cylinder cause fluid in chest?
Or maybe he has infection or pneumonia?
Please help me with this. Is This good to remove 4L in in 4hrs?
And how much water is not overload? So next time we know and can tell them like how much we need to remove extra fluid.
Jennifer Ravert
Nov 04, 2024 5:45 PM
He has water on the lungs, but looks dry to you. He has lost real weight and struggles with fluid weight. He is cramping, and feeling sick. You mentioned he is anemic-- this can cause symptoms, too. He has lung problems and is short of breath-- you suspect it may even be pneumonia, but I can't tell from here if it's fluid, infection, congestion, allergies... there are too many what-ifs.
Oxygen use won't cause fluid in the chest. But oxygen is a medication and should only be used as prescribed. A lot of people think it's "just oxygen" and crank up the flow when they're short of breath, which can worsen respiratory failure.
On the dialysis front...do I think 4L in 4 hours is too much for him? Yes, absolutely. If a person weighs 54kg, and is having 4L removed in 4 hours...the UFR is 18.5. That is in the dangerous zone. It is very hard on the body, and damage is being done at that rate.
You can use the calculator: https://homedialysis.org/home-dialysis-basics/ufr-calculator
Any fluid removal that is more than 10mL per kg per hour is dangerous.
For your dad: 10 mL x 50 kg x 4 hours = 2000 mL / 2L maximum removal for a 4 hour treatment. If you use the higher weight, it's 10 mL x 54 kg x 4 hours = 2160 mL / 2.16 L maximum fluid removal for a 4 hour treatment.
He is having twice that volume removed. To remove 4L safely from his body in one treatment, the treatment time would need to be 8 hours (at minimum) to do that. Fluid accumulates, and having too much on is also deadly. I hope this makes sense.
Jack
Nov 14, 2024 9:49 AM
I have a few questions; please note this is for weight in between 49-60 kg :
1. What would be the best UF rate ?
2. What's the best blood flow rate? In my dad's case it's around 200-225 ml/ hr.
3. What's the max IV saline fluid should be given into patients who use no heparin to stop blood clotting? Last time my dad did a 2000 ml removal in 4 hrs. So before his weight was 54.2 kg and after dialysis he was 53.4 kg . So 0.8 kg weight is lost but then it means they put 1.2 l of saline water into him during dialysis and his blood pressure went from 130/83 ( starting dialysis) to about 145/85 ( after 2 hrs of dialysis) and then 157/98 ( 30 mins before end of dialysis). And the nurses said today it looks great but my dad is not feeling good when he comes home. He is having again coughing and seems like a wet cough and shortness of breath has increased.
4. What should be ideal blood sugar levels during dialysis for non diabetic?
5. What is the best IV fluid which can be used during dialysis? Is it normal saline or Ringer's lactate solution?
6. Let's say if the dry weight is 50 kg ,
a) how much weight gain is ok?
b) how much fluid gain is ok?
c) what is considered extra fluid which. should be removed ?
d) how much additional fluid is ok to leave according to dry weight? For example: dry weight 50kg and next dialysis weight is either 51kg or 52 kg or 53kg . Is it ok to add 0.5l -1l always with respect to dry weight? So the weight would always be around 50 kg( dry weight) + 0.5l or 1l = 50.5kg or 51kg.
7. We re trying our best to increase hemoglobin but so far it seems hard. Any advice?
Thanking you!!!
Jenn
Nov 15, 2024 7:44 PM
I'm happy to answer questions-- but I also want to make sure your dad and your concerns are answered by the people involved in his care.
1. There is no "best" UF rate, we know that anything at or above 10mL/kg/hr is very hard on the body. The "safe" zone is lower-- <8mL/kg/hr.
2. I'm in the US, we run blood pumps very fast-- and we shouldn't. I'm happy to see that your dad's rate is in the 200s. That is good.
3. This is a question I think you should go over with the clinic.
Giving a lot of saline during treatment may make his BP go up and it will also make him more thirsty. And then he'll drink more, and then the fluid is hard to remove... it becomes a bad cycle.
Yes, 1.5L of saline sounds like a lot to me.
4. Blood sugar should always be normal.
5. It is usually saline. LR has electrolytes in it-- like potassium and calcium.
6. Fluids given during treatment are often added to the UF goal to try to get "even" at the end of treatment.
Dry weight is a constantly changing best guess-- do not get too hung up on the exact number. Your dad can probably guess his dry weight. He knows where feels okay and where he feels too heavy or too dry. Ask him and see what he says.
Tell the clinic the symptoms he is having. A lot of people say they feel washed out and terrible after dialysis. I believe everything you are telling me about how awful he feels.
7. Anemia in kidney disease often requires medications to correct. If he does not have much of an appetite, it is very hard to suggest he eat a steak. Hopefully he is being medications for the anemia that will make him feel better. I would ask!
Jack
Nov 21, 2024 3:49 AM
Thanks you so much for your response again. Highly appreciated.
I have to ask my dad but we are already in touch with doctor in here outside USA. We are not satisfied with doctor job.
My dad has no swelling at all, he looks skinny but when we went for checking dry weight, the machine said 4l over hydrated. We have no idea but doctor said ya you should remove water maybe 3000-4000ml/ 4 hrs duration because you are over hydrated. And also during treatment we are interjecting 50-100ml saline every 30mins because it's heaprin free and flushing dialyser with 250-500ml at the end of treatment which goes back into patient body. So the doctor suggested to take around 2500-3000ml water away during treatment which means 3000ml / 4 hrs UF removal.
Is this ok amount? If not then how much it should be? My dad weight is now 54.5kg( dry weight 50.5kg) please consider the amount of saline which they are putting in my dad's body so I can give them an estimated amount of UF removal. He is having dialysis 3 times a week.
And sometimes to stop clotting they use UF rate 1000ml/hr for 5-10 mins but it still gets clotting after some times. And then changed back to 600-700ml/ hrs for rest 2hrs . Usually my dad gets clotting after 2hrs or 3hrs which means either in the mid way or towards ending of dialysis.
Note: he has stent in his heart ( 1 stent) .
Loylyn Jones Walton
Jul 21, 2023 4:11 PM
My dry weight never changed for 6 months at 60.0 kg . That Thursday of my dialysis "incident" was 2.4. Kg/l for 4 hrs. It was the worst! ; Saturday treatment (upon explaining my incident) , the technician lowered the amount of fluid to be taken to 1.6 Kg/L where results were not so severe , but mitigated. I never weighed in 3 lbs or over my dry weight. I began jotting down dry weights in and out on recent treatment dates. Finally! At last adjustments this Tuesday upon my sharing the incident with the Clinical team! My dry weight was changed from 60.0 to 63.0 , fluid weight taken off changed from 1.6 kg/l to 1.2 Kg/L for 4 hrs. . What a huge difference from the adjustment to weight.
I will also share the dry weights in and out . Tues weigh in 64.2, out 63.1 (difference 1.1 L); Thurs. weigh in 64.4, out 63.5 (difference 0.9!). I still experienced nausea and temporal headaches , however, the mitigation was to add fluids!
I am not seeking reassessment of my kidney functions as positive changes are also occurring.
Thank you so much for your dialysis resources! At best, it all may mean less time on dialysis and a higher percentage change in kidney function.
I hope this helps others advocate for themselves.
Beulah Thompson
Aug 17, 2023 7:10 PM
Beth Witten
Jul 21, 2023 4:39 PM
Loylyn Jones Walton
Jul 15, 2023 12:19 PM
My treatment was set at 3 kg/4hrs (the highest ever set!) to remove and my body crashed! I broke into sweats, my heart was beating fast, there was vomiting , nausea, dizziness, my legs were unsteady, the stomach cramping left me with no appetite for hours!
Now I know the reasons why going above 2.5 was harmful. My target weight is 60 kg (I've been told) and I usually gain no more than 2.5 liters of fluid.
Debra Howard
Mar 29, 2023 1:43 AM
Loylyn
Jul 21, 2023 4:20 PM
Wish you the best!
Michael C Harber
Nov 22, 2022 7:31 AM
Jennifer Ravert
Nov 22, 2022 5:24 PM
Sara Slagle
Nov 10, 2021 9:26 PM
Sandy Lawrence
May 13, 2020 8:12 PM
David Leong
Apr 17, 2020 6:50 AM