Ultrafiltration Programs : Clinical Experiences

By : Kay Woodruff, RN, BS, CNN, Divisional Clinical Specialist

Lisa Miller Hedin, RN, CNN, Senior Clinical Specialist

Introduction

The purpose of this article is to provide information about the ultrafiltration profiles available on
the B. Braun Dialog® machine. The information is based on the experience and observations of the
authors. No clinical results or measurements were conducted to compare patient treatments with
and without the use of UF profiles.

Ultrafiltration (UF) is the process by which fluid and some solutes are removed from the patient
through the process of filtration under pressure. The Dialog hemodialysis system provides several
UF programs that vary the percentage of UF at designated time intervals. Some patients shift
fluids easily while other patients do not. Underlying medical conditions such as diabetes or
cardiovascular disease may contribute to a slower or uneven shift of fluid from the tissues to the
blood vessels. The patient may experience episodes of hypotension at various times throughout the
treatment. These hypotensive episodes may be reduced and possibly eliminated by varying the UF
rate throughout the treatment.

The Ultrafiltration programs included with the Dialog machine are designed to optimize the safety
and comfort of the patient during dialysis therapy. The programs automatically increase and
decrease the UF rate at various time segments during the therapy while maintaining the absolute
UF goal.

Instructions for activating and monitoring the UF programs may be found in the Dialog Operators
manual. Instructions for modifying UF programs are included in the Dialog service manual. Please
contact B. Braun Medical (800-621-0445) if you have any questions about UF programs.

B. Braun Medical Inc.

824 Twelfth Avenue
Bethlehem, PA 18018
Customer Service: 800-848-2066
24/7 Technical Service: 800-621-0445

RTD.TR02 1/05
 ULTRAFILTRATION PROGRAMS
Suggested Scenarios for Use

I. DIFFUSIVE PROFILES
Removal of fluid through ultrafiltration; Diffusive clearance through
Dialysate flow through the dialyzer

Program 0 (Default Profile)

Used for low or high weight gainers when the minimum or
maximum UF alarm limit would be exceeded during a high
or low segment of other programs. Offers a constant steady
pull of fluid throughout the therapy.

Program 1

Used when a gradual increase in UF rate is required at the

beginning of therapy ( example: patient drops blood
pressure, becomes nauseated/vomits) or when the patient
drops blood pressure toward the end of therapy. Also helps
if the patient tends to cramp toward the end of therapy.

Program 2.

Used more in the acute setting when the patient is unstable

and is to receive osmotics such as blood or albumin at the
onset of therapy. Ultrafiltration is delayed until the patient
has the osmotic on board. NOT recommended for the
chronic patient who is likely to cut his therapy short.

Program 3
Used for the patient who is volume-overloaded with
shortness of breath at the onset of therapy; or, for patients
who have a tendency to drop their blood pressure toward
the end of therapy.
This profile is a favorite of most patients as they have a tendency to feel more energetic at the end
of therapy. The machine pulls the majority of fluid during the first 40% of therapy when the
patient has the most to give; the body adjusts to the lower fluid volume during the remainder of
the therapy when diffusion and less ultrafiltration is taking place.

Program 5

Used for patients who benefit from a gentle increase in

ultrafiltration, or for patients who have a tendency to drop
their blood pressure at the onset of dialysis.

Program 7
Used for patients who have difficulty shifting fluids freely
from the tissues into the vascular space (diabetics,
cardiovascular compromised, and elderly patients). Some
patients have difficulty at the beginning of therapy. These
patients usually drop their blood pressure randomly
throughout the treatment. With the Dialog® machine it is
possible to customize this program by altering segments
toward the end of the treatment to establish a pattern that
increases and decreases the UF pull throughout the entire treatment. This works beautifully for the
diabetic patient.

Program 8

Used for patients who have a tendency to drop blood

pressure during the last 40% of treatment. Also helpful for
those patients who complain of mild cramps in their fingers
and toes at the end of therapy.

Program 9
Used for patient who have a tendency to cramp or drop
blood pressure toward the end of therapy ( last 60%) when
they do not have as much fluid on board so that the shift of
fluid is not as rapid. The increased ultrafiltration is followed
by a decrease in pull of fluid that allows the patient time to
shift the fluid from the tissues to the vascular space.

Program 10
Identical to Program 0.
 Program 11
Linear profile with more UF at the beginning. This is used for
patients who can tolerate more fluid removal at the beginning
of the therapy with a gradual decrease to a lower amount at
the end. Ideal for patients who drop their blood pressure at the
end or who tend to cramp at the end of therapy.

Program 12
Used for patients who have difficulty shifting fluid freely from
the tissues into the vascular space ( i.e. diabetics,
cardiovascular compromised and elderly patients). This profile
starts off by taking a small amount of fluid off to be gentle at
the beginning then it alternates (every 10% of the therapy)
between high UF to low UF.

Program 13
Exponential UF profile. This profile starts off by taking a
large amount of UF during the first 10% of therapy then
rapidly drops down to a lower UF. Ideal for patients who can
tolerate a large fluid removal at the beginning. Good for
patients who tend to drop their pressure in the middle and at
the end of therapy.

Program 14
Used for patients who have difficulty shifting fluid freely
from the tissues into the vascular space ( i.e. diabetics,
cardiovascular compromised and elderly patients). This
profile starts off by taking a large amount of UF then
alternates every 10% of therapy between low UF and high
UF. Patients tend to tolerate this profile very well, especially
those who cramp and drop their blood pressure randomly
throughout the treatment. Patients often comment that they feel much better after this UF profile.

Program 15
Used for patients who have difficulty shifting fluid freely
from the tissues into the vascular space ( i.e. diabetics,
cardiovascular compromised and elderly patients).
This profile can be used for the more unstable patient.
This profile has a high UF at the first 10% of treatment
then low UF for the next 20% of treatment. This is
alternated throughout the therapy.
 II. COMBINATION PROFILES
SEQUENTIAL (Yellow Segments): ultrafiltration WITHOUT diffusion.
DIFFUSION (Green Segments): ultrafiltration WITH diffusion.

Program 17

Linear UF profile with the first 30% in sequential mode

((ultrafiltration without diffusion). Used for a patient
who is fluid overloaded and needs to pull a majority of
their fluid at the beginning in the Sequential mode.

Program 4
Designed to allow sequential dialysis ( ultrafiltration
without diffusion) for the first 12% of therapy followed by
regular dialysis ( ultrafiltration with diffusive clearance).
Used for patients who present with shortness of breath at
the onset of dialysis; or, for fluid overloaded patients who
need a higher UF at the beginning of therapy. The
treatment time is usually increased to accommodate for
the decreased time of diffusion.

Program 6
Used for patients who require additional fluid removed,
but who cannot withstand a large volume at the onset
of therapy; or, who have a high potassium level and
the clinician does not want to dry the patient out too
quickly which could increase the potassium level in the
blood. Sequential dialysis (ultrafiltration without
diffusion) is performed the last 12% of the therapy.
 III. SEQUENTIAL PROFILES
Ultrafiltration without diffusion

Program 16
All sequential (ultrafiltration without diffusion) straight
across. This is used for the patient who tends to have a
stable blood pressure throughout the entire treatment.
Used for low or high weight gainers when the minimum or
maximum UFR would be exceeded during one of the high
or low segments of other programs. Offers a constant
steady pull of fluid throughout the therapy.

Program 18
This profile is all in sequential mode ( ultrafiltration
without diffusion). Used for patients who are in fluid
overload and have difficulty shifting fluid freely from the
tissues into the vascular space ( i.e. diabetics,
cardiovascular compromised and elderly patients). This
profile starts off by taking a large amount of UF then
alternates every 10% of therapy between low UF and high
UF. Patients tend to tolerate this profile very well, especially those who cramp and drop their
blood pressure randomly throughout the treatment. Patients often comment that they feel much
better after this UF profile.

Program 19
This profile is all in sequential mode ( ultrafiltration without
diffusion). Linear profile with more UF at the beginning. This
is used for patients who can tolerate more fluid removal at
the beginning of their therapy and then it is tapered down
to a less amount at the end. Ideal for patients who drop
their blood pressure at the end or who tend to cramp at the
end of therapy.

Program 20
This profile is all in sequential mode ( ultrafiltration
without diffusion). Exponential UF profile. This profile
starts off by taking a large amount off during the first 10%
of therapy then rapidly drops down to a lower UF. Ideal for
patients who can tolerate a large fluid removal at the
beginning. Good for patients who tend to drop their
pressure in the middle and at the end of therapy.

Programs 21-30: The dialysis unit can customize their own UF profiles. Refer to the Dialog
Service Manual for instructions.
 The Use of Cyclical Ultrafiltration Models in Hemodialysis

Jennifer A. White, RN, BSN, CNN

To optimize the efficiency of fluid removal during dialysis, and to increase patient comfort and stability, it is
important to understand the dynamics involved in fluid shifts. The B. Braun Dialog® Plus hemodialysis
system allows the operator to choose ultrafiltration (UF) profiles that will assist in comfortable and safe
fluid removal.

Review of fluid pressures

There are four primary factors which determine whether fluid will move out of the blood into the interstitial
space, or in the opposite direction. These factors are:
1. Capillary pressure
2. Interstitial fluid pressure
3. Plasma colloid osmotic pressure
4. Interstitial fluid colloid osmotic pressure

Capillary pressure:
Increased pressure within the capillaries causes fluid to move from the intravascular space into the
interstitial space. Capillary pressure may be increased in the dialysis patient from fluid overload,
secondary to increased oral fluid intake and/or increased intake of sodium.

Interstitial fluid pressure:

If the pressure of the fluid in the interstitial space is higher than that of the capillary pressure, it will
cause fluid to move into the intravascular space.

Plasma colloid osmotic pressure and interstitial fluid colloid osmotic pressure:
It is normal for very small amounts of protein to diffuse out of the plasma into the interstitial space.
When these proteins move into the interstitial space, they are quickly removed via the lymph system.
The concentration of proteins in the plasma, therefore, averages about four times that in the interstitial
fluid.

Changes in fluid dynamics specific to the dialysis patient

In the dialysis patient, several factors can change the normal fluid dynamics.
1. Low levels of serum albumin are common; therefore, the plasma colloid osmotic pressure is lower
than normal. This results in less incentive for fluid to move into the intravascular space.
2. Patients, at times, have large interdialytic fluid gains. The intravascular space becomes overloaded
which increases the capillary pressure, forcing more fluid into the interstitial space.
3. Many patients have compromised cardiac function, resulting in sluggish capillary flow, which also
increases capillary pressure.
Issues in Ultrafiltration

In many patients fluid removal is performed using high UF in the beginning of a treatment, with gradually
decreasing UF either in a step or linear model. The theory behind this has been to ultrafilter aggressively
early in the treatment when the patient has the most fluid to remove. This pattern can have good results,
especially in younger patients or those without cardiac disease.
However, high UF early in the treatment can cause depletion of intravascular volume which cannot be made
up quickly. This may be exacerbated by the above-mentioned vascular and nutritional factors, and result in
blood pressure drops which are difficult to reverse. With unstable blood pressures, the staff may decrease
the ultrafiltration goal, the patient may end the treatment above his dry weight, and the cycle of fluid
overload will continue.

An alternative to this model is to ultrafilter the patient using cyclical periods of higher and lower UF
pressures.
The Dialog® Plus hemodialysis system has 6 of these ultrafiltration profiles, with varying patterns. Each of
these is illustrated within the enclosed reference article; Ultrafiltration Programs : Clinical Experiences,
RTD.TR02 1/05, (profiles number 7, 8, 9, 12, 14, and 15).
During cyclical “rest periods” in ultrafiltration, the UF rate is decreased, and the intravascular space has a
chance to refill, since the interstitial fluid pressure can be presumed to be, transiently, greater than the
capillary pressure.
Each time that this cycle occurs, more fluid is moved back into the intravascular space, allowing the
patient’s blood pressure to rebound.
It has been noted anecdotally in clinical practice that the use of UF profiles incorporating “rest periods” has
resulted in patients being able to reach their actual dry weights more comfortably. There are fewer episodes
of hypotension and muscle cramping.

References:
Basic Human Physiology: Normal Function and Mechanisms of Disease, Arthur C. Guyton, M.D.
Chapter 16, Capillary Dynamics; Interstitial Fluid, and the Lymphatic System

Pathology, a Dynamic Introduction to Medicine and Surgery, Second Edition, Thomas M. Peery, M.D., and
Frank N. Miller, M.D.
Chapter 2, Circulatory Disturbances

B. Braun Medical Inc.

824 Twelfth Avenue
Bethlehem, PA 18018
Customer Service: 800-848-2066
24/7 Technical Service: 800-621-0445

RTD.TR02Supl 2/06
Dialog is a registered trademark of B. Braun Medical Inc.