Fluid Management Based on Bioimpedance, Blood Volume, and Patient Reports: A Quality Improvement Project in Maintenance Hemodialysis

Rationale & Objective: Fluid management in hemodialysis aims to remove excess fluid while avoiding symptoms of fluid depletion. This study evaluated the impact of determining euvolemic body mass by bioimpedance spectroscopy, and absolute blood volume (ABV), on clinical practice and patient-reported outcome measures (PROMs) at a bioimpedance/ABV-naïve dialysis center. Study Design: Fourteen week quality improvement project with 3 Assessment phases separated by 2 Adjustment phases. Setting & Participants: Total of 127 patients at a single dialysis center. Quality Improvement Activities: Bioimpedance-spectroscopy-derived fluid overload (FO), ABV, and PROMs were longitudinally recorded. Physicians received data from each Assessment phase to inform treatment decisions. Outcomes: Fluid overload, ABV, PROMs, and agreement between perceived fluid status and FO. Analytic Approach: Generalized linear mixed-effects models analyzed changes over time and associations between FO, ABV, and PROMs. Agreement between perceived fluid status and FO was evaluated with linearly weighted Cohen's κ. Agreement between perceived and bioimpedance-spectroscopy-derived FO was poor (κ: 0.007-0.037 for patients, 0.022-0.018 for nurses). Conclusions: During the introduction of bioimpedance- and ABV-guided fluid management at a hemodialysis center, fluid status improved without significant changes in intradialytic morbid events. The lack of agreement between perceived fluid status and bioimpedance-spectroscopy-derived FO reflects the daily clinical struggle when negotiating fluid management based on objective measures.