School of Medicine, Faculty of Medicine and Health Sciences, David Weatherall Building, Keele University, Keele, Staffordshire, ST5 5BG, UK.
NIHR Devices for Dignity, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
BMC Nephrol. 2024 Nov 6;25(1):398. doi: 10.1186/s12882-024-03837-y.
Fluid assessment and management is a key aspect of good dialysis care and is affected by patient-level characteristics and potentially centre-level practices. In this secondary analysis of the BISTRO trial we wished to establish whether centre-level practices with the potential to affect fluid status were stable over the course of the trial and explore if they had any residual associations with participant's fluid status.
Two surveys (S) of fluid management practices were conducted in 32 participating centres during the trial, (S1: 2017-18 and S2: 2021-22). Domains interrogated included: dialysate sodium concentration, (D-[Na]), fluid and salt intake, residual kidney function, use of diuretics, incremental start, approaches to fluid assessment, management and dialysate temperature, (D-C). Associations of these practices with the closeness of the participant's post-dialysis target weight to their normally hydrated weight, pre- and post-dialysis systolic (SBP) and diastolic blood pressure, (DBP), were analysed using intra-class correlations and multilevel modelling with adjustment for visit, age, sex and comorbidity burden.
Variations in centre practices were reported but did not change during the trial, apart from some relaxation in salt and fluid restriction in S2. For our measures of fluid status, measured 2501 times in 439 non-anuric incident haemodialysis patients, centre-level intraclass correlations were extremely low, whereas patient-level correlations ranged between 0.12 and 0.47, strongest for pre- and post-dialysis-SBP, less so for post-dialysis-DBP. Multi-level analysis found no associations between D-[Na], or assessment methods of fluid status. In S2, one centre, routinely using a D-C of 35°C had more divergence between the target and normally hydrated weight, but this was not observed in S1, and no other associations were found.
Centre-level fluid management practices were stable over the course of the BISTRO trial, and in contrast to patient-level factors, no centre-level associations were detected with fluid status or blood pressure. This may be because the trial imposed a standardised approach to fluid assessment in all trial participants who at least initially had residual kidney function, potentially over-riding the effects of other centre practices. Survey responses revealed substantial scope for developing and evaluating standardised protocols to optimise fluid management.
液体评估和管理是透析护理的关键方面，受到患者个体特征和潜在中心实践的影响。在 BISTRO 试验的这项二次分析中，我们希望确定在试验过程中是否有影响液体状态的中心实践，并探讨它们是否与参与者的液体状态有任何残留关联。
在试验期间，32 个参与中心进行了两次液体管理实践调查（S1：2017-18 年和 S2：2021-22 年）。调查的领域包括：透析液钠浓度（D-[Na]）、液体和盐摄入量、残余肾功能、利尿剂的使用、增量开始、液体评估、管理和透析液温度（D-C）的方法。使用组内相关系数和多水平模型，调整就诊、年龄、性别和合并症负担，分析这些实践与参与者透析后目标体重与正常水化体重的接近程度、透析前和透析后收缩压（SBP）和舒张压（DBP）之间的关联。
报告了中心实践的差异，但在试验期间没有改变，除了在 S2 中盐和液体限制有所放松。对于我们的液体状态测量，在 439 名非无尿性起始血液透析患者中进行了 2501 次测量，中心水平的组内相关系数极低，而患者水平的相关系数在 0.12 到 0.47 之间，最强的是透析前和透析后 SBP，透析后 DBP 较弱。多水平分析发现 D-[Na]或液体状态评估方法之间没有关联。在 S2 中，一个常规使用 35°C 透析液温度的中心，目标体重与正常水化体重之间的差异更大，但在 S1 中没有观察到这种情况，也没有发现其他关联。
在 BISTRO 试验过程中，中心水平的液体管理实践保持稳定，与患者个体因素相反，没有发现中心水平与液体状态或血压之间的关联。这可能是因为试验对所有试验参与者采用了标准化的液体评估方法，这些参与者至少最初具有残余肾功能，可能会超过其他中心实践的影响。调查结果显示，有很大的空间来制定和评估标准化协议，以优化液体管理。
