Abstract: FR-PO0499
Permissive Hypervolemia in ESRD and Hypertrophic Obstructive Cardiomyopathy: Practical Approach to Individualized Fluid Management During Hemodialysis
Session Information
- Dialysis: Hemodiafiltration, Ultrafiltration, Profiling, and Interdialytic Symptoms
November 07, 2025 | Location: Exhibit Hall, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Dialysis
- 801 Dialysis: Hemodialysis and Frequent Dialysis
Authors
- Javed, Aden, Aga Khan University Hospital Clinical Laboratories, Karachi, Sindh, Pakistan
- Javed, Muhammad Ehtesham, Jersey City Medical Center, Jersey City, New Jersey, United States
Introduction
Patients with ESRD on hemodialysis and coexisting hypertrophic obstructive cardiomyopathy (HOCM) face unique challenges in fluid management. Standard ultrafiltration (UF) protocols often exacerbate hemodynamic instability by reducing preload, precipitating left ventricular outflow tract obstruction (LVOTO), and increasing the risk of intradialytic hypotension. This case explores permissive hypervolemia as a strategy to stabilize hemodynamics in such preload-sensitive patients.
Case Description
94-year-old male with ESRD on HD, hypertension, and HOCM presented with syncope and hypotension (BP 79/38 mmHg) during a routine HD session. Symptoms resolved after a 500-mL fluid bolus, Blood Pressure improved to 139/51 mmHg. Examination showed basal ejection murmur and investigations revealed elevated troponin (34.5 ng/L), no ECG changes, and mild pulmonary vascular congestion on chest Xray. Echocardiography revealed severe concentric LVH, EF >70%, and a small LV cavity, consistent with hypertensive HOCM. Real-time blood volume monitoring (BVM) showed rapid intravascular volume decline correlating with hypotension. UF was limited to 0–500 mL/session and dry weight was adjusted accordingly. Pre-dialysis antihypertensives were withheld to further preserve preload and avoid frequent LVOTO episodes.
Discussion
Managing fluid balance in ESRD patients with HOCM poses unique challenges due to opposing therapeutic goals as HD requires fluid removal, and HOCM depends on preload preservation. The steep Frank-Starling relationship in HOCM makes small volume shifts potentially destabilizing. In this case, permissive hypervolemia maintained preload and stabilized hemodynamics. Real-time BVM enabled dynamic UF adjustments, preventing hypotension. Similar strategies are supported in restrictive cardiomyopathy and right heart failure, where preload preservation is critical. Table 1 illustrates a stepwise protocol using BVM, UF modification, and dry weight reassessment.
Workflow for Individualized UF and Permissive Hypervolemia
| Pre-HD Assessment | -Evaluate volume status using clinical markers and BVM -Adjust antihypertensive medications (hold pre-HD doses if needed) -Identify target UF based on BVM, prior intradialytic tolerance, and clinical status |
| During HD Monitoring | -Employ BVM to monitor real-time blood volume changes -Limit UF rates to avoid excessive preload reduction -Address any signs of hemodynamic instability immediately |
| Post-HD Monitoring | -Reassess dry weighy using BVM or clinical evaluation -Document intradialytic events, such as hypotension for further adjustments -Modify dry weifgt gradually to account for evolving fluid needs |
| Long-Term Strategy | -Periodically re-evaluate dry weight with echocardiographic markers (eg LVEDV) -Incorporate multidisciplinary input from nephrology and cardiology teams for comprehensive care |
A stepwise guide to fluid management in preload-sensitive ESRD-HOCM patients, integrating BVM, UF adjustments, and long-term dry weight strategies.