One-Size Dialysis Volume Goals Fall Short in CKD: Jennifer Flythe, MD

Fixed treatment schedules and single-number safety thresholds in dialysis leave many patients with cardiovascular risk and symptoms that individualized volume management could address. Low use of guideline-directed medical therapy (GDMT) in advanced chronic kidney disease (CKD) points to a similar system-level gap, said Jennifer E. Flythe, MD, MPH, chief of the Division of Nephrology and Hypertension and professor of medicine at UNC School of Medicine in Chapel Hill, North Carolina, in an email interview with The American Journal of Managed Care®.

At the American Society of Nephrology’s Kidney Week, Flythe delivered the Garabed Eknoyan, MD, Endowed Lectureship, “Can We Do Better with Volume Management for Patients Treated with Dialysis?,” a session on moving dialysis care away from a one-size-fits-all approach toward care that reflects each patient’s characteristics, risk factors, and goals.¹ In this interview, she described what individualized volume management could look like, which structural barriers stand in the way, and how quality measures might shift toward symptoms, recovery time, and missed treatments.

She also discussed a poster analysis of 106,383 adults with advanced CKD in which the risks of cardiovascular events and death exceeded the risk of kidney failure, yet sodium glucose co-transporter 2 (SGLT2) inhibitor use ranged from only 11% to 17%.²

This interview was edited for clarity.

AJMC: What are the biggest limitations in how volume is managed for most patients receiving maintenance dialysis today?

Flythe: It’s largely one-size-fits-all. Most US patients receive 3 treatments a week with a fixed treatment time and the same weight goal every session, with population-level safety thresholds like an ultrafiltration (UF) rate under 13 mL/kg/h applied to all. Those numbers describe population-level risk, not necessarily what an individual needs. Our approach to date has not solved our volume-related challenges: cardiovascular death remains common, and many patients experience debilitating symptoms related to volume.

AJMC: What would individualized volume management look like for a patient in practice, compared with today’s standard approach?

Flythe: Today, we tend to look at 1 number at a time and respond with a protocol. Individualized care would bring the data together: machine data like UF rates and blood volume trends as well as vital signs, labs, and what patients tell us about cramping, dizziness, and recovery time. That fuller picture, informed by what we know about each patient’s cardiovascular health, residual kidney function, and other clinical factors, would allow us to better match our dialysis prescriptions to patient physiology and experience. This approach requires technology and systems, but it also requires clinical judgment.

AJMC: What gets in the way of delivering individualized care within the current dialysis care delivery structure?

Flythe: The system is built for efficiency and delivering safe care at a population level. Fixed schedules make longer or extra treatments hard to arrange, and protocols have staff react to 1 number at a time rather than the whole patient. Tools like bioimpedance and lung ultrasound are not available in most units, and we don’t capture symptoms in a standardized way. The pieces of the puzzle exist, but they rarely come together in 1 place.

AJMC: How should the way we evaluate dialysis quality change if care moves toward a precision medicine framework?

Flythe: Quality measures built on single thresholds don’t fit a precision approach. A facility can look good on a UF rate metric while patients still feel terrible. I’d like to see us measure what reflects more tailored care and patient well-being: symptoms, recovery time, missed and shortened treatments, and fluid-related hospitalizations. We still need accountability, but we shouldn’t reward uniformity.

AJMC: Pivoting to your research on GDMT, your analysis of more than 106,000 adults with advanced CKD found that SGLT2 inhibitor use ranged from 11% to 17% and renin-angiotensin system inhibitor use from 35% to 39%, even though the risk of cardiovascular events exceeded the risk of kidney failure. What do you think explains that utilization gap?

Flythe: Part of it is the familiar gap between evidence and practice. Strong trial results don’t automatically change prescribing, especially when clinicians are uneasy about hyperkalemia or estimated glomerular filtration rate drops in advanced CKD. But we also rely too heavily on individual physicians to remember, initiate, and monitor these therapies during busy visits. We need system-level supports: electronic health record prompts that flag eligible patients, pharmacist-led initiation and lab monitoring, and population health tools that track who isn’t on therapy. That moves GDMT out of the hands of any one clinician and into the care system.

AJMC: Given these gaps, who should take primary ownership of optimizing GDMT in patients with advanced CKD, and how can nephrology, primary care, and cardiology coordinate better?

Flythe: In advanced CKD, nephrology should lead. We manage potassium and eGFR changes and are best positioned to keep patients on therapy through the expected early eGFR dip. But primary care and cardiology need a shared plan, so no one stops a medication someone else started. Clear notes on who manages what, EHR prompts, and pharmacist support help. When everyone assumes someone else owns it, nobody does.

References

1. Flythe JE. Can we do better with volume management for patients treated with dialysis? The Garabed Eknoyan, MD, Endowed Lectureship. Presented at: ASN Kidney Week; October 21-25, 2026; Denver, Colorado.
2. Contemporary use of guideline-directed medical therapy in US adults with advanced CKD and high risk of cardiovascular events. Presented at: ASN Kidney Week; October 21-25, 2026; Denver, Colorado. Poster SA-PO0463.