Fluid Management News

The National Quality Forum has endorsed a new clinical measure focused on improving fluid management for dialysis patients. The measure focuses on safe and adequate fluid removal, and was developed by the Kidney Care Quality Alliance (KCQA), a group founded by Kidney Care Partners (KCP).

This year, PCORI, the Patient-Centered Outcomes Research Institute, awarded a $6.7 million, five-year grant to two professors from the University of Michigan School of Public Health to do a study entitled "Enhancing the Cardiovascular Safety of Hemodialysis Care: A Cluster-Randomized, Comparative Effectiveness Trial of Multimodal Provider Education and Patient Activation Interventions." It deals primarily with educating dialysis patients and training providers on how to ensure 'patient stability' during the in-center dialysis treatment by properly removing excess fluid and avoiding cardiac damage in the process. 1

Editor’s note: The Kidney Care Quality Alliance, formed in 2008 by Kidney Care Partners, announced recently that it would begin developing a new set of quality measures for the renal community. A top priority, the group says, is a measure for fluid management. We asked Edward R. Jones, MD, and Allen R. Nissenson, MD, co-chairs of the KCQA, how the measures would be developed and the importance of fluid management. KCP is a broad-based coalition of patient advocates, clinicians, care professionals, dialysis providers, researchers and manufacturers working together to improve quality of care for individuals with chronic kidney disease (CKD) and end-stage renal disease.

Fluid overload (FO) is common in hemodialysis patients and leads to complications such as hypertension, left ventricular disease, myocardial stunning, with its associated fibrosis, arrhythmias, heart failure, and sudden cardiac death. Small increases in extracellular volume (ECV) drive left ventricular disease.1 In these patients, greater fluid retention between two subsequent dialysis sessions is associated with even higher all-cause risk of mortality and morbidity.2

Bringing the problem of fluid overload under control among dialysis patients has been central to discussions by clinicians and policy makers over the past two to three years. It has been discussed as a new quality measure for the End Stage Renal Disease Program Quality Incentive Program; policy makers see it as a major cause of expensive hospitalizations among dialysis patients, which consume half of the ESRD Program's annual expenditures. It creates headaches for dialysis staff who must be aggressive about trying to find the ideal dry weight for dialysis patients. It also reduces the effectiveness of drugs aimed at treating other kidney disease-related problems, like anemia.