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Preparations for Next Moonwalk Simulations Underway (and Underwater)

astronaut on ISS processes samples for the Renal Stone investigation
ISS Expedition 13 Flight Engineer, Thomas Reiter, on board ISS processes samples for the Renal Stone investigation.
NASA

Exposure to microgravity induces bone atrophy/bone loss which increases circulating calcium, impacting the renal stone risk. Risk mitigation strategies including exercise and hydration are well-defined although the ability to treat a renal stone during exploration missions is not yet available.

Directed Acyclic Graph Files

+ DAG File Information (HSRB Home Page)

+ Risk of Renal Stone Formation DAG and Narrative (PDF)

+ Risk of Renal Stone Formation DAG Code (TXT)

Human Research Roadmap

+ Risk of Renal Stone Formation Human Research Roadmap

+ 2017 May Evidence Report

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Last Updated
Mar 11, 2025
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Robert E. Lewis

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      Preparations for Next Moonwalk Simulations Underway (and Underwater)
      In-person participants (L-R) – Back row: Jason Lytle, Stuart Lee, Eric Bershad, Ashot Sargsyan, Aaron Everson, Philip Wells, Sergi Vaquer Araujo, Steven Grover, John A. Heit, Mehdi Shishehbor, Laura Bostick; Middle row: Sarah Childress Taoufik, Stephan Moll, Brandon Macias, Kristin Coffey, Ann-Kathrin Vlacil, Dave Francisco; Front row: James Pavela, Doug Ebert, Kathleen McMonigal, Esther Kim, Emma Hwang; Not pictured: Tyson Brunstetter, J. D. Polk
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      Read More about the Risk of VTE The working group was assembled from internal NASA subject matter experts (SMEs), the NASA OCHMO Standards Team, NASA and ESA stakeholders, and external SMEs, including physicians and medical professionals from leading universities and medical centers in the United States and Canada.

      Background
      Spaceflight Venous Thrombosis (SVT)
      Spaceflight Venous Thrombosis (SVT) refers to a phenomenon experienced during spaceflight in which a thrombus (blood clot) forms in the internal jugular vein (and/or associated vasculature) that may be symptomatic (thrombus accompanied by, but not limited to, visible internal jugular vein swelling, facial edema beyond “nominal” spaceflight adaptation, eyelid edema, and/or headache) or asymptomatic. Obstructive thrombi have been identified in a very small number of crewmembers, as shown in the figure below.

      Note that the figure below is for illustrative purposes only; locations are approximate, and size is not to scale.

      Approximate location of identified thrombi in crewmembers.Source: Modified from Cerebral Sinus Venous Thrombosis – University of Colorado Denver With treatment, crewmembers were able to complete their mission, and anticoagulants were discontinued several days prior to landing to minimize the risk of bleeding in the event of a traumatic injury. Some thromboses completely resolved post landing, and some required additional treatment.
      Pathophysiology of Venous Thromboembolism (VTE)
      The proposed pathogenesis of VTE is referred to as Virchow’s triad and suggests that VTE occurs as the result of:
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      The Virchow’s triad of risk factors for venous thrombosis.Bouchnita, 2017 Blood stasis, or venous stasis, refers to a condition in which the blood flow in the veins slows down which leads to pooling in the veins. This slowing of the blood may be due to vein valves becoming damaged or weak, immobility, and/or the absence of muscular contractions. Associated symptoms include swelling, skin changes, varicose veins, and slow-healing sores or ulcers. In terrestrial medicine, venous thrombosis is typically caused by damaged or weakened vein valves, which can be due to many factors, including aging, blood clots, varicose veins, obesity, pregnancy, sedentary lifestyle, estrogen use, and hereditary predisposition.

      Spaceflight Considerations
      Altered Venous Blood Flow and Spaceflight Associated Neuro-ocular Syndrome

      In addition to the terrestrial risk factors of VTE, there are physiological changes associated with spaceflight that are hypothesized to potentially play a role in the development of VTE in weightlessness. Specifically, researchers have explored the effects of the microgravity environment and subsequent observed headward fluid shifts that occur, and the potential impact on blood flow. Crewmembers onboard the International Space Station (ISS) experience weightlessness due to the microgravity environment and thus experience a sustained redistribution of bodily fluids from the legs toward the head. The prolonged headward fluid shifts during weightlessness results in facial puffiness, decreased leg volume, increased cardiac stroke volume, and decreased plasma volume.
      Crewmembers have also experienced altered blood flow during spaceflight, including retrograde venous blood flow (RVBF) (the backflow of venous blood towards the brain) or stasis (a stoppage or slowdown in the flow of blood). While the causes of the observed stasis and retrograde blood flow in spaceflight participants is not well understood, the potential clinical significance of the role it may have in the development of thrombus formation warrants further investigation.
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      Conclusions and Further Work
      Based on expert opinion and the assessment of the risk factors for thrombosis, an algorithm was developed to provide guidance for in-mission assessment and treatment of thrombus formation in weightlessness. The algorithm is based on early in-flight ultrasound testing to determine the flow characteristic of the left internal jugular vein and associated vasculature.
      NASA Working Group Recommendations
      The working group recommended several areas for further investigation to assess feasibility and potential to mitigate the risk of thrombosis in spaceflight:
      Improved detection capabilities to identify when a thrombus has formed in-flight, Pathophysiology/factors leading to thrombi formation during spaceflight, Countermeasures and treatment
      For more information on the working group meeting and a complete list of references, please see the Risk of Venous Thromboembolism (VTE) During Spaceflight Summary Report.
      Risk of Venous Thromboembolism (VTE) During Spaceflight Summary Report Share
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      Risks Concept Risk is inherent in human spaceflight. However, specific risks can and should be understood, managed, and mitigated to reduce threats posed to astronauts. Risk management in the context of human spaceflight can be viewed as a trade-based system. The relevant evidence in life sciences, medicine, and engineering is tracked and evaluated to identify ways to minimize overall risk to the astronauts and to ensure mission success. The Human System Risk Board (HSRB) manages the process by which scientific evidence is utilized to establish and reassess the postures of the various risks to the Human System during all of the various types of existing or anticipated crewed missions. The HSRB operates as part of the Health and Medical Technical Authority of the Office of the Chief Health and Medical Officer of NASA via the JSC Chief Medical Officer.
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      Human System Risks This framework enables the principles of Continuous Risk Management and Risk Informed Decision Making (RIDM) to be applied in an ongoing fashion to the challenges posed by Human System Risks. Using this framework consistently across the 29 risks allows management to see where risks need additional research or technology development to be mitigated or monitored and for the identification of new risks and concerns. Further information on the implementation of the risk management process can be found in the following documents:
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      Risk Custodian Teams
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      Directed Acyclic Graphs 
      Summary
      The HSRB uses Directed Acyclic Graphs (DAG), a type of causal diagramming, as visual tools to create a shared understanding of the risks, improve communication among those stakeholders, and enable the creation of a composite risk network that is vetted by members of the NASA community and configuration managed (Antonsen et al., NASA/TM– 20220006812). The knowledge captured is the Human Health and Performance community’s knowledge about the causal flow of a human system risk, and the relationships that exist between the contributing factors to that risk.
      DAGs are:
      Intended to improve communication between: Managers and subject matter experts who need to discuss human system risks Subject matter experts in different disciplines where human system risks interact with one another in a potentially cumulative fashion Visual representations of known or suspected relationships Directed – the relationship flows in one direction between any two nodes Acyclic – cycles in the graph are not allowed Example of a Directed Acyclic Graph. This is a simplified illustration of how and the individual, the crew, and the system contribute to the likelihood of successful task performance in a mission. Individual readiness is affected by many of the health and performance-oriented risks followed by the HSRB, but the readiness of any individual crew is complemented by the team and the system that the crew works within. Failures of task performance may lead to loss of mission objectives if severe.NASA View Larger (Example of a Directed Acyclic Graph) Image
      Details
      At NASA, the Human System Risks have historically been conceptualized as deriving from five Hazards present in the spaceflight environment. These are: altered gravity, isolation and confinement, radiation, a hostile closed environment, and distance from Earth. These Hazards are aspects of the spaceflight environment that are encountered when someone is launched into space and therefore are the starting point for causal diagramming of spaceflight-related risk issues for the HSRB.
      These Hazards are often interpreted in relation to physiologic changes that occur in humans as a result of the exposure; however, interaction between human crew (behavioral health and performance), which may be degraded due to the spaceflight environment – and the vehicle and mission systems that the crew must operate – can also be influenced by these Hazards.
      Each Human System Risk DAG is intended to show the causal flow of risk from Hazards to Mission Level Outcomes. As such, the structure of each DAG starts with at least one Hazard and ends with at least one of the pre-defined Mission Level Outcomes. In between are the nodes and edges of the causal flow diagrams that are relevant to the Risk under consideration. These are called ‘contributing factors’ in the HSRB terminology, and include countermeasures, medical conditions, and other Human System Risks. A graph data structure is composed of a set of vertices (nodes), and a set of edges (links). Each edge represents a relationship between two nodes. There can be two types of relationships between nodes: directed and undirected. For example, if an edge exists between two nodes A and B and the edge is undirected, it is represented as A–B, (no arrow). If the edge were directed, for example from A to B, then this is represented with an arrow (A->B). Each directed arrow connecting one node to another on a DAG indicates a claim of causality. A directed graph can potentially contain a cycle, meaning that, from a specific node, there exists a path that would eventually return to that node. A directed graph that has no cycles is known as acyclic. Thus, a graph with directed links and no cycles is a DAG.  DAGs are a type of network diagram that represent causality in a visual format.
      DAGs are updated with the regular Human System Risk updates generally every 1-2 years. Approved DAGs can be found in the NASA/TP 20220015709 below or broken down under each Human System Risk.
      Documents
      Directed Acyclic Graph Guidance Documentation – NASA/TM 20220006812 Directed Acyclic Graphs: A Tool for Understanding the NASA Human Spaceflight System Risks – NASA/TP 20220015709 Publications
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      Apr 22, 2024
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      Apr 22, 2024
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      npj Microgravity –
      Updates to the NASA human system risk management process
      for space exploration
      Apr 22, 2024
      PDF (2.24 MB)
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      Human System Risks Share
      Details
      Last Updated Mar 11, 2025 EditorRobert E. LewisLocationJohnson Space Center Related Terms
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