Ultrafiltration Rate Clinical Performance Measures: Ready for Primetime?

Mounting evidence supports a strong association between fluid management and outcomes among individuals receiving maintenance hemodialysis. The speed of fluid removal during dialysis (ultrafiltration, UF) is a modifiable aspect of fluid management that has attracted recent attention as a potential performance measure for facility fluid management practices. Observational data support an association between higher UF rates and adverse outcomes. This association is supported by the plausible pathophysiologic rationale of hypoperfusion-induced ischemic injury to the heart and other end-organs. However, no published clinical trial has studied the impact of lowering UF rates on clinical and patient-centered outcomes. Lowering UF rates requires interdialytic weigh gain reduction and/or extension of dialysis time. Weight gain reduction has proven difficult despite nutritional programs focused on salt and fluid restrictions, and patients are generally averse to longer treatment times. Thus, imposition of UF rate limitations may lead to failed target weight achievement and volume expansion over time. Despite these potential unintended consequences, the National Quality Forum endorsed an UF rate clinical performance measure in 2015. Prior to implementation of quality measure-imposed UF rate limitations, prospective studies of UF rates and outcomes are needed.