Dry Weight Reduction Intervention Via Extra Ultrafiltration

This is a randomized trial of patients who are receiving in-center hemodialysis treatments for end stage kidney disease and have clinical suspicion of fluid overload. Enrolled participants will be randomly assigned in 1:1:1 fashion to either a four-week ultrafiltration strategy, an eight-week ultrafiltration strategy, or continuation of their regular thrice weekly hemodialysis treatments. Each ultrafiltration strategy will add two extra four-hour ultrafiltration treatments per week plus pharmacist-guided tapering of blood pressure medications. We will test the impact of these strategies on primary outcomes of

• Change in 24-hour continuous ambulatory blood pressure from baseline to 24-weeks
• Change in symptoms of congestion from baseline to 24-weeks We will also test the impact of the treatment strategies on related symptoms, physical activity levels, hemodynamics. and measures of safety.

Inclusion criteria

• Receiving thrice weekly in-center hemodialysis treatments for end stage kidney disease for at least four weeks and clinical suspicion of volume excess based on either:

• Persistent hypertension defined by three consecutive pre-dialysis systolic blood pressures ≥140 mmHg or three consecutive pre-dialysis systolic blood pressures 130-140 mmHg plus use of at least two anti-hypertensive medications that can be tapered.

OR

• Symptoms of congestion defined by a 12-item Kidney Modified Kansas City Cardiomyopathy Questionnaire (KM-KCCQ) score <75.

Exclusion criteria

• Age <18 years
• Receiving hemodialysis treatments for acute kidney injury
• Receiving hemodialysis treatments for less than four weeks
• Planned switch to peritoneal or home dialysis within next three months
• Current or planned incremental hemodialysis (less than 3 treatments per week)
• Current or planned intensive hemodialysis (four or more treatments per week)
• Scheduled kidney transplantation
• Major cardiovascular or bleeding event within previous 90 days
• Receiving chemotherapy or radiation treatment for cancer
• History of cirrhosis with ascites
• Inability to complete 24-hour ambulatory blood pressure measurement
• Wheelchair dependance or other inability to complete six-minute walk test
• Pre-dialysis systolic blood pressure <100 mmHg
• Scheduled use of midodrine with hemodialysis treatments
• History of non-adherence with dialysis treatments
• Pregnancy
• Institutionalized
• Current or pending enrollment in hospice care
• Inappropriate for enrollment based on investigator or nephrologist discretion