POCUS-guided fluid removal on haemodialysis using LVOT VTI in a patient with complex hemodynamics, case report

Fluid removal during hemodialysis plays a vital role in achieving optimal patient outcomes. Traditional methods to guide dialysis prescription by estimating dry weight are often sufficient, however, lack precision when assessing the nuanced interplay of venous and arterial physiology in hemodynamically complex patients. Left ventricular outflow tract velocity–time integral (LVOT VTI) provides a dynamic marker of forward stroke volume and can offer additional insight into intravascular volume status when conventional ultrasound markers of congestion are limited. LVOT VTI reflects effective left ventricular forward flow and is sensitive to changes in preload. LVOT VTI may improve with judicious fluid removal despite intradialytic hypotension, offering a practical physiological target to guide ultrafiltration in patients with challenging hemodynamics. We present a 70-year-old gentleman with end-stage renal disease (ESRD) who switched to hemodialysis in September 2021 from peritoneal dialysis (PD) due to poor ultrafiltration, resulting in persistent fluid overload, including recurrent pleural effusions. An echocardiogram performed in October 2019 revealed significant pulmonary hypertension, severe tricuspid regurgitation (TR), and moderate mitral regurgitation (MR). Fluid management during hemodialysis proved challenging due to persistent predialysis hypotension and further drops in blood pressure during dialysis sessions. To address these challenges and guide fluid removal more precisely, we utilised point-of-care ultrasound (POCUS) to monitor the patient’s volume status. By prioritising stroke volume surrogates, specifically velocity-time integrals (LVOT VTI), over blood pressure as a guide for fluid removal, we were able to safely increase fluid removal per session and reduce his dry weight by 4 kg over 4 weeks. This was accompanied by significant improvement in his symptoms from fluid overload. Fluid removal was guided by POCUS to address the patient’s complex hemodynamics. Despite intradialytic hypotension, we observed a significant increase in the patient’s LVOT VTI with ongoing fluid removal. This metric may serve as an adjunctive tool to guide dialysis prescription for select cases.