#NephMadness 2019: Koyner’s Knowledge on the Volume Assessment Region

Jay Koyner @jaykoyner

Jay Koyner, is an Associate Professor of Medicine and the Director of the Acute Dialysis Unit for the Section of Nephrology at the University of Chicago. His clinical research focuses on several aspects of critical care nephrology and his active research protocols include investigations to improve the care of inpatients at risk for AKI. Nephmadness combines two of his interests, Nephrology and Basketball, having played in the same pick-up basketball league for aging dads for the last 11 years.

Competitors for the Volume Assessment Region

Old School vs New School

Dry on Dialysis vs Wet on Dialysis

Is there any more quintessential nephrology question than, “What is the patient’s volume status?”

On a daily basis we are asked to do this over and over and over again. While this process is certainly not the isolated domain of nephrologists, on some level it forms the cornerstone of much of the care that we, as nephrologists, provide. It is at the heart of all our practice areas. Whether in the outpatient dialysis unit assessing the 65-year-old patient with diabetes, the hypertensive patient with end-stage kidney disease (ESKD) who possesses the vexing combination of autonomic dysfunction and large interdialytic weight gains, or in the ICU with the new consult for acute kidney injury (AKI) in the setting of end-stage liver disease with cirrhosis, we are constantly attempting to determine, whether with diuretics, ultrafiltration, or both, “How much fluid does this patient need removed?” As we all know, it is even present in our outpatient clinics where we are constantly attempting to maintain euvolemia to help control a patient’s blood pressure, improve their quality of life, and forestall the need to start renal replacement therapy. Honestly, it’s about time this universal question, “What’s the patient’s volume status?” gets the spotlight it deserves.

Dry on Dialysis vs Wet on Dialysis

From my perspective, let’s tackle this second match-up first. While this is a constant struggle, I think this issue is very much patient-dependent. Although there is evidence that volume overload in the setting of ESKD is associated with adverse outcomes, we all know that certain patients just do not seem to tolerate volume removal. Or alternatively, they are unwilling to comply with the necessary lifestyle modifications or lengthening of dialysis sessions that are associated with volume overload. Similarly, there are patients who lose quality of life from being dried out. Perhaps this is an oversimplified view of this question, as undoubtedly there are nuances and subtleties to this issue, but anyone who has ever spent 5 minutes talking to me can tell you I am not one for subtleties.

Dialysis prescriptions should be tailored to optimize how dry you can get your patient without impacting their quality of life and ability to function. Thus, if I had to lay my nickel down, I think Dry on Dialysis wins this matchup, but I think it’s a moot point as in this age of.. gasp…personalized medicine, there is too much gray and equipoise in this debate to think the winner of this match-up stands a chance against the winner of the first matchup:

Old School vs New School

First off, I love the idea of commenting on whether Old School or New School is the way to go, as I think this debate permeates so many aspects of nephrology. For a field that is so entrenched in physiology and has some highly revered tenets, we are often slow to adopt new tools and are often skeptical of their place in our practice.

As an aside, I don’t have much experience with writing blog posts like this so I find it ironic that the only other one I have ever written tackles this old school vs. new school issue. Regardless, this is a timeless debate. Are these new tools perfect? Of course not. Point-of-Care Ultrasound (POCUS) at its very heart is a user-dependent variable. The more you use it the more comfortable you will become with it and the more effective and reliable it can be for you. There are eventual limits to this benefit, but to me, the benefits are clear.

Certainly, most nephrologists recognize the benefit ultrasound has brought to line placement, recognizing that 15-20 years ago we didn’t use this emerging technology to place temporary catheters (or at least I didn’t). Current trainees would think it is sacrilege to place a line (or perform any other procedure) without using some sort of imaging guidance. Whether or not fellows (or nephrologists in general) should be placing lines is a separate issue, and perhaps its own question for NephMadness 2020…

Tools like bioelectrical impedance analysis (BIA) and POCUS are certainly useful and have repeatedly been shown to be effective in identifying volume excess in patients in several clinical settings, including ESKD. Just because you adopt a new technology does not mean you throw out the physical exam and older tools. These New School resources represent a way to augment our ability to optimize patient care. While I understand the desire to stay true to our roots and the tenets of the physical exam (JVD, peripheral edema etc…), these bedrocks of physiology are just as imperfect as the aforementioned “new school” tools.  

As nephrologists, we don’t want to be viewed as that older neighbor yelling at the local kids to stay off the lawn and turn down their music. These same tools (POCUS and BIA) are gaining wider and wider acceptance in the world of critical care and cardiology. As such, it is incumbent on us to determine the strengths and weaknesses of these tools in the nephrology space. As the preliminary data show, there will undoubtedly be utility in the setting of ESKD (as well as AKI and advanced CKD), and for that I am optimistic that New School should emerge victorious over Old School.

However, having spent the last decade of my research career focused on investigating and validating novel biomarkers of AKI, I have learned that nephrologists are at times resistant to change and in general are not early adopters, so I am voting with my head rather than my heart. I anticipate the Blue Ribbon Panel will remain true to their physiology-loving nephrology roots and stick with the Old School tools even in the face of mounting evidence that New School is the correct choice (I hope I am wrong). Either way, I envision the winner of the new school vs old school matchup advancing out of the Volume Assessment Bracket.

– Guest Post written by Jay Koyner @jaykoyner


As with all content on the AJKD Blog, the opinions expressed are those of the author of each post, and are not necessarily shared or endorsed by the AJKD Blog, AJKD, the National Kidney Foundation, Elsevier, or any other entity unless explicitly stated.

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1 Comment on #NephMadness 2019: Koyner’s Knowledge on the Volume Assessment Region

  1. I am 200% in agreement with you that neophrologists in general tend to be too ‘traditional’. With the data presented in the scouting report, for eg: the very low sensitivity of physical exam (3% for leg edema!!), I definitely feel we should integrate POCUS as a tool to augment patient assessment. I am speaking from personal experience when I say it takes 3 minutes to accurately diagnose a hydro, volume overload and pulmonary edema with POCUS without needing the radiation of Xray, the wait of a much delayed PVR or the expensive Echocardiogram.

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