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Preference Dry Weight
Preference Dry Weight
Abstract
Background and objectives Larger weight gain and higher ultraltration rates have been associated with poorer
outcomes among patients on dialysis. Dietary restrictions reduce uid-related risk; however, adherence is
challenging. Alternative uid mitigation strategies include treatment time extension, more frequent dialysis,
adjunct peritoneal dialysis, and wearable ultraltration devices. No data regarding patient preferences for uid
management exist. A survey was designed, tested, and administered to assess patient-stated preferences
regarding uid mitigation.
Design, setting, participants, & measurements A written survey concerning uid-related symptoms, patient and
treatment characteristics, and uid management preferences was developed. The cross-sectional survey was
completed by 600 patients on hemodialysis at 18 geographically diverse ambulatory facilities. Comparisons of
patient willingness to engage in volume mitigation strategies across uid symptom burden, dietary restriction
experience, and patient characteristics were performed.
Results Final analyses included 588 surveys. Overall, if allowed to liberalize uid intake, 44.6% of patients were
willing to extend treatment time by 15 minutes. Willingness to extend treatment time was incrementally less for
longer treatment extensions; 12.2% of patients were willing to add a fourth weekly treatment session, and 13.5%
of patients were willing to participate in nocturnal dialysis three nights per week. Patients more bothered by their
uid restrictions (versus less bothered) were more willing to engage in uid mitigation strategies. Demographic
characteristics and symptoms, such as cramping and dyspnea, were not consistently associated with willingness
to engage in the proposed strategies. More than 25% of patients were unsure of their dry weights and typical
interdialytic weight gains.
Conclusions Patients were generally averse to treatment time extension.15 minutes. Patients more bothered
(versus less bothered) by their prescribed uid restrictions were more willing to engage in volume mitigation
strategies. Additional study of patient-stated preferences in hemodialysis treatment practices is needed to guide
patient care and identify deciencies in patient treatment and disease-related knowledge.
Clin J Am Soc Nephrol 9: 14181425, 2014. doi: 10.2215/CJN.03280314
Introduction
Patients on hemodialysis (HD) have mortality
rates.6-fold the rates of the general population (1).
An expanding evidence base suggests that volumerelated metrics, including greater interdialytic weight
gain (IDWG) and more rapid uid removal during
HD, may contribute to poor outcomes (26).
Higher IDWG necessitates more rapid ultraltration
(UF) rates during dialysis, and inadequate uid removal
results in chronic volume expansion. Higher IDWG and
UF rates have been linked to greater morbidity and
mortality (26). Currently, uid and salt restrictions are
the principle means used to minimize IDWG and
thereby, rapid UF rates, but research and clinical experience show that adherence to these otherwise physiologically sound interventions is difcult (7,8). As a
result, as many as 25%50% of patients on HD are
chronically volume-expanded, and many patients are
routinely exposed to high UF rates (9). To mitigate risk
1418
Harvard Medical
School, Boston,
Massachusetts;
Health Services
Division, John Snow,
Inc., Boston,
Massachusetts; and
DaVita Clinical
Research,
Minneapolis,
Minnesota
Correspondence:
Dr. Jennifer E. Flythe,
University of North
Carolina Kidney
Center, 7024 BurnettWomack CB #7155,
Chapel Hill, NC
27599-7155. Email:
jflythe@med.unc.edu
1419
unclear items and commented on survey length; the instrument was modied to incorporate feedback. Field pilot testing of the modied instrument was performed in 50 patients
on HD during a routine outpatient HD session and repeated
2 weeks later in 48 of the 50 patients. Pilot study results were
analyzed for item response distribution and frequency, construct validity, reliability, and testretest reliability. The instrument was modied on the basis of patient feedback and
psychometric results. (Supplemental Table 2 displays characteristics of patients participating in instrument pretesting.)
Survey Administration and Data Collection
The nal survey instrument was distributed to patients at
18 DCI outpatient dialysis units. Patients on in-center HD
aged$18 years old who were able to read and complete an
English language written survey without assistance were
eligible. Exclusion criteria included patients on PD and
home HD. HD treatment and demographic data were selfreported; facility staff did not assist with survey completion.
Written survey completion represented implied consent to
participate in research; patients received no remuneration. In
total, 1163 surveys were mailed to HD units, and 600 surveys were returned. Surveys with ,50% question responses
(n=5) or missing age (n=3) or sex (n=4) were excluded, leaving 588 surveys for analysis.
Statistical Analyses
Pilot survey results were evaluated for response category
frequency and distribution by counts and histograms.
Psychometric analyses included assessment of reliability,
construct validity, and testretest reliability. Cronbach a (a
threshold of 0.70 is regarded as good reliability among test
items) was used to assess internal consistency and reliability within constructs. Testretest reliability was assessed
with the k-statistic (proportion of chance-corrected agreement or a measure of agreement) (10) between responses to
the volume mitigation strategy willingness questions from
the two pilot survey administrations.
Unit response rates were calculated by dividing the
number of returned surveys by the number of mailed
surveys on a facility-to-facility basis. Mailed survey numbers
were on the basis of rough estimates of eligible patients by
clinic administrators and medical directors. Data regarding
the actual number of patients approached who declined to
complete surveys are not available. Reported response rates
are likely underestimations, because most units reported
receiving more surveys than they had eligible patients.
Demographic and HD treatment data were reported as
counts and proportions for categorical variables and means
and SDs for continuous variables. Bivariable comparisons
across categories of uid restriction burden, residual urine
output, lower extremity swelling, IDWG, dyspnea, and HDassociated cramping were made using chi-squared tests. All
analyses were performed using STATA 12.1MP (College
Station, TX).
Results
Survey Instrument Pilot and Psychometric Testing
The survey pilot test was completed by 50 patients on
HD (76% participation rate) during a routinely scheduled
ambulatory HD session at a Boston, Massachusetts, dialysis
1420
Location
Northeast
Maine (1)
Massachusetts (2)
New York (1)
Pennsylvania (2)
Midwest
Indiana (1)
Missouri (2)
Southeast
Alabama (3)
Florida (3)
West
Montana (1)
New Mexico (2)
Total patients
State are listed with the number of participating units in
parentheses.
n
13
58
53
65
91
23
70
110
63
54
600
1421
Table 2. Demographic characteristics of surveyed patients by volume-related risk mitigation strategy willingness
Characteristic
Age (yr)
#39
4059
6069
$70
Sex
Men
Women
Race
White
Black
Othera
Missing
Education
No HS graduation
HS graduate/GED
Some college or more
Missing
Employment statusb
Collecting disability
Retired, homemaker
Unemployed, looking
Part-time work
Full-time work
Missing
Heart failure
Yes
No
Missing
Location
Northeast
Southeast
Midwest
West
Total (n=588)
(+) TT by
15 min (n=262)
(2) TT by
15 min (n=321)
60 (10.2%)
235 (40.0%)
135 (23.0%)
158 (26.8%)
27 (10.3%)
99 (37.8%)
66 (25.2%)
70 (26.7%)
32 (10.0%)
136 (42.3%)
68 (21.2%)
85 (26.5%)
11 (15.3%)
32 (44.4%)
13 (18.1%)
16 (22.2%)
48 (9.4%)
201 (39.5%)
121 (23.8%)
139 (27.3%)
339 (57.6%)
249 (42.4%)
143 (54.6%)
119 (45.4%)
194 (60.4%)
127 (39.6%)
37 (51.4%)
35 (48.6%)
299 (58.7%)
210 (41.3%)
202 (34.3%)
280 (47.6%)
105 (17.9%)
1 (0.2%)
98 (37.4%)
125 (47.7%)
39 (14.9%)
0
103 (32.1%)
154 (48.0%)
63 (19.6%)
1 (0.3%)
20 (27.8%)
43 (59.7%)
9 (12.5%)
0
180 (35.3%)
236 (46.4%)
92 (18.1%)
1 (0.2%)
105 (17.8%)
227 (38.6%)
255 (43.4%)
1 (0.2%)
48 (18.3%)
92 (35.1%)
122 (46.6%)
0
54 (16.8%)
133 (41.4%)
133 (41.4%)
1 (0.3%)
17 (23.6%)
27 (37.5%)
27 (37.5%)
1 (1.4%)
85 (16.7%)
198 (38.9%)
226 (44.4%)
0
202 (34.4%)
289 (49.1%)
25 (4.2%)
36 (6.1%)
35 (6.0%)
1 (0.2%)
82 (31.3%)
139 (53.1%)
11 (4.2%)
14 (5.3%)
15 (5.7%)
1 (0.4%)
118 (36.8%)
147 (45.8%)
14 (4.4%)
22 (6.8%)
20 (6.2%)
0
27 (37.5%)
36 (50.0%)
1 (1.4%)
2 (2.8%)
6 (8.3%)
0
172 (33.8%)
249 (48.9%)
24 (4.7%)
34 (6.7%)
29 (5.7%)
1 (0.2%)
219 (37.2%)
365 (62.1%)
4 (0.7%)
93 (35.5%)
168 (64.1%)
1 (0.4%)
125 (38.9%)
194 (60.5%)
2 (0.6%)
22 (30.6%)
50 (69.4%)
0
196 (38.5%)
310 (60.9%)
3 (0.6%)
186 (31.6%)
172 (29.3%)
114 (19.4%)
116 (19.7%)
83 (31.7%)
74 (28.2%)
52 (19.9%)
53 (20.2%)
102 (31.8%)
96 (29.9%)
62 (19.3%)
61 (19.0%)
22 (30.5%)
11 (15.3%)
26 (36.1%)
13 (18.1%)
163 (32.0%)
158 (31.0%)
88 (17.3%)
100 (19.7%)
All characteristics (with the exception of geographic region) were patient reported. Five patients omitted the 15-minute increase
question, and seven patients omitted the fourth weekly session question; these patients were excluded from table comparisons. HS,
high school; GED, general equivalency diploma; TT, treatment time; HD, hemodialysis.
a
Includes American Indian, Alaskan, Hawaiian, Pacic Islander, and Hispanic/Latino.
b
Selection of more than one response category was allowed.
Discussion
Patients on HD experience signicant morbidity and
mortality from volume overload and rapid uid removal;
however, no data regarding patient-stated preferences for
treatment approaches to uid management exist. Our
survey revealed that, if patients were allowed to drink as
much uid as they desired, .40% would be willing to
extend their TT by 15 minutes, but willingness to extend
TT decreased incrementally with greater TT extension. Patients who were more bothered by uid restrictions were
more likely to be willing to engage in different volume/UF
mitigation strategies. Demographic characteristics and
symptoms, such as cramping, dizziness, and dyspnea,
were not consistently associated with willingness to engage in the volume/UF mitigation strategies. Finally, our
results revealed that .25% of patients were unsure of their
dry weights and typical IDWGs, and .40% of patients
1422
Table 3. Self-reported dialysis characteristics of surveyed patients by volume-related risk mitigation strategy willingness
Characteristic
Dry weight
(quartiles; kg)
#67
6880
8197
$98
Not sure
Missing
IDWG (tertiles; kg)
#2
2.13
$3.1
Not sure
Missing
TT (min)
#239
$240
Not sure
Prescribed a uid
restriction
Yes
No
Missing
Fluid restriction
amount (L)
#1
1.11.9
$2
Missing
Frequency of meeting
uid restriction
Less than one time
per week
One to three times
per week
Daily
Missing
Vintage (yr)
#0.9
15
$5.1
Missing
Residual urine output
None
A little
Some
A lot
Missing
Total (n=588)
(+) TT by
15 min (n=262)
(2) TT by
15 min (n=321)
112 (19.1%)
93 (15.8%)
100 (17.0%)
96 (16.3%)
180 (30.6%)
7 (1.2%)
51 (19.5%)
43 (16.4%)
45 (17.2%)
47 (17.9%)
73 (27.9%)
3 (1.1%)
60 (18.7%)
49 (15.3%)
55 (17.1%)
48 (14.9%)
105 (32.7%)
4 (1.3%)
13 (18.0%)
11 (15.3%)
16 (22.2%)
12 (16.7%)
20 (27.8%)
0
98 (19.3%)
81 (15.9%)
84 (16.5%)
82 (16.1%)
157 (30.8%)
7 (1.4%)
165 (28.1%)
159 (27.0%)
104 (17.7%)
154 (26.2%)
6 (1.0%)
55 (21.0%)
86 (32.8%)
53 (20.2%)
65 (24.8%)
3 (1.2%)
107 (33.3%)
73 (22.8%)
51 (15.9%)
87 (27.1%)
3 (0.9%)
18 (25.0%)
26 (36.1%)
19 (26.4%)
9 (12.5%)
0
143 (28.1%)
133 (26.1%)
84 (16.5%)
143 (28.1%)
6 (1.2%)
255 (43.4%)
298 (50.7%)
35 (5.9%)
106 (40.5%)
141 (53.8%)
15 (5.7%)
145 (45.2%)
157 (48.9%)
19 (5.9%)
29 (40.3%)
39 (54.2%)
4 (5.6%)
221 (43.4%)
258 (50.7%)
30 (5.9%)
436 (74.2%)
150 (25.5%)
2 (0.3%)
209 (79.8%)
53 (20.2%)
0
224 (69.8%)
96 (29.9%)
1 (0.3%)
55 (76.4%)
17 (23.6%)
0
376 (73.9%)
132 (25.9%)
1 (0.2%)
299 (68.6%)
38 (8.7%)
43 (9.9%)
56 (12.8%)
138 (66.0%)
25 (12.0%)
21 (10.0%)
25 (12.0%)
160 (71.4%)
12 (5.4%)
22 (9.8%)
30 (13.4%)
41 (74.5%)
4 (7.3%)
6 (10.9%)
4 (7.3%)
256 (68.1%)
32 (8.5%)
37 (9.8%)
51 (13.6%)
186 (42.7%)
79 (37.8%)
106 (47.3%)
25 (45.4%)
159 (42.3%)
151 (34.6%)
74 (35.4%)
75 (33.5%)
19 (34.6%)
129 (34.3%)
89 (20.4%)
10 (2.3%)
51 (24.4%)
5 (2.4%)
38 (17.0%)
5 (2.2%)
10 (18.2%)
1 (1.8%)
79 (21.0%)
9 (2.4%)
155 (26.3%)
272 (46.3%)
153 (26.0%)
8 (1.4%)
61 (23.3%)
127 (48.5%)
71 (27.1%)
3 (1.1%)
93 (29.0%)
142 (44.2%)
81 (25.2%)
5 (1.6%)
17 (23.6%)
25 (34.7%)
29 (40.3%)
1 (1.4%)
137 (26.9%)
242 (47.5%)
123 (24.2%)
7 (1.4%)
129 (21.9%)
175 (29.8%)
206 (35.0%)
73 (12.4%)
5 (0.9%)
63 (24.0%)
87 (33.2%)
87 (33.2%)
23 (8.8%)
2 (0.8%)
66 (20.6%)
88 (27.4%)
115 (35.8%)
50 (15.6%)
2 (0.6%)
21 (29.2%)
23 (31.9%)
22 (30.6%)
6 (8.3%)
0
108 (21.2%)
151 (29.6%)
179 (35.2%)
67 (13.2%)
4 (0.8%)
All dialysis characteristics were patient reported. Five patients omitted the 15-minute increase question, and seven patients omitted the
fourth weekly session question; these patients were excluded from table comparisons. IDWG, interdialytic weight gain.
Although dietary restriction remains a viable volume mitigation strategy with intensive patient support and education,
it is imperative that we develop alternative interventions.
This need is underscored by our nding that .40% of patients self-reported daily uid restriction adherence ,1 day
per week. To mitigate IDWG-related harm, non-HD day
therapies, such as adjunct PD and wearable UF devices,
may be benecial. PD in patients with refractory heart failure has been shown to decrease hospitalizations and improve functional status (17). In a 13-patient study of 4-weeks
duration, Jones et al. (18) showed lower pre-HD BP and
IDWG among patients treated with near daily UF (4 days
of UF and 2 days of UF and HD). Wearable UF and articial kidney devices could provide a similar benet (19) and
1423
Figure 1. | Fluid restriction bother defined as moderately, very much, or extremely bothered by their prescribed fluid restriction (versus not
at all or somewhat bothered). P values reflect bivariable comparisons across two categories of fluid restriction burden. HD, hemodialysis; TT,
treatment time; UF, ultrafiltration. aPatients on active nocturnal dialysis (n=12) were excluded from analysis.
Table 4. Willingness to participate in volume mitigation strategies by incrementally greater perceived fluid restriction bother
Strategy
Increase TT by 15 min
Increase TT by 30 min
Increase TT by 45 min
Add fourth HD per week
Nocturnal HD three
times per weekb
PD on non-HD days
Wearable UF device
Not Bothered
(n=270)
Somewhat
Bothered (n=129)
Moderately
Bothered (n=96)
Very Much
or Extremely
Bothered (n=89)
P for
Trenda
89 (33.2%)
37 (13.8%)
20 (7.5%)
24 (9.0%)
29 (11.0%)
61 (48.0%)
24 (18.9%)
6 (4.7%)
12 (9.5%)
22 (17.6%)
53 (55.2%)
27 (28.1%)
13 (13.5%)
16 (16.8%)
12 (12.8%)
57 (64.0%)
35 (39.3%)
18 (20.2%)
20 (22.5%)
14 (16.7%)
,0.001
,0.001
0.002
0.001
0.16
29 (10.3%)
37 (14.1%)
14 (11.5%)
26 (21.3%)
8 (8.9%)
23 (25.3%)
11 (12.4%)
31 (35.2%)
0.77
,0.001
Five patients omitted the 15- and 30-minute increase questions, and seven patients omitted the fourth weekly session question; these
patients were excluded from table comparisons. PD, peritoneal dialysis; UF, ultraltration.
a
Nonparametric test for trend across ordered groups by an extension of Wilcoxon rank sum testing.
b
Active nocturnal dialysis patients (n=12) were excluded from analysis.
1424
understanding of HD-related symptom physiology. Although our survey did not directly assess health literacy
and HD-related knowledge, our results revealed that
30.6% of patients did not know their dry weights, 26.2%
of patients did not know their typical IDWGs, and 5.9% of
patients did not know their TTs. These ndings expose
important knowledge gaps and highlight the need for educational programs focused on disease-specic health literacy and motivational programs designed to engage
patients in treatment plans.
Additionally, we found that .40% of patients would be
willing to extend TT by 15 minutes if they could increase
uid intake; however, this willingness fell to ,10% with
45 minutes of TT extension. Such resistance to TT extension is consistent with clinical experience. However, we
were surprised that more patients were willing to add an
extra weekly HD session than were willing to extend sessions by 45 minutes three times per week, suggesting that
longer HD duration carries greater aversion than greater
HD frequency (despite the greater cumulative TT associated with the latter). In contrast, more patients were willing to try 8-hour nocturnal dialysis than extend sessions by
45 minutes. This nding could be attributed to increased
patient awareness of associations between nocturnal dialysis and improved quality of life (23) and is supported by
our nding that patients more bothered by fatigue were
more likely to be willing to participate in nocturnal HD.
Finally, our results revealed general aversion to adoption
of most of the proposed uid mitigation strategies. Such
ndings underscore the need for research focused on identifying alternative strategies for uid management and the
need for consideration of patient opinion in such research.
Incorporation of patient opinion in the early stages of research may provide important data regarding potential for
trial enrollment success and more importantly, the likelihood
of ultimate therapeutic adoption.
To our knowledge, this study is the rst effort to broadly
assess patient preferences regarding uid management. Its
strengths include a large, geographically diverse sample size
with demographic and treatment characteristics similar to the
broader United States HD population and the use of a survey
instrument developed with patient input and attention to
patient-reported outcome standards (24).
Our study does have important limitations. First, convenience samples for instrument development were used, and
participants may not have been representative of the broader
HD population. Second, unit survey response rates varied
widely; nonresponse bias may have affected results. Although
it is reassuring that survey responders were similar to the
broader United States HD population in terms of age, sex, TT,
IDWG, and dialytic vintage, survey responders may have
been differentially likely to engage in or may have differential
experience with various volume mitigation strategies. Response rates might have been improved by allowing dialysis
facility staff to aid in survey completion; however, it would
have impaired our assessment of patient treatment knowledge. Third, HD and demographic data were self-reported;
incorrect reporting may have introduced misclassication
bias. Fourth, black patients were disproportionately represented in our survey responders; however, responses to
strategy questions did not differ signicantly between black
and nonblack respondents. Additionally, we excluded pa-
1425
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Received: March 31, 2014 Accepted: May 7, 2014
Published online ahead of print. Publication date available at www.
cjasn.org.
This article contains supplemental material online at http://cjasn.
asnjournals.org/lookup/suppl/doi:10.2215/CJN.03280314/-/
DCSupplemental.