A year-long quality improvement project on fluid management using blood volume monitoring during hemodialysis.

Background: Inadequate removal of extracellular volume markedly increases blood pressure and contributes to high morbidity and mortality in hemodialysis patients. Advances in fluid management are needed to improve clinical outcomes. The aim of this quality improvement project was to examine the advantages of using a hematocrit-based, blood volume monitor (Crit-Line * ) for 12 months, as part of a clinic-wide, fluid management program in one dialysis facility.

Methods: Forty-five individuals were receiving hemodialysis at one facility at project initiation and are included in this analysis. Monthly averaged clinical parameters (dialysis treatment information, blood pressures, blood volume, and laboratory data) were compared from Months 1-12. Analyses were conducted overall and according to the presence/absence of hypertension at Month 1 (Baseline). Antihypertensive medication changes were assessed for patients with hypertension at Month 1.

Results: Average hemodialysis treatment time (+10.6 minutes, p = 0.002), eKt/V (+0.25, p < 0.001) and online clearance (+0.21, p < 0.0001) increased significantly in Month 12 versus Month 1. Average albumin levels and normalized protein catabolic rate increased from Month 1 to 12. Post-dialysis systolic blood pressure (SBP) decreased by Month 12 (p = 0.003). In hypertensive patients (SBP ≥ 140 mmHg in Month 1), there were significant differences in pre- and post-dialysis SBP between Month 1 and Month 12 (pre-hemodialysis: p = 0.02; post-hemodialysis: p = 0.0003), and antihypertensive medication use decreased in 29% of patients, while only 11% increased use. Treatment time in hypertensive patients increased by 15.4 minutes (p = 0.0005).

Limitations: This was a single, clinic-wide, quality improvement project with no control group. All data analyzed were from existing clinical records, so only routinely measured clinical variables were available and missing data were possible.

Conclusions: During this year-long fluid management quality improvement project, decreases in post-dialysis SBP and increases in adequacy and treatment time were observed. Patients with hypertension at Month 1 experienced reductions in pre-dialysis SBP and antihypertensive medications.