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Abedi F, Zarei B, Elyasi S. Albumin: a comprehensive review and practical guideline for clinical use. Eur J Clin Pharmacol 2024; 80:1151-1169. [PMID: 38607390 DOI: 10.1007/s00228-024-03664-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 03/04/2024] [Indexed: 04/13/2024]
Abstract
PURPOSE Nowadays, it is largely accepted that albumin should not be used in hypoalbuminemia or for nutritional purpose. The most discussed indication of albumin at present is the resuscitation in shock states, especially distributive shocks such as septic shock. The main evidence-based indication is also liver disease. In this review, we provided updated evidence-based instruction for definite and potential indications of albumin administration in clinical practice, with appropriate dosing and duration. METHODS Data collection was carried out until November 2023 by search of electronic databases including PubMed, Google Scholar, Scopus, and Web of Science. GRADE system has been used to determine the quality of evidence and strength of recommendations for each albumin indication. RESULTS A total of 165 relevant studies were included in this review. Fluid replacement in plasmapheresis and liver diseases, including hepatorenal syndrome, spontaneous bacterial peritonitis, and large-volume paracentesis, have a moderate to high quality of evidence and a strong recommendation for administering albumin. Moreover, albumin is used as a second-line and adjunctive to crystalloids for fluid resuscitation in hypovolemic shock, sepsis and septic shock, severe burns, toxic epidermal necrolysis, intradialytic hypotension, ovarian hyperstimulation syndrome, major surgery, non-traumatic brain injury, extracorporeal membrane oxygenation, acute respiratory distress syndrome, and severe and refractory edema with hypoalbuminemia has a low to moderate quality of evidence and weak recommendation to use. Also, in modest volume paracentesis, severe hyponatremia in cirrhosis has a low to moderate quality of evidence and a weak recommendation. CONCLUSION Albumin administration is most indicated in management of cirrhosis complications. Fluid resuscitation or treatment of severe and refractory edema, especially in patients with hypoalbuminemia and not responding to other treatments, is another rational use for albumin. Implementation of evidence-based guidelines in hospitals can be an effective measure to reduce inappropriate uses of albumin.
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Affiliation(s)
- Farshad Abedi
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, P.O. Box, Mashhad, 91775-1365, Iran
| | - Batool Zarei
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, P.O. Box, Mashhad, 91775-1365, Iran.
| | - Sepideh Elyasi
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, P.O. Box, Mashhad, 91775-1365, Iran.
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Abstract
BACKGROUND, AREAS OF UNCERTAINTY Intradialytic hypotension (IDH) is one of the most common complications of the hemodialysis procedure. Although there are no clear-cut answers as to the best strategy on the management of IDH, data suggest that the administration of osmotically active drugs may decrease the occurrence of blood pressure decline during dialysis. The use of mannitol for IDH management in hemodialysis patients is scarce. This article highlights the use and benefits of mannitol and to assess the role of mannitol role in the management of IDH. DATA SOURCES Primary literature identified through MEDLINE/PubMed database and Google Scholar with no restrictions. Relevant and current literatures related to mannitol and IDH were used. RESULTS AND DATA SYNTHESIS Multiple studies have shown the benefits of mannitol for the management of IDH. Because of its oncotic effect, mannitol increases plasma osmolality to maintain adequate blood pressure and prevent the occurrence of IDH. Two observational studies and several reports were identified as being the most recent and applicable to clinical practice. Studies and data on the use of mannitol in IDH are scarce or outdated. The 2 studies used in this article conclude that mannitol carries benefits for both the adult and pediatric population. However, additional research in the future will be needed to confirm the evidence for various age groups. These 2 observational trials were also very small in number, and any future studies conducted should have a longer duration and larger population size. Although lacking data, these studies will suffice in introducing the benefits of mannitol in IDH. CONCLUSIONS Mannitol may be considered for the management of IDH; however, additional studies are required to evaluate the long-term risk and benefits associated with mannitol, as it carries a risk of accumulation in the body.
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Hryciw N, Joannidis M, Hiremath S, Callum J, Clark EG. Intravenous Albumin for Mitigating Hypotension and Augmenting Ultrafiltration during Kidney Replacement Therapy. Clin J Am Soc Nephrol 2021; 16:820-828. [PMID: 33115729 PMCID: PMC8259476 DOI: 10.2215/cjn.09670620] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Among its many functions, owing to its oversized effect on colloid oncotic pressure, intravascular albumin helps preserve the effective circulatory volume. Hypoalbuminemia is common in hospitalized patients and is found especially frequently in patients who require KRT either for AKI or as maintenance hemodialysis. In such patients, hypoalbuminemia is strongly associated with morbidity, intradialytic hypotension, and mortality. Intravenous albumin may be administered in an effort to prevent or treat hypotension or to augment fluid removal, but this practice is controversial. Theoretically, intravenous albumin administration might prevent or treat hypotension by promoting plasma refilling in response to ultrafiltration. However, clinical trials have demonstrated that albumin administration is not nearly as effective a volume expander as might be assumed according to its oncotic properties. Although intravenous albumin is generally considered to be safe, it is also very expensive. In addition, there are potential risks to using it to prevent or treat intradialytic hypotension. Some recent studies have suggested that hyperoncotic albumin solutions may precipitate or worsen AKI in patients with sepsis or shock; however, the overall evidence supporting this effect is weak. In this review, we explore the theoretical benefits and risks of using intravenous albumin to mitigate intradialytic hypotension and/or enhance ultrafiltration and summarize the current evidence relating to this practice. This includes studies relevant to its use in patients on maintenance hemodialysis and critically ill patients with AKI who require KRT in the intensive care unit. Despite evidence of its frequent use and high costs, at present, there are minimal data that support the routine use of intravenous albumin during KRT. As such, adequately powered trials to evaluate the efficacy of intravenous albumin in this setting are clearly needed.
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Affiliation(s)
- Nicole Hryciw
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Swapnil Hiremath
- Division of Nephrology, Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Jeannie Callum
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Edward G. Clark
- Division of Nephrology, Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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A randomized trial of albumin infusion to prevent intradialytic hypotension in hospitalized hypoalbuminemic patients. Crit Care 2021; 25:18. [PMID: 33407747 PMCID: PMC7789619 DOI: 10.1186/s13054-020-03441-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 12/16/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intradialytic hypotension (IDH) is a frequent complication of intermittent hemodialysis (IHD), occurring from 15 to 50% of ambulatory sessions, and is more frequent among hospitalized patients with hypoalbuminemia. IDH limits adequate fluid removal and increases the risk for vascular access thrombosis, early hemodialysis (HD) termination, and mortality. Albumin infusion before and during therapy has been used for treating IDH with the varying results. We evaluated the efficacy of albumin infusion in preventing IDH during IHD in hypoalbuminemic inpatients. METHODS A randomized, crossover trial was performed in 65 AKI or ESKD patients with hypoalbuminemia (albumin < 3 g/dl) who required HD during hospitalization. Patients were randomized to receive 100 ml of either 0.9%sodium chloride or 25% albumin intravenously at the initiation of each dialysis. These two solutions were alternated for up to six sessions. Patients' vital signs and ultrafiltration removal rate were recorded every 15 to 30 min during dialysis. IDH was assessed by different definitions reported in the literature. All symptoms associated with a noted hypotensive event as well as interventions during the dialysis were recorded. RESULTS Sixty-five patients were submitted to 249 sessions; the mean age was 58 ([Formula: see text] 12), and 46 (70%) were male with a mean weight of 76 ([Formula: see text] 18) kg. The presence of IDH was lower during albumin sessions based on all definitions. The hypotension risk was significantly decreased based on the Kidney Disease Outcomes Quality Initiative definition; (15% with NS vs. 7% with albumin, p = 0.002). The lowest intradialytic SBP was significantly worse in patients who received 0.9% sodium chloride than albumin (NS 83 vs. albumin 90 mmHg, p = 0.035). Overall ultrafiltration rate was significantly higher in the albumin therapies [NS - 8.25 ml/kg/h (- 11.18 5.80) vs. 8.27 ml/kg/h (- 12.22 to 5.53) with albumin, p = 0.011]. CONCLUSION In hypoalbuminemic patients who need HD, albumin administration before the dialysis results in fewer episodes of hypotension and improves fluid removal. Albumin infusion may be of benefit to improve the safety of HD and achievement of fluid balance in these high-risk patients. ClinicalTrials.gov Identifier: NCT04522635.
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Timofte D, Tanasescu MD, Balcangiu-Stroescu AE, Balan DG, Tulin A, Stiru O, Vacaroiu IA, Mihai A, Constantin PC, Cosconel CI, Enyedi M, Miricescu D, Ionescu D. Dyselectrolytemia-management and implications in hemodialysis (Review). Exp Ther Med 2021; 21:102. [PMID: 33363613 PMCID: PMC7725007 DOI: 10.3892/etm.2020.9534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 08/11/2020] [Indexed: 12/27/2022] Open
Abstract
Hemodialysis is a method for the renal replacement therapy followed by series of acute and chronic complications. Dyselectrolytemia appears in patients undergoing dialysis through mechanisms related to the chronic kidney disease and/or to the dialysis therapy and for this group of patients it is associated with an increase of morbidity and mortality. The dialysate has a standard composition, which can be modified according to the patient's characteristics. During hemodialysis patients are exposed to 18,000-36.000 litres of water/year, and the water purity along with the biochemical composition of the dialysate are essential. The individualization of the dialysis prescription is recommended for each patient and it has an important role in preventing the occurrence of dyselectrolyemia. The individualization of the treatment prescription according to the blood constants of each patient is the prerogative of the nephrologist and the association of the electrolyte imbalances with the patients cardiovascular mortality explains the importance of paying special attention to them.
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Affiliation(s)
- Delia Timofte
- Department of Dialysis, Emergency University Hospital, 050098 Bucharest, Romania
| | - Maria-Daniela Tanasescu
- Department of Medical Semiology, Discipline of Internal Medicine I and Nephrology, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Nephrology, Emergency University Hospital, 050098 Bucharest, Romania
| | - Andra-Elena Balcangiu-Stroescu
- Department of Dialysis, Emergency University Hospital, 050098 Bucharest, Romania
- Discipline of Physiology, Faculty of Dental Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Daniela Gabriela Balan
- Discipline of Physiology, Faculty of Dental Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Adrian Tulin
- Department of Anatomy, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of General Surgery, ‘Prof. Dr. Agrippa Ionescu’ Clinical Emergency Hospital, 011356 Bucharest, Romania
| | - Ovidiu Stiru
- Department of Cardiovascular Surgery, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Cardiovascular Surgery, ‘Prof. Dr. C.C. Iliescu’ Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania
| | - Ileana Adela Vacaroiu
- Department of Nephrology and Dialysis, St. Ioan Emergency Clinical Hospital, 042122 Bucharest, Romania
- Department of Nephrology, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Andrada Mihai
- Discipline of Diabetes, ‘Prof. N. Paulescu’ National Institute of Diabetes, Nutrition and Metabolic Diseases, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Second Department of Diabetes, ‘Prof. N. Paulescu’ National Institute of Diabetes, Nutrition and Metabolic Diseases, 020474 Bucharest, Romania
| | - Popa Cristian Constantin
- Department of Surgery, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Surgery, Emergency University Hospital, 050098 Bucharest, Romania
| | - Cristina-Ileana Cosconel
- Discipline of Foreign Languages, Faculty of Dental Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Mihaly Enyedi
- Department of Anatomy, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Radiology, ‘Victor Babes’ Private Medical Clinic, 030303 Bucharest, Romania
| | - Daniela Miricescu
- Discipline of Biochemistry, Faculty of Dental Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Dorin Ionescu
- Department of Medical Semiology, Discipline of Internal Medicine I and Nephrology, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Nephrology, Emergency University Hospital, 050098 Bucharest, Romania
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Yin L, Dubovetsky D, Louzon-Lynch P. Implementation of an Algorithm Utilizing Saline Versus Albumin for the Treatment of Intradialytic Hypotension. Ann Pharmacother 2018; 53:159-164. [DOI: 10.1177/1060028018801024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Intradialytic hypotension (IDH) is the most commonly reported complication of hemodialysis (HD) treatment. At our institution, dialysis patients often have both 25% albumin and normal saline ordered as rescue options for management of IDH, without specification of which agent to use first. Objective: The purpose of this study was to determine the effect of an algorithm for IDH management. Methods: A retrospective study was conducted in HD patients who experienced IDH. The primary end point was to evaluate albumin use. Secondary end points included albumin costs, study fluid use per dialysis session, compliance with algorithm, efficacy of hypotension reversal to mean arterial pressure (MAP) ⩾60 mm Hg, percentage of target ultrafiltration achieved, time required to restore systolic blood pressure ⩾90 mm Hg, blood pressure post–study fluids, IDH treatment failure rate, and early termination of dialysis as a result of persistent IDH. Results: Implementation of the algorithm was observed in 94% of patients (n = 90). Total albumin use was significantly reduced from 11 400 to 4700 mL in the pre– (n = 90) and post–algorithm implementation group (n = 90; P < 0.001). The associated total cost of albumin was reduced by 59% ($10 534 vs $4343; P < 0.001). No statistical differences were observed between the 2 groups regarding efficacy of hypotension reversal to MAP ⩾60 mm Hg, early HD termination, or treatment failure rates (all P = 0.99). Conclusion and Relevance: Implementation of an evidence-based, standardized algorithm and pharmacy education to nursing staff can result in a reduction in albumin use and its associated drug costs for IDH management without compromising efficacy of IDH reversal.
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Affiliation(s)
- Ling Yin
- Florida Hospital Orlando, FL, USA
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Castillo AM, Natkowski J, Rubal-Peace G. Assessing adherence to current national guidelines for appropriate albumin use at an academic medical center. Pharm Pract (Granada) 2018; 16:1190. [PMID: 30023030 PMCID: PMC6041205 DOI: 10.18549/pharmpract.2018.02.1190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 06/06/2018] [Indexed: 12/29/2022] Open
Abstract
Objective: To assess adherence to current national guidelines for appropriate albumin use at an academic medical center. Methods: This retrospective chart review of 150 randomly selected patients prescribed and administered at least one dose of albumin was conducted in an urban academic medical center to evaluate the adherence of albumin orders to current national guidelines. Inclusion criteria consisted of discharged patients at least 18-years-old admitted to the intensive care unit or medical/surgical unit from September 1, 2015 to August 31, 2016. The primary outcome was the number of patients who inappropriately received albumin based on national guidelines and FDA approved indications. Secondary outcomes included the number of patients who received the incorrect concentration or dose of albumin based on indication, as well as the cost associated with inappropriate albumin prescribing. Descriptive statistics were used to report outcomes. Results: There were 68 instances (45%) where albumin was prescribed inappropriately according to guideline recommendations. Of the 82 instances where albumin was used appropriately, 18 patients received an incorrect dose (22%), and 6 received the inappropriate concentration of albumin (7%). The cost for the 150 patients included in the study associated with inappropriate albumin prescribing was approximately $13,000. Conclusions: This study identified areas for pharmacist intervention to ensure appropriate albumin utilization, as well as proper dosing for the most frequently incorrectly dosed indications, including hepato-renal syndrome, spontaneous bacterial peritonitis, and paracentesis. This study also identified an unexpected indication with significant inappropriate albumin utilization, perioperative hypotension, which is an area for further intervention to monitor and decrease use.
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Affiliation(s)
- Angelina M Castillo
- Clinical Inpatient Pharmacist. The Hospitals of Providence - East Campus. El Paso, TX (United States).
| | - Jamie Natkowski
- Clinical Pharmacist - Intensive Care. Banner University Medical Center South. Tucson, AZ (United States).
| | - Georgina Rubal-Peace
- Pharmacy Program Coordinator, Residency Program Director. Banner University Medical Center South. Tucson, AZ (United States).
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Sekiguchi H, Seaburg LA, Suzuki J, Astorne WJ, Patel AS, Keller AS, Gajic O, Kashani KB. Central venous pressure and ultrasonographic measurement correlation and their associations with intradialytic adverse events in hospitalized patients: A prospective observational study. J Crit Care 2017; 44:168-174. [PMID: 29132056 DOI: 10.1016/j.jcrc.2017.10.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 10/19/2017] [Accepted: 10/28/2017] [Indexed: 02/06/2023]
Abstract
PURPOSE To investigate correlation of central venous pressure (CVP) with ultrasonographic measurement of central veins, along with association between these variables and occurrence of intradialytic adverse events in hospitalized patients. MATERIALS AND METHODS Patients requiring hemodialysis via dialysis catheter were prospectively enrolled. CVP measurements through catheter, internal jugular vein aspect ratio, subclavian vein collapsibility, inferior vena cava (IVC) maximal diameter, and IVC collapsibility were recorded before and after hemodialysis. Predictive accuracy of ultrasonographic measurements in discriminating high versus low CVP and their association with intradialytic adverse events were evaluated. Area under receiver operating characteristic curves (AUCs) were calculated. RESULTS Fifty-nine patients were enrolled. Median (interquartile range) pre- and post-dialysis CVPs were 8 (4-13)mmHg and 6 (3-10)mmHg, respectively (P<0.01). In pre-dialysis, IVC collapsibility had the highest AUC (0.79, P<0.01) to predict CVP >8mmHg. In post-dialysis, IVC maximal diameter had the highest AUC (0.86, P<0.01) to predict CVP ≤4mmHg. Fifteen patients (25%) had adverse events. Neither pre-dialytic CVP nor ultrasonographic variables were associated with occurrence of adverse events. CONCLUSIONS Highest accuracy in predicting low and high CVP was observed with ultrasonographic assessment of IVC diameter and collapsibility. Adverse events were not predicted by pre-dialytic CVP or ultrasonographic measurements.
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Affiliation(s)
- Hiroshi Sekiguchi
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, United States.
| | - Luke A Seaburg
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Jun Suzuki
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, United States
| | - Walter J Astorne
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, United States; Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, United States
| | - Anil S Patel
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, United States
| | - A Scott Keller
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, United States
| | - Kianoush B Kashani
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, United States; Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, United States
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Schytz PA, Mace ML, Soja AMB, Nilsson B, Karamperis N, Kristensen B, Ladefoged SD, Hansen HP. Impact of extracorporeal blood flow rate on blood pressure, pulse rate and cardiac output during haemodialysis. Nephrol Dial Transplant 2015; 30:2075-9. [PMID: 26333543 DOI: 10.1093/ndt/gfv316] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 08/04/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND If blood pressure (BP) falls during haemodialysis (HD) [intradialytic hypotension (IDH)] a common clinical practice is to reduce the extracorporeal blood flow rate (EBFR). Consequently the efficacy of the HD (Kt/V) is reduced. However, only very limited knowledge on the effect of reducing EBFR on BP exists and data are conflicting. The aim of this study was to evaluate the effect and the potential mechanism(s) involved by investigating the impact of changes in EBFR on BP, pulse rate (PR) and cardiac output (CO) in HD patients with arteriovenous-fistulas (AV-fistulas). METHODS We performed a randomized, crossover trial in 22 haemodynamically stable HD patients with AV-fistula. After a conventional HD session each patient was examined during EBFR of 200, 300 and 400 mL/min in random order. After 15 min when steady state was achieved CO, BP and PR were measured at each EFBR, respectively. RESULTS Mean (SD) age was 71 (11) years. Systolic BP was significantly higher at an EBFR of 200 mL/min as compared with 300 mL/min [133 (23) versus 128 (24) mmHg; P < 0.05], but not as compared with 400 mL/min [133 (23) versus 130 (19) mmHg; P = 0.20]. At EBFR of 200, 300 and 400 mL/min diastolic BP, mean arterial pressure, PR and CO remained unchanged. CONCLUSION Our study does not show any consistent trend in BP changes by a reduction in EBFR. Reduction in EBFR if BP falls during IDH is thus not supported. However, none of the patients experienced IDH. Further studies are required to evaluate the impact of changes in EBFR on BP during IDH.
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Pakula AM, Skinner RA. Acute Kidney Injury in the Critically Ill Patient: A Current Review of the Literature. J Intensive Care Med 2015; 31:319-24. [PMID: 25752308 DOI: 10.1177/0885066615575699] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 01/16/2015] [Indexed: 12/12/2022]
Abstract
PURPOSE A comprehensive review of the literature to provide a focused and thorough update on the issue of acute kidney injury (AKI) in the surgical patient. METHODS A PubMed and Medline search was performed and keywords included AKI, renal failure, critically ill, and renal replacement therapy (RRT). PRINCIPAL FINDINGS A common clinical problem encountered in critically ill patients is AKI. The recent consensus definitions for the diagnosis and classification of AKI (ie, Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease/Acute Kidney Injury Network) have enabled us to standardize the severity of AKI and facilitate strategies for prevention. These strategies as well as treatment modalities of AKI are discussed. We provide a concise overview of the issue of renal failure. We describe strategies for prevention including types of fluids used for resuscitation, timing of initiation of RRT, and different treatment modalities currently available for clinical practice. CONCLUSIONS Acute kidney injury is a common problem in the critically ill patient and is associated with worse clinical outcomes. A standardized definition and staging system has led to improved diagnosis and understanding of the pathophysiology of AKI. There are many trials leading to improved prevention and management of the disease.
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Affiliation(s)
- Andrea M Pakula
- Department of Surgery and Surgical Critical Care, Kern Medical Center, Bakersfield, CA, USA
| | - Ruby A Skinner
- Department of Surgery and Surgical Critical Care, Kern Medical Center, Bakersfield, CA, USA
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Affiliation(s)
- Ashita Tolwani
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL 35294-0007, USA.
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12
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Hofmann RM. Preventing harm during treatment of acute kidney injury: what do we really know? Adv Chronic Kidney Dis 2012; 19:142-8. [PMID: 22578673 DOI: 10.1053/j.ackd.2012.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 03/25/2012] [Accepted: 03/27/2012] [Indexed: 11/11/2022]
Abstract
Acute kidney injury (AKI) affects approximately 5% of all hospitalized patients, and its incidence continues to increase. The treatment of AKI involves tremendous financial costs, estimated to exceed $10 billion in the United States annually. Although our understanding of the pathophysiology of AKI has progressed at a tremendous pace, mortality remains high at 50% to 80%, with no improvement during the past several decades. More questions than answers currently exist regarding the optimal dialysis dose, optimal modality, and optimal timing of the initiation of renal replacement therapy in the setting of AKI, making it particularly difficult for the practicing clinician to both optimize treatment and practice cost-effective medicine. This article will review current evidence and concerns regarding these issues and identify areas of future research.
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Shimizu K, Kurosawa T, Ishikawa R, Sanjo T. Vasopressin secretion by hypertonic saline infusion during hemodialysis: effect of cardiopulmonary recirculation. Nephrol Dial Transplant 2011; 27:796-803. [DOI: 10.1093/ndt/gfr272] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
BACKGROUND Intradialytic hypotension (IDH) occurs in 20% to 55% of haemodialysis sessions and is more frequent among patients on long-term haemodialysis. Symptomatic IDH is generally defined as a decrease in systolic blood pressure (BP) of at least 10 mm Hg or a systolic BP less than 100 mm Hg, with symptoms such as cramps, nausea, vomiting, and dizziness. IDH is managed acutely by volume expansion through the intravenous administration of fluids. OBJECTIVES To compare the benefits and harms of volume expansion with human albumin, alone or in combination with crystalloid or non-protein colloids, for treating IDH in haemodialysis patients. SEARCH STRATEGY The Cochrane Renal Group's Specialised Register and the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 9) MEDLINE (1966 to Oct 2009), and EMBASE (1980 to Oct 2009) were searched. SELECTION CRITERIA Randomised controlled trials (RCTs), quasi-RCTs as well as randomised crossover studies were to be included. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed trial quality. Relative risk (RR) was to be used to analyse dichotomous variables and mean difference (MD) used to analyse continuous variables. MAIN RESULTS One double blind randomised crossover trial met the inclusion criteria and compared 5% albumin to normal saline in patients with a previous history of IDH. Results from 45 assessable participants did not lead to rejection of the null hypothesis of no difference between 5% albumin and normal saline in the primary outcome measure of percentage target ultrafiltration achieved, nor in 11/12 secondary outcomes. Additional (unblinded) saline was given less often when 5% albumin was used compared with saline (16% versus 36%, P = 0.04). However, the volume of additional fluid administered was similar in both groups. There were no significant differences in the nursing time required to treat IDH and the time to restore BP. AUTHORS' CONCLUSIONS No randomised or controlled trial was identified comparing albumin to crystalloids (other than normal saline) or non-protein colloids, or a combination of both, in the treatment of symptomatic hypotension during dialysis. One double blind crossover RCT in 45 assessable patients showed that 5% albumin is not superior to normal saline for the treatment of symptomatic hypotension in maintenance haemodialysis patients with a previous history of IDH. Given the cost and relative rarity of albumin use compared to saline, saline should be first line of therapy for treatment of IDH in stable dialysis patients.
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Affiliation(s)
- Patricia M Fortin
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, 2176 Health Sciences Mall, Vancouver, BC, Canada, V6T 1Z3
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Liumbruno GM, Bennardello F, Lattanzio A, Piccoli P, Rossettias G. Recommendations for the use of albumin and immunoglobulins. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2009; 7:216-34. [PMID: 19657486 PMCID: PMC2719274 DOI: 10.2450/2009.0094-09] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Giancarlo Maria Liumbruno
- UU.OO.CC. di Immunoematologia e Medicina Trasfusionale e Patologia Clinica, Ospedale San Giovanni Calibita Fatebenefratelli, Roma, Italy.
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16
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Rauf AA, Long KH, Gajic O, Anderson SS, Swaminathan L, Albright RC. Intermittent hemodialysis versus continuous renal replacement therapy for acute renal failure in the intensive care unit: an observational outcomes analysis. J Intensive Care Med 2008; 23:195-203. [PMID: 18474503 DOI: 10.1177/0885066608315743] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Studies have failed to show a survival difference between intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT). Comparative cost analyses are limited and fail to control for differences in patient disease severity and comorbid conditions. The authors retrospectively estimated clinical and economic outcomes associated with CRRT and IHD among critically ill patients experiencing acute renal failure (ARF) in 2 tertiary care hospitals in Rochester, Minnesota, between January 1, 2000, and December 12, 2001. METHODS 161 critically ill patients requiring dialysis for ARF were analyzed. Patient demographics, comorbid conditions, ARF etiology, mode of renal replacement therapy (RRT), renal recovery, and survival were abstracted from medical chart. APACHE II scores at dialysis initiation were calculated. Administrative data tracked length of stay (LOS) and direct medical costs from initiation of RRT to death or intensive care unit (ICU) and hospital discharge. Multivariate modeling was used to adjust outcomes for baseline differences. RESULTS 84 (52%) of the patients received CRRT and 77 (48%) received IHD. CRRT-treated patients were younger (58 vs 65 years), less likely male (58% vs 77%), had higher APACHE II scores (32 vs 27) with a higher incidence of sepsis (46% vs 30%) and respiratory disease (56% vs 39%), and were less likely to have chronic renal insufficiency (32% vs 49%). With adjustment for differences in baseline patient characteristics, the RRT method did not affect the likelihood of renal recovery, in-hospital survival, or survival during follow-up. Mean adjusted ICU LOS was 9.5 days shorter for IHD-treated than CRRT-treated patients (P< .001), and the adjusted mean difference in hospital and total costs associated with ICU stay was $56,564 and $60 827, in favor of IHD (P< .001). Mean adjusted total costs through hospital discharge were $93 611 and $140,733 among IHD-treated and CRRT-treated patients, respectively (P< .001). CONCLUSIONS This observational study suggests that costs may significantly differ by mode of RRT despite similar severity-adjusted patient outcomes. Future prospective comparisons of renal replacement modalities will need to include both clinical and economic outcomes.
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Affiliation(s)
- Anis Abdul Rauf
- Departments of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA.
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17
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Mangoni AA, Hewitson CL, Woodman RJ, Whiting MJ, McAteer-Carr B, Barbara JA. Symmetric dimethylarginine is an independent predictor of intradialytic hypotension. Am J Hypertens 2008; 21:955-9. [PMID: 18551101 DOI: 10.1038/ajh.2008.214] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Hemodialysis (HD) is associated with significant reductions in the plasma concentrations of the nitric oxide (NO) inhibitors N(G)-monomethyl L-arginine (L-NMMA), asymmetric dimethylarginine (ADMA), and symmetric dimethylarginine (SDMA). We sought to determine whether elevated concentrations of these NO inhibitors pre-HD and/or their acute decrease during HD might mediate intradialytic hypotension (IDH). METHODS Systolic blood pressure (SBP), L-arginine, L-NMMA, ADMA, and SDMA were measured at the beginning (pre-HD) and at the end (end-HD) in 52 consecutive HD patients (age 64.4 +/- 13.4 years). IDH was defined as a SBP reduction of >20 mm Hg end-HD vs. pre-HD. RESULTS Fourteen patients demonstrated IDH. The mean SBP reduction during HD in this group was -35 +/- 13 mm Hg compared to an increase of +2 +/- 12 mm Hg among the 38 patients without IDH (no-IDH). Baseline demographic, clinical, and biochemical parameters did not differ between the IDH and no-IDH groups. However, the IDH group had higher pre-HD SBP (155 +/- 17 vs. 132 +/- 14 mm Hg, P < 0.001), pre-HD plasma SDMA concentrations (1.98 +/- 0.61 vs. 1.64 +/- 0.46 micromol/l, P = 0.04), and greater SDMA reductions during HD (-0.78 +/- 0.43 vs. -0.56 +/- 0.32 micromol/l, P = 0.06) than the no-IHD group. After adjusting for pre-HD SBP, the odds of IDH occurring were higher with increased pre-HD SDMA plasma concentrations (OR = 1.31 per 0.1 micromol/l SDMA increase; 95% CI = 1.04-1.65, P = 0.02) and with decreases in SDMA during HD (OR = 1.39 per 0.1 micromol/l SDMA decrease; 95% CI = 1.02-1.91, P = 0.04). CONCLUSION Increased pre-HD SDMA plasma concentrations and greater SDMA reductions during HD independently predict IDH after adjusting for demographic and clinical variables, pre-HD SBP, and other methylated forms of L-arginine.
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Shimizu K, Kurosawa T, Sanjo T. Effect of Hyperosmolality on Vasopressin Secretion in Intradialytic Hypotension: A Mechanistic Study. Am J Kidney Dis 2008; 52:294-304. [DOI: 10.1053/j.ajkd.2008.03.024] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2007] [Accepted: 03/31/2008] [Indexed: 11/11/2022]
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19
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Renal Replacement Therapy. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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20
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Fortin PM, Bassett K, Musini VM. Human albumin for intradialytic hypotension in haemodialysis patients. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2007. [DOI: 10.1002/14651858.cd006758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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21
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Abstract
Acute renal failure in critically ill patients is a growing clinical problem. Options for renal replacement therapy in these patients use convective and diffusive clearance and may be intermittent, as in classic hemodialysis, or continuous. New ways of delivering dialysis in the intensive care unit, such as sustained low-efficiency dialysis, are also under development. It may be that renal replacement therapy needs to be tailored to the needs of each individual patient. Current and future research studies should provide the answers to many of these questions.
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Affiliation(s)
- Philip O'Reilly
- Department of Medicine, University of Alabama at Birmingham, ZRB 604, 1530 3rd Avenue South, Birmingham, AL 35294-0007, USA
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22
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Dumler F, McCullough PA. Optimal dialysis for the end-stage renal disease patient with cardiovascular disease. Adv Chronic Kidney Dis 2004; 11:261-73. [PMID: 15241741 DOI: 10.1053/j.arrt.2004.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The increasing incidence and prevalence of end-stage renal disease (ESRD) that requires renal replacement therapy has placed a focus on the dialysis procedure itself with respect to its hemodynamic and cardiovascular complications. More than 50% of patients with ESRD will die of cardiovascular disease (CVD). A considerable contribution to cardiovascular events occurs with the dialysis procedure itself. This paper explores the intradialytic complications of hemodialysis as they relate to the cardiovascular system and highlights opportunities for research and improved quality of care.
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Affiliation(s)
- Francis Dumler
- Department of Medicine, Division of Nephrology, William Beaumont Hospital, Royal Oak, MI 48073, USA.
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23
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Martelli A, Strada P, Cagliani I, Brambilla G. Guidelines for the clinical use of albumin: comparison of use in two Italian hospitals and a third hospital without guidelines. CURRENT THERAPEUTIC RESEARCH 2003; 64:676-84. [PMID: 24944415 PMCID: PMC4053060 DOI: 10.1016/j.curtheres.2003.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/09/2003] [Indexed: 12/01/2022]
Abstract
BACKGROUND In the absence of clinical practice guidelines prior to 1999, the consumption of human albumin in the Liguria region of Italy was very high, despite possible adverse effects, limited supply, and significant cost. OBJECTIVE The purpose of this study was to assess the impact of comprehensive guidelines on the amount of albumin used in 2 general hospitals and to compare it with that of a third general hospital that did not adopt the guidelines. METHODS We analyzed the influence of the guidelines on albumin use in 2 general hospitals (hospitals 1 and 2) in the Liguria region by comparing albumin consumption during the year before the distribution of the guidelines (1999) with consumption in the 2 years after their distribution (2000 and 2001). We compared these data with those of a third general hospital that did not adopt the guidelines (hospital 3). The parameters considered were total consumption of albumin, consumption per bed, consumption per hospital stay, mean time to discharge, expenditure per bed, and mortality rate. RESULTS In the years 2000 and 2001, the adoption of guidelines reduced albumin consumption in hospitals 1 and 2. In hospital 1, where the release of albumin was carefully controlled by the transfusion service, albumin use per hospital stay decreased 8.7% in 2000 and 7.6% in 2001 from 1999; in hospital 2, use decreased 73.8% and 77.4%, respectively, from 1999. In hospital 3, rejection of the guidelines was coupled with an increase of 2.9% and 8.4%, respectively, in the amount of albumin used per hospital stay. In the years 2000 and 2001, the savings in the expenditure for albumin was ∼17,000 euro in hospital 1 and ∼200,000 euro in hospital 2. CONCLUSION This study confirms that the adoption of guidelines may substantially reduce the inappropriate use of albumin and relative costs.
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Affiliation(s)
- Antonietta Martelli
- Department of Internal Medicine, Division of Clinical Pharmacology and Toxicology, University of Genoa, Genoa, Italy
| | - Paolo Strada
- Transfusion Service of Galliera Hospital, Genoa, Italy
| | | | - Giovanni Brambilla
- Department of Internal Medicine, Division of Clinical Pharmacology and Toxicology, University of Genoa, Genoa, Italy
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24
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Doshi M, Murray PT. Approach to intradialytic hypotension in intensive care unit patients with acute renal failure. Artif Organs 2003; 27:772-80. [PMID: 12940898 DOI: 10.1046/j.1525-1594.2003.07291.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The increasing prevalence of acute renal failure (ARF) patients with hemodynamic intolerance of intermittent hemodialysis (HD), generally because of septic vasoparesis or severe cardiac dysfunction, has led to the development of several strategies to improve the delivery of renal replacement therapy (RRT) in ARF patients. Intradialytic hypotension (IDH) is caused by the interaction of dialysis-dependent and dialysis-independent factors. Dialysis-dependent factors include the prescriptions for fluid removal, solute removal, and dialysate components such as sodium, buffer, and calcium. Dialysis-independent factors include hemodynamic compromise caused by hypovolemic, cardiogenic, vasodilatory, and mixed mechanisms. We propose an approach to the prevention and management of IDH in critically ill ARF patients, which minimizes hypovolemic, cardiogenic, and vasodilatory insults by optimizing fluid removal, cardiac function, and vascular contractility.
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Affiliation(s)
- Mona Doshi
- Department of Medicine, University of Chicago, Chicago, IL, USA
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25
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Abstract
The approach to end-stage renal disease (ESRD) patients who develop intradialytic hypotension (IDH) encompasses an understanding of the pathophysiology, appropriate dialysis prescription modification, application of newer pharmacologic therapies, and development of strategies for prevention. Patients should have a "minimal data set" as part of their predialysis assessment. This information is critical to prescription modifications that may help decrease the risk for IDH. Individuals at "high risk" for IDH should be kept to a "safe zone" for dialysis ultrafiltration (</=3% of body weight). Specific maneuvers that may decrease the risk for IDH include adjustment of the dialysate sodium or calcium concentration and dialysate temperature. The first priority for patients developing IDH should be the stabilization of the blood pressure and improvement in the patient's symptomology. Pharmacologic intervention should be considered for patients who require repeat interventions for IDH. "At-risk" patients with a strong cardiac history should undergo an assessment of their cardiovascular status if IDH episodes occur. The use of pharmacologic therapy, ie, midodrine, alone or in combination with prescription modification, can be helpful in decreasing interventions required for IDH. Noncompliance and high interdialytic weight gain in the setting of left ventricular hypertrophy (LVH) and diastolic dysfunction can increase the risk of IDH. Assessment of antihypertensive medications should be performed on a regular basis to determine the correct dosing schedule for patients with hypertension who develop IDH. Coronary flow reserve may be compromised in patients with LVH, adding to the risk for perfusion injury with low blood pressure. Increasing the dialysate calcium concentration may decrease the incidence of arrhythmogenicity in certain patients. Patients with low body temperature may benefit most from cool dialysate. Unit personnel should be aware of the potential link between hypotension and the increased relative risk for death in ESRD patients. Clinical training sessions on IDH risk recognition and appropriate treatment should be implemented within the dialysis unit. Because repeated bouts of IDH can be disruptive to the smooth efficiency of unit operations, attention to prevention as well as acute intervention of IDH is important. Preventive strategies can be developed in each unit to decrease the number of future IDH events. Considering the importance of hypotension in overall patient survival, attention to identifying the percentage of patients in each unit who experience IDH and/or who present with low blood pressure (systolic <110 mm Hg) should be tracked as a quality assurance initiative.
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Affiliation(s)
- M J Schreiber
- Department of Clinical Nephrology and Hypertension, Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
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26
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Affiliation(s)
- P Murray
- Department of Medicine and Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois, USA
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27
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Manns BJ, Taub KJ, Donaldson C. Economic evaluation and end-stage renal disease: from basics to bedside. Am J Kidney Dis 2000; 36:12-28. [PMID: 10873867 DOI: 10.1053/ajkd.2000.8235] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Economic evaluation is the comparative analysis of alternative health care interventions in terms of their relative costs (resource use) and effectiveness (health effects). High-quality studies of economic evaluation have been increasingly published in medical journals and read by clinicians, although publication of these studies in nephrology journals has been a more recent phenomenon. This article shows how the basic principles of economics can be applied to health care through the use of economic evaluation. Different types of economic evaluation are discussed, and pitfalls common to such studies are identified. A simple framework is introduced that can be used to interpret the results of economic evaluations. Using this framework, selected therapies for patients with end-stage renal disease (ESRD) are categorized to highlight therapies that are very efficient, encourage their use, and draw attention to therapies in current use that are less effective and more expensive (ie, less efficient) than alternative therapy. Using examples pertinent to care of the patient with ESRD, we show how economic evaluation can be used to link medical outcomes, quality of life, and costs in a common index for multiple therapies with disparate outcome measures. This article highlights the need for clinical studies and economic evaluations of therapies in ESRD for which the effects of the therapy on health outcomes and/or costs are unknown.
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Affiliation(s)
- B J Manns
- Department of Medicine, Division of Nephrology, and the Departments of Community Health Sciences and Economics, The University of Calgary, Calgary, Canada
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28
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van Der Sande FM, Kooman JP, Leunissen KM. Strategies for improving hemodynamic stability in cardiac-compromised dialysis patients. Am J Kidney Dis 2000; 35:E19. [PMID: 10793048 DOI: 10.1016/s0272-6386(00)70284-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
In hemodialysis patients, structural changes at all levels of the cardiovascular system are common. The presence of these cardiovascular changes is a risk factor for the development of intradialytic hypotension. This explains the clinical observation that the incidence of symptomatic hypotension is high in elderly hemodialysis patients, who often have a history of long-standing hypertension and atherosclerosis, and in hemodialysis patients with cardiovascular disease. With an increasing number of cardiovascular compromised dialysis patients, special attention should be given to this group of patients. As the age of patients on hemodialysis increases steadily, it is a challenge to provide comfortable treatment in these patients by reducing the incidence of symptomatic hypotensive periods. This article describes the use of relatively new and simple clinical maneuvers to reduce the incidence of symptomatic hypotension.
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Affiliation(s)
- F M van Der Sande
- Department of Internal Medicine and Nephrology, University Hospital Maastricht, Maastricht, The Netherlands
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29
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Abstract
The benefit of albumin administration in the critically ill patient is unproven. Epidemiological evidence suggests that there is an increase in death among patients with burns, hypoalbuminaemia, and hypotension treated with human albumin solution (HAS). In critical illness, hypoalbuminaemia is a result of transcapillary leak, decreased synthesis, large volume body fluid losses, and dilution caused by fluid resuscitation. When treating patients with hypoalbuminaemia, efforts must be centred around correction of the underlying disorder rather than reversal of hypoalbuminaemia. Problems with using albumin arise because it is an expensive blood product, and can result in systemic changes that include cardiovascular, haematological, renal, pulmonary, and immunological effects.
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Affiliation(s)
- T B Pulimood
- John Farman Intensive Care Unit, Addenbrooke's Hospital, Hill's Road, Cambridge, UK
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