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Ovid: Oxford Handbook of Dialysis

Editors: Levy, Jeremy; Morgan, Julie; Brown, Edwina Title: Oxford Handbook of Dialysis, 2nd Edition Copyright ©2004 Oxford University Press > Table of Contents > Part 9 – Complications of ESRD: Fluid overload Part 9 Complications of ESRD: Fluid overload Can be symptomatic, asymptomatic but clinically detectable or covert (usually manifesting solely as hypertension). Symptoms and signs (dyspnoea, orthopnoea, cough, peripheral oedema, abdominal distension, chest crepitations, raised JVP, etc.) indistinguishable from those of primary cardiac failure, although BP almost always raised (low if heart failure). Echocardiography will exclude functional ventricular impairment. Asymptomatic patients may have raised central venous pressures, ankle oedema, and chest signs, but not complain of breathlessness, especially if volume overload has developed insidiously. Large numbers of patients are not considered fluid overloaded because they have no symptoms or signs, become hypotensive on dialysis if their dry weight is reduced further, but remain hypertensive. This cohort almost certainly is fluid overloaded, as units using long slow dialysis techniques are able to withdraw antihypertensive drugs in almost all patients. Persistent hypertension despite being on an ACEI or A2RB is also suggestive of fluid overload. Fluid overload may be driven by salt intake. Non-invasive monitoring techniques may help achieve true dry weight in patients dialysed for shorter times (BVM). Patients must be educated in the importance of restricting salt intake (most important), and fluid intake according to their urine output (maximum 1 kg/day), and the necessity of achieving a true dry weight to minimize the long-term risks of volume overload (LVH). Management is discussed in the appropriate sections on HD and PD. Diuretics (high doses) are often used to maintain urine output in patients with ESRD. This can be useful in some patients on both HD and PD, as the extra urine volume reduces the patient’s fluid restriction. Diuretics should be stopped after loss of residual function. Diuretics do not alter the rate of change of solute clearance in ESRD (neither slow or hasten the decline), and hence do not preserve residual function, but simply maintain additional urine output in some patients.

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