Assistive Technologies to Guide the Management of Volume Overload in Hemodialysis Patients: Are They Ready for Implementation in Daily Clinical Practice?

Hypervolemia in hemodialysis patients is often covert and physical examination is frequently inaccurate in diagnosing the presence of subclinical volume expansion. Newer technologies, such as relative blood volume monitoring during dialysis, bioimpedance spectroscopy and lung ultrasound, offer promise for a more accurate assessment of volume status in these patients. Prospective observational studies support the notion that hypervolemia, as assessed with these assistive methods, is a strong and independent predictor of adverse cardiovascular outcomes and mortality in hemodialysis patients. However, randomized controlled trials and meta-analyses have failed to demonstrate that as compared with usual care, a volume management strategy based on the use of these assistive techniques is more effective in mitigating the risk of adverse intradialytic events and in improving long-term cardiovascular outcomes. In this article, we explore the question: whether assistive technologies are ready for implementation in daily clinical practice for the long-term management of volume overload in hemodialysis patients. We critically evaluate evidence from recently completed randomized trials and provide directions for future research in this important scientific area.