REVIEW
Assessment of Dry Weight in Hemodialysis: An Overview
JACK Q. JAEGER and RAVINDRA L. MEHTA
Division of Nephrology, Department of Medicine, University of California, San Diego, California.
Abstract. Fluid balance is an integral component of hemodial-
ysis treatments to prevent under- or overhydration, both of
which have been demonstrated to have significant effects on
intradialytic morbidity and long-term cardiovascular compli-
cations. Fluid removal is usually achieved by ultrafiltration to
achieve a clinically derived value for dry weight. Unfortu-
nately, there is no standard measure of dry weight and as a
consequence it is difficult to ascertain adequacy of fluid re-
moval for an individual patient. Additionally, there is a lack of
Fluid removal to achieve fluid balance is an important com-
ponent of hemodialysis (HD) treatment for end-stage renal
disease (ESRD), as both under- or overhydration are associated
with deleterious consequences. Despite considerable advances
in assessment of dialysis adequacy with respect to solute re-
moval, there is at present no measure of adequacy for fluid
removal. The majority of HD treatments incorporate a pre-
scription for fluid removal targeted to a patients dry weight.
In most centers, dry weight is clinically determined and usually
reflects the lowest weight a patient can tolerate without intra-
dialytic symptoms and hypotension in the absence of overt
fluid overload (1).This trial-and-error method is imprecise and
does not account for changes in nutritional status and lean body
mass. As a consequence, it is difficult to determine whether an
individual patient is over- or underhydrated. Additionally, the
dry weight is used to calculate ultrafiltration (UF) volume and
rates for each dialysis treatment. It is well recognized that
intradialytic complications are influenced by the balance be-
tween ultrafiltration rates and plasma refilling. UF rates in
excess of plasma refilling capacity predispose to dialysis-
induced hypotension. It is evident that better methods of de-
termining volume changes during HD are required for defining
the goal for fluid removal and to develop strategies for safer
dialysis treatments. This article describes the current status of
dry weight estimation and reviews emerging techniques for
evaluation of fluid shifts. Additionally, it explores the need for
a marker of adequacy for fluid removal.
Received April 29, 1998. Accepted August 14, 1998.
Correspondence to Dr. Ravindra L. Mehta, UCSD Medical Center, 200 West
Arbor Drive #8342, San Diego, CA 92103. Phone: 619-294-6083; Fax: 619-
291-3353; E-mail: rmehta@ucsd.edu
1046-6673/1002-0392$03.00/0
Journal of the American Society of Nephrology
Copyright 1999 by the American Society of Nephrology
J Am Soc Nephrol 10: 392 403, 1999
information on the effect of ultrafiltration on fluid shifts in the
extracellular and intracellular fluid spaces. It is evident that a
better understanding of both interdialytic fluid status and fluid
changes during hemodialysis is required to develop a precise
measure of fluid balance. This article describes the current
status of dry weight estimation and reviews emerging tech-
niques for evaluation of fluid shifts. Additionally, it explores
the need for a marker of adequacy for fluid removal.
What is Dry Weight?
The standard HD prescription targets fluid removal to a
clinically derived estimate of dry weight. Dry weight is cur-
rently defined as the lowest weight a patient can tolerate
without the development of symptoms or hypotension (1).
Since physiologic dry weight is that weight resulting from
normal renal function, vascular permeability, serum protein
concentration, and body volume regulation, dry weight in HD
should theoretically be lower than physiologic to prophylax
interdialytic weight gains. In most instances, dry weight is
estimated by trial and error, and the degree of imprecision is
reflected in the development of intradialytic symptoms or
chronic volume overload with poor control of BP (2,3). From
a clinical standpoint, the aim of HD is to normalize the milieu
interior as much as possible. The healthy human body at steady
state is composed of several fluid and solid compartments
(Table 1) (4), which are maintained within tight boundaries. An
accurate assessment of a patients volume status requires
knowledge of three factors: (1) the capacity of body compart-
ments (e.g., extracellular fluid [ECF] and intracellular fluid
[ICF]); (2) the amount of water in each compartment; and (3)
the solute content (e.g., sodium), which may affect fluid shifts
between compartments, interdialytic weight gain, and have an
effect on the success of fluid removal during HD. Compart-
ment size, amount of water, and content of solutes can be
independently estimated by different techniques (as discussed
below), however, all three must be considered in the definition
of dry weight. Although different terminologies have been
used in the literature to express the state of volume deficit or
excess, we have used the term hydration status in this article to
encompass the three components of volume measurement re-
ferred to above.
Problems Associated with an Inaccurate
Assessment of Dry Weight
At initiation of dialysis, most patients have typically been
catabolic for several months due to chronic illness. At the same
J Am Soc Nephrol 10: 392 403, 1999 Assessment of Dry Weight in Hemodialysis: An Overview 393

Table 1. Body fluid compartmentsa portant to note that in Vertes study of 40 patients, an early
benchmark study of this concept, only five were truly hyper-
Percent of Total
Body Weight reninemic, all of them responding adversely to volume deple-
Percent of tion and favorably to bilateral nephrectomy (7). Also, in
Compartment Total Body
Water Normal Normal Charras group of patients treated with long, slow hemodialy-
Adult Adult
Man Woman sis, less than 2% remained hypertensive off antihypertensive
agents, thus deemphasizing renin-dependent mechanisms of
Intracellular fluid 55 33 27.5 hypertension in the general dialysis population (11). Indeed,
Extracellular fluid 45 27 22.5 Fishbane et al. used plasma atrial natriuretic peptide (ANP), a
Interstitial fluid 20 12 10 marker of intravascular hypervolemia, to show that dialysis-
Plasma 7.5 4.5 3.75 resistant hypertensive patients were actually volume over-
Bone 7.5 4.5 3.75 loaded at the end of dialysis (8). Others have confirmed that
Connective tissue 7.5 4.5 3.75 removing excess salt and water during maintenance hemodial-
Transcellular 2.5 1.5 1.25 ysis normalizes BP in at least 70% of cases (9), while it has
Total body water 100 60 50 also been shown that postdialytic BP correlates with total body
water by bioimpedance spectroscopy (10). Although other non-
a
Adapted from Edelman and Leibman, 1959 (4). volume-related mechanisms for dialysis-resistant hypertension
have been forwarded, such as sympathetic nervous system
hyperactivity (14,15), endothelins (16), and prostaglandins, the
time, adequate excretion of salt and water has given way to preponderance of evidence points toward chronic volume over-
progressive nephron dropout. This altered bodily fluid physi- load as the major cause of hypertension in the ESRD and
ology results in a shrunken body cell mass with a relatively dialysis population.
expanded extracellular space. As dialysis improves the uremic Hypertension and Excess Death in Hemodialysis Pa-
state, an increase in lean body mass may occur undetected due tients. According to the U.S. Renal Data System (USRDS)
to a coincident reduction in extracellular volume. Similarly, a (17), cardiovascular disease and stroke are the most prevalent
reduction in lean body mass and a consequent increase in the causes of morbidity and mortality in dialysis patients, which in
extracellular fluid may go unnoticed during an acute illness. turn have been linked to markers of volume overload. These
Complicating this issue further is the fact that, barring a large markers include hypertension, left ventricular dysfunction, and
interdialytic weight gain, a dialysis patient may not have left ventricular hypertrophy. In the general nonuremic popula-
achieved their dry weight, yet still suffer intradialytic hypoten- tion, hypertension is a major cause of cardiovascular and
sive episodes routinely for various nonvolume reasons. Con- cerebrovascular morbidity and mortality (18,19). As would be
versely, they may arrive at and leave dialysis normotensive, expected, hypertension has been linked to excess cardiovascu-
nonedematous, and without any other overt signs of fluid lar and cerebrovascular adverse events in dialysis patients as
overload, yet remain quite above their true dry weight. Ambu- well (20). Indeed, in an analysis of iliac artery biopsies at time
latory BP monitoring has been, to this point, the only way to of transplant in 50 nondiabetic hemodialysis patients, the pres-
diagnose this silent hypervolemia, which may lead to the ence of atherosclerosis was found to be independent of lipid
development of hypertension as late as 12 h after leaving the abnormalities and duration on dialysis, but correlated almost
dialysis unit (5,6). Recognition of these changes is an integral exclusively with the presence of hypertension (21). Others
component of the clinical acumen of the nephrologist. How- have agreed that BP control is essential for prolonged survival
ever, the appropriate adjustment of dry weight may not always (22). And while Charra et al.s (11) cohort of patients are
be timely or precise as reflected by the complications of over- younger, narrowly representative of the general dialysis pop-
and underhydration and intradialytic morbid events, which are ulation, and uncontrolled for other unknown beneficial effects
discussed further. of long, slow hemodialysis, their 75% 10-yr survival rate
associated with excellent dry weight control of BP remains the
Overestimation of Dry Weight most compelling evidence for the beneficial effects of BP
Hypertension. Studies have shown that at least 80% of all control (23). It is thus evident that if dry weight is the major
hypertension in dialysis patients is due to chronic hypervol- component of hypertension, and hypertension is a major pre-
emia (5,711). Early animal studies by Langston and Guyton in dictor of death in dialysis patients, we should be focusing on
1963 and 1969 (12) suggested that chronic volume overload dry weight.
led to secondarily increased peripheral vascular resistance, Cardiac Dysfunction. Although it is difficult to separate
even in nephrectomized dogs. At the same time, a subset of cause and effect when discussing the various cardiac disorders
dialysis-resistant hypertensive patients with high serum renin in hemodialysis patients, it seems that an excessive dry weight
activity were described, which led to the dichotomous descrip- is a sufficient risk factor allowing the final expression of
tion of hypertension in dialysis patients: salt-water dependent cardiac dysfunction and indirectly, sudden death. In 1836,
and renin-dependent (7). Some studies have categorized up to Bright first noted autopsy findings of left ventricular hypertro-
half of their hypertensive patients as dialysis-resistant, imply- phy in patients dying of ESRD (24). As discussed previously,
ing a renin-dependent mechanism (5,13). However, it is im- the majority of patients are hypertensive at presentation to
394 Journal of the American Society of Nephrology
dialysis, largely due to impaired salt and water excretion, and
given the known association of chronic hypervolemia and
hypertension, and hypertension and left ventricular hypertro-
phy (LVH) (25), it is no surprise that most ESRD patients
present to dialysis with LVH as well (26 29). LVH addition-
ally has been shown to be deleterious to hemodialysis patients
for several reasons: (1) similar to nonuremic patients, it is
predictive of an increased incidence of myocardial infarction
(30), congestive heart failure (31), and sudden death (32); and
(2) LVH can lead to diastolic dysfunction, which has been
linked to an increased incidence of intradialytic morbid events
(33). Indeed, Parfrey et al. showed that 40% of their cohort of
dialysis patients with congestive heart failure had hypertrophic
changes, 43% had either LV dilation or systolic dysfunction,
and only 16% had normal echocardiograms upon presentation
to dialysis (31). LVH was thought to be due to chronically
increased afterload, while dilation and systolic dysfunction
were thought to be due to chronic hypervolemia. Although
these changes did not regress over the 17-mo follow-up, there
was no intervention to lower the clinically derived dry weight.
Both forms of left ventricular abnormalities were associated
with a markedly poor median survival from 38 to 56 mo. As
stated above, however, it is probable that both types of ven-
tricular abnormality are volume-related. LV dilation and sys-
tolic dysfunction are probably a form of burnt-out hypertensive
heart disease due to an imbalance between appropriate hyper-
trophy and cell death and fibrosis. Other studies have shown
the link between chronic hypervolemia and the development of
LVH in dialysis patients as well (34).
It is obviously important to recognize that other risk factors
for the development of LVH are increased age, diabetes mel-
litus, anemia, and possibly hyperparathyroidism, and for LV
dilation, anemia, ischemic heart disease, and hypoalbumine-
mia. Likewise, these disorders are present at the initiation of
dialysis, and have not been shown to be reversible in hemodi-
alysis patients. However, regression of LV dilation and LVH
has been shown in studies in normal populations (35), and
perhaps most intriguing are studies showing regression of LVH
in hypertensive ESRD patients started on continuous ambula-
tory peritoneal dialysis (36). It is therefore possible that ag-
gressive control of volume may lead to regression of left
ventricular abnormalities, which are surrogate markers for poor
survival in hemodialysis patients.
Missing Changes in Lean Body Mass. There is also the
occasional patient who has achieved their so-called dry weight,
but over time subtle negative changes in lean body mass occur
due to inadequate dialysis prescription, inadequate dialysis
delivery, comorbid illness, depression, or other causes. This
change might not be reflected in serum albumin or urea kinet-
ics studies, and failure to adjust dry weight results in a greater
proportion of their body weight becoming ECF. An increase in
BP with recognition of lean body mass change and consequent
adjustment of dry weight may occur. Alternatively, there may
be no BP response to this ECF expansion, a failure to adjust
dry weight downward, and henceforth failure to identify this
subtle change in nutritional status. Such small changes in
nutritional status might be significant for the patient.
J Am Soc Nephrol 10: 392 403, 1999
Underestimation of Dry Weight
Underestimation of dry weight is more likely to be recog-
nized due to its immediate consequences of intradialytic mor-
bidity. It usually occurs when there is a failure to adjust the
ultrafiltration prescription to account for increases in either
lean body mass or fat mass over time. A previously stable
patient becomes frequently hypotensive during hemodialysis,
but the change in ultrafiltration prescription is often delayed
either due to physician reluctance to change the dry weight, or
to efforts to investigate other more threatening etiologies of
hypotension. This situation, one of patients most frequent
complaints (37), leads to patient dissatisfaction with the dial-
ysis prescription, early withdrawal from dialysis, failure to
arrive at the dialysis unit, and frequent interrupted sessions, all
of which lead to reduced solute removal. The resulting inade-
quate solute removal leads to decreased appetite, poor intake,
and subsequently to poor nutritional status, which have their
own adverse effects on dialysis outcome. On the other hand,
not knowing the true dry weight of a patient, one might attempt
to mitigate frequent hypotensive events due myocardial is-
chemia, pericardial effusion, cardiac arrythmia, or other disor-
ders by increasing the dry weight goal, thus missing the diag-
nosis of a more serious underlying condition.
Measuring Dry Weight
It is obvious from the above discussion that clinical assess-
ment of dry weight is crude and often imprecise. Recently,
several different techniques have been used to derive a more
standard method of assessing dry weight (38 41). However,
no single method has emerged as a gold standard, as there is no
clear-cut definition of what constitutes dry weight. The follow-
ing section reviews these methods as they have been devel-
oped, and offers a critical appraisal of their use.
Biochemical Markers
Atrial Natriuretic Peptide. ANP is a peptide hormone
synthesized, stored, and released in atrial tissue in response to
changes in atrial transmural pressure. The hormone follows the
usual cleavage synthesis pathway as a prepro-, pro-, and a
biologically active 28 amino acid peptide. It is rapidly de-
graded, primarily by the kidney, but also by other organs, with
a serum half-life of 2 to 4 min. Its end-organ effects and role
in maintenance of salt and water homeostasis, which are well
characterized elsewhere (42), as well as its short half-life and
somewhat minimal clearance by hemodialysis, initiated excite-
ment about its possible role in determining fluid status in
hemodialysis patients. Rascher et al. were the first to suggest
its use as an indicator of volume status in hemodialysis (43). In
this and subsequent studies (44,45), ANP levels were found to
be elevated in hemodialysis patients, before dialysis, relative to
control subjects, and levels were significantly lower after both
hemofiltration (45) and hemodialysis (44). Plasma ANP levels
correlated with BP, and although ANP levels changed signif-
icantly during HD, in most studies postdialysis levels remained
significantly higher than controls (43,44). Others (46 48) have
established marked interpatient variability and persistent post-
dialysis elevation. Additionally, ANP levels have been shown
J Am Soc Nephrol 10: 392 403, 1999
to be persistently elevated after HD in patients with altered left
atrial hemodynamics compared to those with normal left atrial
hemodynamics (49), making ANP levels difficult to interpret
in this setting. As discussed previously, Fishbane et al.s (8)
cohort of persistently hypertensive patients had high plasma
ANP, and were not believed to be at their dry weight, raising
the possibility that the persistent postdialysis ANP elevations
in the previously mentioned studies might have been due to
inadequate dry weight achievement or the presence of altered
left atrial hemodynamics. Kojima et al. (46) showed that
plasma ANP levels were still routinely elevated after hemodi-
alysis even when patients are determined to be clinically at
their dry weight. But in this study, ANP also correlated well
with BP. A possible explanation for the persistently elevated
levels of ANP in this study may be that these patients were
really not at their dry weight as evidenced by the persistent
hypertension. Because of these uncertainties, a serum level at
which ANP should be predictive of dry weight in a dialysis
patient is a matter of considerable controversy. In summary,
plasma ANP is sensitive for detecting overhydrated patients,
but not specific. Concordantly, it often remains elevated in dry
individuals and hence is not sensitive in detecting underhy-
drated patients. A low ANP values specificity for detecting
underhydration is unknown.
Cyclic Guanidine Monophosphate (cGMP). cGMP is
generated when ANP activates membrane-bound guanylate
cyclase, and hence was predicted to be an indicator of volume
status in dialysis patients (50). This biochemical marker was
perhaps best systematically studied by Lauster et al.
(40,51,52). Because cGMP is more stable in serum at room
temperature than ANP (53), and the RIA for cGMP is some-
what less arduous, it was believed that cGMP would poten-
tially be a better marker than ANP for the routine assessment
of fluid status. Their studies determined: (1) that cGMP levels
of 20 pmol/L immediately postdialysis correlated with achieve-
ment of clinical dry weight; (2) the majority of those with
postdialysis levels greater than 20 pmol/L had evidence of fluid
overload or congestive heart failure; (3) that reductions in dry
weight in these remaining patients were associated with both a
reduction in cGMP levels to approximately 20 pmol/L and
clinical resolution of the fluid overloaded state; and (4) those
whose levels could not be lowered beyond this point had left
ventricular dysfunction. However, these measurements were
not validated against other objective parameters, and others
have not confirmed these findings. Franz et al. found that 28%
of their patients had postdialysis cGMP levels of greater than
20 pmol/L, the majority of which were in sinus rhythm, had no
evidence of congestive heart failure, and were not believed to
be fluid overloaded (54). As with ANP, the meaning of a low
level is unknown, and cGMP levels are influenced by cardiac
or valvular dysfunction, thus limiting its clinical utility in this
setting.
Vena Cava Diameter
Because echocardiographic examination of the inferior vena
cava diameter (VCD) is simple, quick, and noninvasive, efforts
to standardize its dimensional characteristics in relationship to
Assessment of Dry Weight in Hemodialysis: An Overview 395
central blood volume were first undertaken by Natori et al. in
1979 (55). They showed that supine measurements of caval
diameter taken during expiration and its inspirational decrease
in diameter correlated well with central venous pressure. Ando
et al. (1985) were the first to quantify VCD changes during
hemodialysis (56). In 1989, Cheriex et al. attempted to use this
technique to assess dry weight in hemodialysis patients, show-
ing that postdialysis measurement of inferior caval diameter
taken subdiaphragmatically correlated with right atrial pressure
and circulating blood volume (57). Linear regression to right
atrial pressure defined overhydration as a caval diameter
greater than 11 mm/m2 body surface area or a collapsible index
(Expiratory caval diameter ! Inspiratory caval diameter/Expi-
ratory diameter " 100%) as less than 40%. Underhydration
was defined as a caval diameter of less than 8 mm/m2 and a
collapsible index of greater than 75%. Nearly two-thirds of
their patients who had met clinical criteria for dry weight were
actually hypervolemic, according to these criteria. Those who
were considered underhydrated by these criteria had greater
increases in heart rate and stroke volume, and greater decreases
in BP during dialysis when compared to their normally or
overhydrated counterparts. Others have not been able to con-
firm these findings. Mandelbaum et al. found a wide range of
caval diameters in their dialysis population, and they were not
correlated to age, height, weight, or body surface area of the
patients (58), thus rejecting the nomogram-based generali-
zation of this measurement to the general dialysis population.
Franz et al. divided their patients into three groups of hydration
status based on Cheriex et al.s criteria above and showed that
mean cGMP levels were higher in the hypervolemic group
compared with the normovolemic and underhydrated patients,
but there was no statistically significant linear correlation be-
tween caval size and cGMP level (54). In their study, as would
be expected, a major limitation of this technique was measur-
ing volume status in patients with heart failure. The presence of
tricuspid insufficiency requires its own criteria for assessment
of volume status via vena caval diameter (59). On the other
hand, Katzarski et al. used VCD to confirm the volume hy-
pothesis of hypertension in hemodialysis patients (60). They
studied two cohorts of hypertensive and normotensive patients
and showed that caval diameter was significantly larger post-
dialysis in their group of hypertensive patients. Leunissen et al.
(61) and Kouw et al. (62) have subsequently shown that
postdialysis VCD measurements reliably predict hemodynamic
changes during dialysis. In summary, while interpatient and
interoperator variability and the presence of right-sided failure
limit its use, VCD may be better suited than the biochemical
markers for prediction of the underhydrated state.
Bioimpedance Analysis and Bioimpedance
Spectroscopy
Single or Dual Frequency Bioimpedance Analysis. The
basic principles of bioimpedance were initially described by
Thomassett in 1963 (63), but the technique first gained prom-
inence in the early 1970s when Nyboer reported that the
impedance of the body to an alternating current roughly cor-
related with changes in blood volume (64). These measure-
396 Journal of the American Society of Nephrology
ments are based on the basic principle that the electrical im-
pedance of a cylinder is directly proportional to its length and
inversely proportional to its cross-sectional area multiplied by
its specific resistivity. Application of simple multiplication and
rearrangement resulted in the equation for volume V # L2/Z,
where V is specific resistivity, L is length, and Z is the mea-
sured impedance. Operating on the assumption that the human
body is a sum of homogeneous cylinders, and that current
would pass only through ion- and water-containing media, in
1969 Hoffer was the first to attempt to measure total body
water by this method (65). In his and subsequent analyses (66),
Height2/Impedance at a frequency of 50 kHz indeed showed
the best-fit regression to deuterium water space with a corre-
lation coefficient of 0.92. Subsequent multiple equations based
on variations of this principal, usually with the addition of
gender-specific dummy variables or anthropometric parame-
ters have been derived (6770). Although this technique is
simple and remains valid for the measurement of total body
water, single frequency analysis is unable to distinguish be-
tween intracellular and extracellular compartments. Based on
the assumption that a low frequency current would transgress
only the extracellular space, Jenin et al. in 1975 first used a low
1-kHz frequency paired with a 100-kHz frequency to estimate
ECF volume and ICF volume separately (71). In 1988,
Lukaski, using a single frequency method and a regression
equation including reactance, improved the correlation to bro-
mide space to 0.83 (70). Standard error of estimate for both
single and double frequency methods ranges from 1.5 to 3.5 L.
Bioimpedance Spectroscopy, the Multifrequency Ap-
proach. Multiple frequency analyzers were developed to
take advantage of the dielectric theory of electrical conduction
through mixed, emulsified bodies (72). In this theory, conduc-
tion of current through the intracellular space is modeled as
flow through innumerably different parallel circuits consisting
of a capacitance and a resistance in series, while parallel flow
through the extracellular space is limited only by the resistance
to flow through ion and water. The result is that at low
frequencies, current cannot bridge the cell membrane (capac-
itor) and will flow only through the extracellular space, while
at increasingly higher frequencies the cell membrane capaci-
tors will offer less and less reactance. As reactance approaches
zero, impedance is purely resistance, and resistance at this
frequency reflects the resistance of total body water (TBW).
Current analyzers offer frequency ranges from 1 kHz to 1
MHz, plot impedance loci at these frequencies, and extrapolate
reactance to zero along the locus via curve fitting at infinite
extremes of frequency. What results are imaginary-real resis-
tances where true resistance for ECF (Re) and resistance for
TBW values should theoretically lie (Resistance of ICF [Ri] is
computed from the component circuit). These resistance values
and the patients height, weight, gender, and Hanai mixture
equations are used to extrapolate to volume (73). The potential
advantages of this approach over linear single and double
frequency measurements are: (1) Complex impedance at any
single frequency (characteristic frequency) may be different
from patient to patient or from time to time. Thus, curve fitting
and extrapolation may help smooth out these interpatient and
J Am Soc Nephrol 10: 392 403, 1999
measurement differences. (2) Intuitively, extrapolation of data
to zero and infinite frequencies is probably more accurate than
arbitrarily choosing a single frequency for analysis, for the
same reasons as above.
A few studies have compared the techniques. Ho et al. found
that both techniques correlated very well with TBW by deute-
rium space (74). However, multifrequency modeling of TBW
was slightly more precise than the linear equation (6.2 versus
6.7%, respectively). And while multifrequency bioimpedance
tended to consistently underestimate TBW, the linear equation
both over- and underpredicted TBW with more scatter along
the line of identity. Another study revealed that modeled bio-
impedance spectroscopy (BIS) and dual frequency resistances
showed very little intermeasurement differences ($ 0.04), thus
confirming the underling Cole modeling scheme of BIS (75).
Whether one uses single, dual, or multiple frequency modeling,
one could make the argument that there is no need to extrap-
olate these resistances to volume terms, since (1) resistivity
constants (or components therein) are derived in a linear man-
ner from nonuremic populations, and (2) their calculation
involves the use of Hanai mixture theory, which has not been
validated in whole organisms (76).
Bioimpedance and Dry Weight: Clinical Utility. Bioim-
pedance analysis has proven to be a useful tool in assessment
of dry weight in hemodialysis patients. We have shown that
BIS measurements during HD track ECF volume change and
show excellent correlation to ultrafiltrate removed and change
in weight (77). Kouw et al. (78), using multiple frequencies,
compared ECF and ICF in 29 hemodialysis patients and 31
control subjects. Compared with control subjects, hemodialysis
patients had markedly expanded ECF compartments predialy-
sis, which were reduced to control values after dialysis. Pa-
tients classified as underhydrated by comparison to control
subjects experienced more hypotension and greater blood vol-
ume changes adjusted for ultrafiltration. In a later study (79),
they were able to show that gradually increasing dry weight in
these underhydrated patients resulted in gradual reductions in
the intradialytic change in blood volume and better hemody-
namic tolerance of ultrafiltration. Fisch and Spiegel, using
resistive index (L2/R) to bone mineral content or lean body
mass ratios and multifrequency analysis confirmed that fluid is
removed primarily from the extracellular compartment during
hemodialysis (80). Katzarski et al. were later able to show that
when their patients were divided into two groups based on the
presence or absence of hypertension, those with hypertension
had larger TBW and ECF expressed as a percentage of body
weight (81). Gradual reductions in body weight in these pa-
tients were followed by concordant changes in volume by BIS
and BP. Thus, even when used singularly, bioimpedance anal-
ysis is useful for detecting and managing both the over- and
underhydrated state in hemodialysis.
The limitations of this tool, however, are multiple. As dis-
cussed previously, extrapolation of Re and Ri into volumetric
terms is based on resistivity constants derived by regression
against bromide or deuterium space from a nonuremic patient
population. Hence, hydric volumes estimated for dialysis pa-
tients from these equations must be interpreted with caution
J Am Soc Nephrol 10: 392 403, 1999
Table 2. Comparison of methodsa
Technique Benefits
Biochemical markers Ease of use
No additional labor cost
Highly sensitive for the
volume overloaded state
Reflective of intravascular
volume status
Vena cava diameter Widely available
Reflective of intravascular
volume status
Change in size correlates well
with ultrafiltration volume/
hemodynamic parameters
Bioimpedance Hydric volumes correlate well
with isotope dilution
methods
Ease of use, immediate
results
Reproducible/repeatable
Measurement of interstitial
space and ICF
Immediate assessment of
nutritional status
Has potential to be readily
normalized
Continuous/hemodynamic and
static/dry weight utility
Sensitive in detecting the
underhydrated state
Blood volume monitoring Ease of use and
understanding
Allows for concomitant
prevention of hypotension
May be useful to screen for
an inappropriately high or
low dry weight
a
ECF, extracellular fluid; ICF, intracellular fluid.
until more data are available. There has been some concern that
changes in electrolyte composition and hematocrit may alter
the conducting properties of both the extracellular and intra-
cellular fluid and thereby alter measurement of TBW (82).
Sinning et al. (83), using a single frequency bioimpedance
analysis measurement, did not find any correlation between
changes in electrolytes during the course of HD, whereas
changes in hematocrit and protein (reflecting reduction in
blood volume [BV]) had a high correlation to measured resis-
tance. Another concern is timing of the measurement. Al-
though initial studies showed that ECF change during hemo-
dialysis tracked well with UF volume, other investigators (84)
Assessment of Dry Weight in Hemodialysis: An Overview 397
Limitations References
Difficult to use in heart Benefits: 40,43,45,46,51,52
failure, tricuspid/mitral Limitations: 44,4749
valve disease
Cannot detect the
underhydrated state
Normal range?
Meaning of low value?
Difficult to use in heart Benefits: 6062
failure Limitations: 53,54,57,58,59
Overestimates degree of
dehydration postdialysis
Interoperator error
Highly variable/difficult to
normalize to population
Postdialysis measurements Benefits: 74,7779,81
of ECF often Limitations: 76,8284
underestimate
ultrafiltration volume
Underestimates volume
removed from trunk
Accurate measurement of
ICF confounded by
temperature and ion
effect
Accurate measurement of
ECF confounded by effect
of recumbancy
Continuous plasma volume Benefits: 9395
dependent on numerous Limitations: 89
factors other than
hydration of the
interstitial space
Measures relative volumes
only
Interpatient variability
are not finding this to be the case. Indeed, in these studies (84)
ECF change as measured by bioimpedance pre- and posthe-
modialysis often underestimates UF volume by as much as
30%. There are several possible explanations for this error, but
the most likely is the following: During cumulative ultrafiltra-
tion, according to Daugirdas regional blood flow theory (85),
a larger fraction of ultrafiltration is occurring from high flow
low resistance flow circuits in the body. That is, as dialysis
proceeds, progressively more and more fluid is taken from the
trunk. The ability of bioimpedance to detect changes in volume
is roughly proportional to the resistance to current flow through
that volume bed. Since the trunk contributes only 5% or 20
398 Journal of the American Society of Nephrology
Figure 1. Comparison of extracellular fluid volume (VECF) and blood volume (BV) changes during dialysis. A decrease in BV is associated
with a decrease in VECF. At the end of ultrafiltration, BV is repleted while VECF continues to decline. VECF versus %BV total (up to 154
min; r # 0.718; P % 0.006); VECF versus %BV at the end of dialysis (ultrafiltration [UF] stopped to end; r # 0.962; P % 0.001).
ohm to total body resistance due to its large cross-sectional
area, removal of fluid from this segment escapes detection by
whole body bioimpedance techniques. Unfortunately, there is
no simple solution to this problem, since accurate measurement
of resistance to current flow through the trunk would require
large, cumbersome electrodes, and the heterogeneous nature of
trunk contents might make measured resistances unpredictable.
Recently, Levin and Schneditz et al. used sum of segmental
resistances to confirm this hypothesis (86). And while dry
weight, and hence ECF, should be assessed postdialysis, ICF
must be measured predialysis. Measurement of high frequency
impedance is greatly affected by temperature and ion changes
that occur during hemodialysis. The result is the possible
overestimation of intracellular fluid volume after hemodialysis.
Despite its limitations, bioimpedance is a convenient, safe, and
noninvasive tool that, unlike the biochemical markers and
VCD (which are markers of intravascular volume), can addi-
tionally determine interstitial and intracellular fluid status.
Blood Volume Monitoring
Ultrafiltration during dialysis removes fluid from the intra-
vascular compartment and results in a progressive decline in
BV (87). However, this decrease is limited by refilling from the
interstitial space (88). It is recognized that plasma refilling
capacity is influenced by several factors including the tissue
hydration state (89). As long as plasma refilling can keep pace
with ultrafiltration, hypovolemia can be avoided and intradia-
lytic complications reduced. Several investigators have ex-
plored the use of noninvasive methods to monitor BV changes
during dialysis (90,91). In general, all of these methods are
based on measuring the change in hematocrit or protein con-
centration during HD. The increase in hematocrit and protein is
inversely proportional to the change in BV (91). Thus, it is
possible to assess the change in BV in real time during a
hemodialysis treatment. Steuer et al. (91,92) have described
the use of an optical method to measure hematocrit that is
simple, practical, and reliably tracks changes in BV. We have
J Am Soc Nephrol 10: 392 403, 1999
used this device to monitor changes in BV in dialysis patients
and confirmed these observations, and demonstrated that in
hypotension-prone patients, intradialytic symptoms are usually
preceded by a consistent and predictable change in BV (93).
Further investigation in this area suggests that it may be pos-
sible to identify a threshold for each patient below which
intradialytic complications are likely (94). We have further
demonstrated that this method can be used to target non-
constant ultrafiltration and reduce complications (95).
As an isolated technique for determination of dry weight,
however, BV measurement has its limitations. The difficulty
that arises in standardization of this technique is that different
patients and disease states dictate different levels of vascular
refilling from the interstitial compartment, and thus it is a
nonquantifiable method of measurement. For example, there is
little agreement on whether rate of change, absolute change, or
absolute level of blood volume is or are predictive of hypo-
tension. Different patients respond to different patterns, and
their own pattern usually must be established over a period of
trial and error. In fact, some patients tolerate as much as 20%
change in blood volume, whereas others (e.g., the elderly,
diabetic patients, and patients with pulmonary hypertension
and congestive heart failure) cannot tolerate even the slightest
change. That said, in general, a flat blood volume line through-
out dialysis in a patient who tolerated that session well hemo-
dynamically suggests that that patient is not yet at his or her dry
weight. On the other hand, multiple early rapid changes in BV
accompanied by symptoms are generally predictive of under-
estimation of dry weight. A hypotensive episode in a patient
with a flat blood volume curve might be predictive of a serious
underlying problem not related to hydration status, but this
remains to be proven.
Combination and Cross Validation of the Techniques
Because each of the aforementioned techniques has its lim-
itations (Table 2), several studies have been done in an attempt
to cross-validate the methods, or use them in combination in
J Am Soc Nephrol 10: 392 403, 1999 Assessment of Dry Weight in Hemodialysis: An Overview 399

Figure 2. Postdialysis volume shifts from extracellular fluid (ECF) compartment as tracked by bioimpedance spectroscopy and simultaneous
blood volume monitoring. At the end of dialysis, there is a shift of fluid from the extravascular (interstitial fluid) compartment, which includes
a redistribution to the intravascular space and a compartmental shift to the intracellular space. There is a continued decline in ECF up to 30
min postdialysis (as evaluated in these experiments). The influence of dialysate sodium concentration on the compartmental shifts has not been
evaluated. VECF, extracellular fluid volume; VICF, intracellular fluid volume; PV, plasma volume.

hopes of better defining fluid shifts during dialysis and deter-
mining dry weight.
Determination of Fluid Shifts. As changes in BV are
proportional to the balance between ultrafiltration rates and
plasma refilling, in the absence of ultrafiltration it is possible to
determine plasma refilling rates and absolute BV (96). Addi-
tionally, if BIS measurements are combined with BV monitor-
ing during dialysis, changes in the ECF and intravascular
compartments can be determined, permitting an estimate of
plasma refilling (9799). We have used both of these tech-
niques simultaneously and extended measurements for approx-
imately 1 h after dialysis (Figure 1). Our data show that both
BIS (ECF) and hematocrit measurements (BV) have an excel-
lent correlation with the volume of fluid removed (97). Bo-
gaard et al. (98) had similar findings using a single frequency
BIS measurement and an optical method of hematocrit deter-
mination. These authors used the ratio between change in BV
and the volume of ultrafiltrate as a reflection of plasma refilling
and found that there were significant differences in the rate of
change in BV in dehydrated, normally hydrated, and overhy-
drated patients. We have calculated absolute plasma volume
and plasma refilling rates at the end of dialysis and have shown
that at the end of dialysis there is a continued decline in ECF
associated with plasma refilling. This suggests that the inter-
stitial fluid compartment contributes fluid for plasma refilling
and may replenish the intracellular space (99) (Figure 2). We
have subsequently calculated absolute plasma volume for dif-
ferent time points during dialysis and, in conjunction with the
ECF measurements done simultaneously, have computed the
volume of interstitial fluid. The difference in change in BV and
ultrafiltration rate reflects the plasma refilling rate. Our data
show that there is a good correlation between interstitial fluid
volume and plasma refilling (99). De Vries et al. (79) have
further used both techniques to adjust dry weights in hemodi-
alysis patients and thereby reduced the frequency of hypoten-
sive episodes.
Determination of Dry Weight. Kouw et al. measured
routine hemodynamic parameters noninvasively during dialy-
sis and then stratified patients as over- or underhydrated based
on posthemodialysis measurements of caval diameter, conduc-
tivity (lower extremity, single frequency [bioimpedance anal-
ysis], ECF), cGMP levels, and ANP levels (62). They found
that caval diameter and conductivity correlated well with ul-
trafiltration volume, the dehydrated state, and each other, both
pre- and posthemodialysis. There was a weak correlation be-
tween postdialysis cGMP levels, change in blood volume, and
hemodynamic parameters, indicating that cGMP is less valu-
able in assessing dry weight than either conductivity or caval
diameter. When patients were separated by ANP levels, there
was no correlation with change in hemodynamics, caval diam-
eter, or conductivity, indicating that it provides no value in
defining dry weight in their study. Notably, caval diameter
routinely underestimated dry weight, whereas conductivity
overestimated dry weight. Both measurements were taken im-
mediately after dialysis, raising the question as to whether
enough time had elapsed to allow refilling of the plasma from
the interstitium. Note that this is a slightly different mechanism
of overestimation of postdialysis ECF volume than stated in the
above discussion of bioimpedance. Another study by the same
group that year compared bioimpedance and BV monitoring.
400 Journal of the American Society of Nephrology
They stratified patients as underhydrated, normal, or overhy-
drated based on previously developed conductivity criteria
taken postdialysis and then measured blood volume changes
and hemodynamic parameters in these three groups (94). They
found that in the underhydrated group, there was significantly
greater change in overall blood volume corrected for ultrafil-
tration volume and more hypotensive episodes compared with
normal or overhydrated patients. Conversely, Lopot et al.
recently stratified patients based on blood volume profiles
characterized as overhydrated, normal, and underhydrated, and
then compared these profiles with conductivity measurements
and VCD (100). Those with blood volume profiles indicative
of overhydration had larger postdialysis values of ECF and
VCD. Likewise, those characterized as underhydrated on the
basis of rapid changes in blood volume had smaller postdialy-
sis ECF and VCD values. This is perhaps the only study
utilizing and confirming the blood volume method as a screen-
ing tool to detect an inappropriately high dry weight. In the
third part of Katzarski et al.s study showing hypertension as
dependent on bioimpedance-determined volume (81), they ad-
ditionally showed that ECF and VCD decreased in tandem
during dialysis and correlated well postdialysis. Thirty minutes
postdialysis, VCD increased markedly, likely indicative of
plasma refilling from the interstitial space. However, ECF
values remained stable. We believe that this might be due to
refilling of plasma volume from more easily accessible fluid
sites not measured by bioimpedance due to the peripheral
arrangement of electrodes in this study.
Beyond Dry Weight? An Index for Adequacy of
Fluid Removal
From the above discussion, it is evident that contemporary
management of fluid in the dialysis patient is largely dependent
on a clinically derived estimate of dry weight. Clinical assess-
ment of dry weight inevitably leads to both overestimation and
underestimation of dry weight. Overestimation of dry weight
leads to hypertension, stroke, and congestive heart failure,
which are the main causes of excess death in dialysis. Under-
estimation leads to persistent hypotensive episodes, alienating
dialysis patients from their caretakers, and affecting delivery of
prescribed dialysis. Moreover, the current focus on Kt/V as an
index for adequacy of dialysis in terms of solute removal
ignores the contribution of volume as an independent factor
influencing outcome. Unfortunately, despite this recognition
we have not attempted to rectify this problem in any systematic
way. It is our belief that a possible approach to this problem is
the development of an index for adequacy for fluid manage-
ment.
Peritoneal dialysis provides the ideal model for achieving
dry weight, since slow continuous peritoneal ultrafiltration
permits physiologic or perhaps subphysiologic dry body
weight control of BP. The goal for fluid removal in HD is to
attain a lower than physiologic dry weight immediately post-
dialysis, allowing a time-averaged physiologic dry weight in
the interdialytic period. This would be particularly true for
patients without large interdialytic weight gains (%2 L), con-
J Am Soc Nephrol 10: 392 403, 1999
gestive heart failure, left ventricular disorders, diabetic auto-
nomic neuropathy, severe hypoalbuminemia, or other condi-
tions predisposing to hypotension in dialysis. On the other
hand, physiologic dry weight might be an appropriate goal for
patients with persistent large interdialytic weight gains or the
above conditions that predispose to hypotension. Furthermore,
the use of nonlinear ultrafiltration may assist dry weight
achievement in these patients (95). Because of this complexity,
it is easy to recognize that objective tools used for estimating
dry weight are necessary. However, the individual techniques
each have limitations or are inherently insufficient for singular
use in dry weight assessment (Table 2). Therefore, some com-
bination of these tools will need be used to achieve this goal.
Furthermore, dry weight assessment might further be stratified
into two major categories: (1) the interdialytic measurement of
static dry weight and body composition and (2) intradialytic
assessment of online data or comparison of pre- and posthe-
modialysis data. Either might be used on a monthly or other
periodic basis as a means of following dry weight and deriving
an index of adequacy for fluid removal (101).
We have extensively reviewed the technologic methods for
actual measurement of volume status in dialysis patients as
they have developed thus far, as well as addressed their limi-
tations. Further development of these techniques is necessary
for attaining an easily derived and utilized index for adequacy
of fluid removal. The development of this index should be
undertaken whereby both interdialytic and intradialytic meth-
ods will be described and utilized on a periodic basis. Pending
further research and development, the interdialytic measure-
ment of dry weight and body composition will perhaps be best
accomplished with bioimpedance spectroscopy, because of its
unique ability to provide insight into nutritional status as well.
Intradialytic methods will arise out of further interrogation of
fluid shifts that occur during dialysis. At some point, these
technologies might be incorporated into dialysis machines
whereby volumetric control of ultrafiltration will take on a new
meaning and result in profiled dialysis. It is obvious that we
have a long way to go, however, it is our belief that recognition
of the need for this process is an initial step that will hopefully
result in further investigation in this field.
Acknowledgment
We thank Dr. Robert Steiner for his recommendations and assis-
tance in preparation of this manuscript.
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