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Reducing Excessive Interdialytic Weight Gain in Young Hemodialysis Patients: A Quality Improvement Initiative
Malek Al Barbandi1, Marissa J DeFreitas1,2, Chryso P Katsoufis1,2
1Holtz Children's Hospital at Jackson Memorial Hospital, Miami, FL.
Insights
Excessive interdialytic weight gain (IDWG) in pediatric hemodialysis patients was reduced by 51% using a quality improvement approach. Key interventions included patient education and reduced dialysate sodium, improving outcomes without increasing burden.
Area of Science:
- Nephrology
- Pediatric Dialysis
- Quality Improvement Science
Background:
- Excessive interdialytic weight gain (IDWG) is a significant risk factor for cardiovascular complications in hemodialysis patients.
- Current strategies to manage IDWG in pediatric populations require optimization to improve patient outcomes.
Purpose of the Study:
- To decrease the incidence of excessive IDWG events by 50% over two years in pediatric and young adult hemodialysis patients.
- To implement and evaluate a multi-interventional quality improvement program targeting IDWG.
Main Methods:
- A prospective, single-center quality improvement initiative utilizing Plan-Do-Study-Act cycles.
- Interventions included individualized patient education, nurse-driven communication, monthly IDWG tracking, and a reduction in dialysate sodium concentration.
- Statistical process control charts and t-tests were used to analyze trends and compare pre- and postintervention data.
Main Results:
- Excessive IDWG events decreased from 39% at baseline to 19% postintervention, a 51% reduction.
- Reduced dialysate sodium and enhanced nurse-patient communication demonstrated the most significant impact.
- No adverse effects were observed on blood pressure, serum sodium levels, or the need for additional dialysis sessions, with minimal increase in nurse documentation time.
Conclusions:
- A multidisciplinary, multimodal quality improvement intervention effectively reduced excessive IDWG in pediatric hemodialysis patients.
- Lowering dialysate sodium and implementing nurse-led counseling are effective strategies that do not increase patient treatment burden.
- Future research should explore the sustainability of these interventions, integration of behavioral health, and long-term cardiovascular outcomes.
Rationale & Objective:
Excessive interdialytic weight gain (IDWG) is associated with increased cardiovascular risk in hemodialysis patients. We aimed to reduce excessive IDWG events by 50% over 2 years using a multi-interventional quality improvement approach.
Study Design:
Prospective, single-center, multimodal quality improvement initiative using Plan-Do-Study-Act cycles.
Setting & Participants:
All pediatric and young adult patients (<27 years old) receiving outpatient hemodialysis at a single pediatric dialysis center (n = 17; 4,166 sessions) from June 2020 to June 2022.
Exposures:
Interventions included individualized chairside education, dialysis nurse-driven patient communication, monthly IDWG tracking in team meetings, and a reduction in dialysate sodium concentration from 140 to 137 mEq/L.
Outcomes:
The primary outcome was percent of hemodialysis sessions with excessive IDWG (≥5%). Balancing measures included additional dialysis sessions, serum sodium levels, blood pressure trends, and dialysis nurse documentation burden.
Analytical Approach:
Statistical process control charts assessed outcome trends. t Test compared pre- and postintervention data. Statistical process control chart centerlines and control limits identified special cause variation.
Results:
At baseline, 39% of dialysis sessions showed excessive IDWG. Following the full implementation of interventions, the mean shifted to 19%, representing a 51% reduction. The dialysate sodium change and nurse-driven communication had the greatest impact. There were no significant changes in blood pressure, serum sodium, or additional dialysis sessions. Documentation time added per session averaged <3 minutes.
Limitations:
We did not extract patient-level clinical data such as baseline hypertension, cardiac comorbid conditions, adherence metrics, level of engagement in psychology, or antihypertensive medication adjustments.
Conclusions:
A multidisciplinary, multimodal quality improvement intervention significantly reduced the frequency of excessive IDWG in pediatric dialysis patients. Lowering dialysate sodium and nurse-led counseling were particularly impactful without increasing treatment burden. Future work should focus on sustainability, behavioral health integration, and long-term cardiovascular outcomes.
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