Blood volume monitoring a crucial step in reducing mortality.

Weir articulates it best in his editorial commentary in Hypertension: "Ultimately, the main goal of treatment of blood pressure is to prevent cardiac events. Perhaps the most important strategy in the dialysis patient is to achieve an appropriate dry weight, minimize volume overload, and use blood pressure-lowering medications only in the setting of 'hypertension' when dry weight is truly probed and demonstrated. It is possible that if more patients achieved dry weight, then less antihypertensive medication would be required, as is observed in patients on longer-session nocturnal hemodialysis. I suspect that long-term volume/pressure overload of the left ventricle, because of inadequate achievement of dry weight, may be one of the most important cardiovascular concerns in the hemodialysis patient." I do believe euvolemia is possible. In the Grass Valley study (Rodriguez et al), we evaluated post-dialytic vascular compartment refill. After deciding that refill could be evaluated after 10 minutes of ultrafiltration in minimum (200 mL/ hour), we used the following steps. Step 1. Note hematocrit Step 2. Place UF in minimum Step 3. Wait 10 minutes Step 4. Note hematocrit If hematocrit declines by 0.5 or more in 10 minutes, patient has refill, and is "not dry:' If hematocrit declines by 0.4 or less in 10 minutes, patient is "vascularly dry" If additional fluid is available, and willing to shift from the extracellular compartment to the intravascular compartment, it will decrease the hematocrit by hemodilution, hence the "not dry" patient has a decline in hematocrit in the absence of ultrafiltration (see Table 1).