87 Year old male, End stage renal disease

Yesterday, my Husband was taken to a hospital with shortness of breath, major confusion, and weakness. He had just finished hemodialysis. The Doctor at the hospital said that he was retaining fluid and it should be removed so he would feel better. The people at Davita in my town said they did remove fluid from him. This has been going on for quite a few months, off and on, but this time was really the worst. Many thought that he was in the beginning stages of dementia but I have watched him go down hill since he stopped PD and went back to hemo.
Note: The first time he had hemo in 2016 he died for 10 minutes and was brought back. No repercussions from it though at the time.
My question is if there was that much fluid in him, why did they take off so little in treatment? I was also told that he was not the same person he used to be a few months ago and he was dying slowly by one of the technicians.
I would like your opinion of this.
Thank you for your help.
Judy Pierce

Is he getting down to his dry weight on dialysis?

You mentioned that your husband switched from PD to ICHD. The diet and fluid restrictions are different now. He should be taking in very little liquids so the fluid to be removed is Minimal each treatment.
Also, during treatments if his blood pressure is dropping, they cannot pull off fluid. This results in more fluid build up. His heart may be weaker now with age and time on dialysis.
Meet with his dietitian to review his labs and fluid gains, she will be able to assist you with some good tips for diet and fluid restriction.
Also, is he using a chest catheter for dialysis? Infection in older folks frequently results in mental changes. Please speak with your clinic nurses or nephrologist to help you understand his condition. That is part of their job

I have been on dialysis since May 2019, 5 months on hemo and I always felt totally wasted after each treatment, but was responding well and went on PD in late October for 10 hrs (5 cycles) per day, actually at night and feel much much better and more active. Of course I will turn 78 in June. Weight has gone up and appetite improved so much since going on PD.

Has your husband been evaluated by his nephrologist recently. Is he/she aware of the changes you and the dialysis staff have observed? I hope his nephrologist will see him in the hospital, but it’s possible that he’ll be seen by a hospitalist who directs patients’ care .Hospitalists have access to medical records, but don’t KNOW the history patients they see in the hospital and unless they specialize in kidneys, s/he may not be able to tease out what is happening. I’d strongly recommend talking with his nephrologist and asking for an appointment in his/her office after discharge.

I am sorry to hear your husband is having such a hard time of it. I am not sure if it will help but while I can make some general comments, the issue of fluid - how much is there to remove, how to assess it, and how to remove it - are all questions that need by-the-bedside assessment, and can only be assessed by an on-the-spot doctor familiar with the patient. Thus, anything I might say from half a globe away may be fraught with error.

Fluid, fluid volume, and the method, rate, and frequency of its removal can be a very difficult problem, compounded here by your husbands age (87) and his past known cardiac history. What that means is, his heart is not strong, and removing fluid in this circumstance would be a tight-wire balancing act for any dialysis team.

It is quite possible - no, from your description, probable - that he DOES have excess fluid to remove. I think that sounds ‘a given’. But, all too often, when attempts are made to remove the excess fluid from patients with fragile hearts, the blood pressure falls and fluid removal is therefore either incomplete, or may even be counteracted if saline has to be given to restore an acute fall in blood pressure.

DaVita’s comment that they had already removed as much fluid as they could may be correct - especially if the blood pressure destablised and they had felt that they had ‘removed as much as they could’. But, this doesn’t mean they got it all, or enough of it, and that there wasn’t still more to remove [= consistent with the hospital doctor’s comment].

This is where a gently, gently approach is absolutely essential … and I am assuming here that the diagnosis of excess fluid on board is a correct one [and only on-site assessment can confirm or deny that].

This is where fluid removal MUST be slow and gentle.

To avoid crashing the blood pressure … to avoid reducing in-treatment ‘stunning’ of the heart via a loss of oxygen delivery to the heart muscle … but to allow maximal fluid removal, two things must happen.

First, dialysis needs to be slower, and longer. Fluid much NOT be ‘hurried off’. Long, gentle, slow, low ultrafiltration rate dialysis is essential.

Second, fluid removal may be aided by a higher frequency of treatments - daily for a time, if necessary - to slowly edge down his fluid excess. This was first modeled by George Ting [San Francisco] in his short-daily ‘rescue’ approach.

But, for reasons obscure to me, it seems that US dialysis services are often not set up to easily enable this softly, softly approach … but it IS the safest way to remove excess fluid.

So … if there IS more to come off, then using daily, slow, long (if possible), and low UFR dialysis is the way I would approach him.

Remember, though, this can ONLY be determined by careful, on-site, fluid assessment and dialysis in the hands of a careful, gentle team.