A fresh look at dry weight

The concept of dry weight (DW) is central to dialysis therapy. The most commonly used definition of DW is the weight below which patients become hypotensive on dialysis. However, this definition is dependent on patient symptoms. A more rigorous definition of DW is the body weight at a physiological extracellular volume (ECV) state. Overhydration is an excess in ECV above that found in healthy subjects. In healthy subjects, within extremes of salt intake, ECV may vary between 280 and 340 mL/kg lean body mass. Sodium accumulation is one of the many consequences of renal failure; it results in increased water intake and an increase in ECV, and an accompanying rise in blood pressure with its clinical sequelae, most prominently cardiovascular and cerebrovascular diseases. Recently characterized endogenous digitalis‐like factors which are released in response to ECV expansion have extended this traditional picture. Efforts to reduce a positive sodium balance include dietary counseling and avoidance of iatrogenic intradialytic sodium loading, such as dialysate sodium exceeding serum levels, sodium profiling, and intravenous saline. Excess ECV is predominantly located in the interstitial compartment and must be removed during dialysis therapy by ultrafiltration. During this process, interstitial fluid redistributes to the intravascular space via uptake in the capillary bed. In addition to that mechanism, we propose that increased lymphatic flow into the venous system contributes to plasma refilling. Both clinical and technical means are used to assess the presence of DW. Continuous segmental calf bioimpedance is a promising new technology for intradialytic DW diagnosis.