Department: Nursing Name of Document

COE specific SOP- Guiding Weight and Blood Pressure

Management On Dialysis Patient

Prepared by: - Corporate Nursing Team Date of issue: 30/07/2021

Date of review: 29/06/2023
Reviewed by: - Capt. Usha Banerjee To be reviewed earlier in case of any
Approved by: Write name of the unit Nursing Head change in guidelines

Guiding Weight and Blood Pressure Management On Dialysis Patient

Introduction

Fluid removal (ultrafiltration) during dialysis

A patient’s tolerance to dialysis and ultrafiltration (UF) is more easily

accepted when performed separately, but as this would double the
treatment time a compromise is necessary. This SOP guides safe fluid
removal during dialysis. If a patient is gaining excessive amounts of fluid
weight between dialysis sessions this should be addressed in a sensitive
and supportive manner by the wider MDT.

During dialysis, fluid can only be removed from the vascular

compartment. This facilitates slower re-filling from the extra-vascular
compartment. In order to prevent precipitation of hypotension, which
would occur when fluid removal from the vascular compartment
exceeds the ability of the physiological compensatory response, and is
associated with changes in myocardial blood supply and poor outcomes,
UF can only be performed at a maximum rate of 10ml-15ml/kg/hr.

Definitions:
 Department: Nursing Name of Document
COE specific SOP- Guiding Weight and Blood Pressure
Management On Dialysis Patient

Prepared by: - Corporate Nursing Team Date of issue: 30/07/2021

Date of review: 29/06/2023
Reviewed by: - Capt. Usha Banerjee To be reviewed earlier in case of any
Fluid removal (Ultrafiltration): Ultrafiltration is the removal of fluid
from a patient and is one of the functions of the kidneys that dialysis
treatment replaces. Ultrafiltration occurs when fluid
Approved by: Write name of the unit Nursing Head change in guidelines

passes across a semipermeable membrane (a membrane that allows

some substances to pass through but not others) due to a driving
pressure.
Dry weight: It is the weight of the patient without the excess fluid that
builds up between dialysis treatments. This weight is similar to what a
person with normal kidney function would weigh after urinating.
Intradialytic hypertension: It is rise of at least 15 mmHg in mean BP
during dialysis or a rise of at least 10 mmHg in systolic BP during or
immediately post-dialysis in a certain number of dialysis sessions (the
last three or four dialysis sessions).
Intradialytic hypotension: It is defined as a systolic blood pressure of
less than 100 mmHg or a systolic blood pressure decrease of greater
than 10 mmHg, or a mean arterial pressure decrease of greater than 30
mmHg with or without symptoms.
Scope: Dialysis Unit and All Critical care units.
Background:
Hypertension is very prevalent in patients undergoing dialysis therapy.
As is for general population, it is one of the major causes of
cardiovascular mortality for those who take dialysis. It is still
challenging to treat hypertension in patients on dialysis because there
are many unsolved problems and concerns for the management of
hypertension, mainly due to few good quality clinical trials. In this
review, these problems will be discussed according to therapy types of
dialysis: haemodialysis (HD) and peritoneal dialysis (PD).
Responsibility: Treating consultant, dialysis technician and nursing staff
posted for the care of patient on dialysis.
 Department: Nursing Name of Document
COE specific SOP- Guiding Weight and Blood Pressure
Management On Dialysis Patient

Prepared by: - Corporate Nursing Team Date of issue: 30/07/2021

Date of review: 29/06/2023
Reviewed by: - Capt. Usha Banerjee To be reviewed earlier in case of any
Management:
1. Assessment of residual urine output. It is essential that this is
regularly recorded as it is a vital piece of information for guiding
Approved by: Write name of the unit Nursing Head change in guidelines

individualised fluid intake guidance. It should be measured within

a month of commencing chronic haemodialysis and every six
months thereafter. Diuretic as per treating consultant prescription
be administered to help maintain urine output. In addition,
nephrotoxic drugs may should be avoided in patients with residual
renal function.

2. Insensible loss (i.e. fluid lost through sweating and the

gastrointestinal loss) is approximately 750mls/day. This may be
greater in hot weather or in patients with higher than average
activity levels. Individualised fluid intake guidance should be
developed. In an anuric patient this generally amounts to a
1000ml/day fluid restriction but will depend on the patient’s size.
This can be increased in a patient passing urine. In general fluid
intake should be such that fluid gained between dialysis sessions is
2 litres or less and always such that weight gain is <5% between
even a 3-day break. Dietetic advice should be given with regards to
low salt intake in addition.

3. Calculated fluid removal should be based on the patient’s dry

weight. However, ultrafiltration rates should not be higher than
1015ml/kg/hr. This is often misquoted as ‘1 litre per hour’ but will
depend on the patient’s dry weight (a 50kg patient is very different
from a 120kg patient) and other co-morbidities affecting tolerance
to rate of fluid removal.
4. Effective estimation of dry weight is important and should be
reviewed regularly. This can be difficult and should be based upon
blood pressure changes (using sitting and standing if necessary),
 Department: Nursing Name of Document
COE specific SOP- Guiding Weight and Blood Pressure
Management On Dialysis Patient

Prepared by: - Corporate Nursing Team Date of issue: 30/07/2021

Date of review: 29/06/2023
Reviewed by: - Capt. Usha Banerjee To be reviewed earlier in case of any
central/jugular venous pressure, peripheral oedema, any
symptoms of pulmonary oedema and bioimpedance etc. Senior
nursing staff should be skilled to adjust dry weight and all nursing
staff should be able to communicate the need to adjust dry weight
effectively to patients.

Approved by: Write name of the unit Nursing Head change in guidelines

5. If fluid removal results in hypotension or symptoms of

hypovolaemia above dry weight various methods can be utilised to
aid adequate fluid removal:
a. Advise against eating and drinking during dialysis
b. Consider alternative ultrafiltration schedules. Sodium profiling
should not be used as tends to
sodium load patients and worsen intradialytic fluid
gains
c. If hypotension occurs at the beginning of dialysis, consider a
fluid bolus at start of dialysis.
d. Consider lowering temperature of dialysate to 36°C or even
35.5°C.
Further reduction is unlikely to be helpful
e. Consider cautious changes in dialysate sodium following
discussion with unit consultant.

6. If patient is still not able to tolerate removal of gained fluid, then

consideration should be given increased frequency of dialysis. This
can be performed in centre if short term to allow ‘re-setting’ of dry
weight or if serious co-morbidity, but consideration should also be
given to home haemodialysis (as per unit protocols) to allow
regular increased frequency dialysis.

Conclusion:
 Department: Nursing Name of Document
COE specific SOP- Guiding Weight and Blood Pressure
Management On Dialysis Patient

Prepared by: - Corporate Nursing Team Date of issue: 30/07/2021

Date of review: 29/06/2023
Reviewed by: - Capt. Usha Banerjee To be reviewed earlier in case of any
Managing blood pressure and weight in dialysis requires multidisciplinary
approach with integration of numerous clinical, dialysis treatment, and
patient factors. Bolstered by shared commitments and focusing on patient
priorities, hence numerous strategies and technologies that should be
considered in the effective management of weight and blood pressure
during the process.

Approved by: Write name of the unit Nursing Head change in guidelines

S.No Hospitals Validated by

1. Apollo Hospitals, Bengaluru a. Dr Deepashree
Consultant Nephrology

2. Apollo Hospitals, Chennai a. Dr Subba Rao –

Main Senior Consultant Nephrology

b. Dr Vivek
Consultant Nephrology
3. Apollo Hospitals, Kolkata a. Dr Manjit Kumar
Junior Consultant Nephrology

4. Apollo Hospitals, Navi a. Dr Amit Langote

Mumbai Consultant Nephrologist

b. Dr Ravindra Nikhalji
Consultant Nephrologist
 Department: Nursing Name of Document
COE specific SOP- Guiding Weight and Blood Pressure
Management On Dialysis Patient

Prepared by: - Corporate Nursing Team Date of issue: 30/07/2021

Date of review: 29/06/2023
Reviewed by: - Capt. Usha Banerjee To be reviewed earlier in case of any

5. Indraprastha Apollo a. Dr Anil

Hospitals, Nephrology Registrar
Delhi
b. Dr Kuldeep
Nephrology Registrar

c. Mr Ahmar Khan
HOD Dialysis Unit