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Stuard S, Ridel C, Cioffi M, Trost-Rupnik A, Gurevich K, Bojic M, Karibayev Y, Mohebbi N, Marcinkowski W, Kupres V, Maslovaric J, Antebi A, Ponce P, Nada M, Salvador MEB, Rosenberger J, Jirka T, Enden K, Novakivskyy V, Voiculescu D, Pachmann M, Arkossy O. Hemodialysis Procedures for Stable Incident and Prevalent Patients Optimize Hemodynamic Stability, Dialysis Dose, Electrolytes, and Fluid Balance. J Clin Med 2024; 13:3211. [PMID: 38892922 PMCID: PMC11173331 DOI: 10.3390/jcm13113211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 05/14/2024] [Accepted: 05/20/2024] [Indexed: 06/21/2024] Open
Abstract
The demographic profile of patients transitioning from chronic kidney disease to kidney replacement therapy is changing, with a higher prevalence of aging patients with multiple comorbidities such as diabetes mellitus and heart failure. Cardiovascular disease remains the leading cause of mortality in this population, exacerbated by the cardiovascular stress imposed by the HD procedure. The first year after transitioning to hemodialysis is associated with increased risks of hospitalization and mortality, particularly within the first 90-120 days, with greater vulnerability observed among the elderly. Based on data from clinics in Fresenius Medical Care Europe, Middle East, and Africa NephroCare, this review aims to optimize hemodialysis procedures to reduce mortality risk in stable incident and prevalent patients. It addresses critical aspects such as treatment duration, frequency, choice of dialysis membrane, dialysate composition, blood and dialysate flow rates, electrolyte composition, temperature control, target weight management, dialysis adequacy, and additional protocols, with a focus on mitigating prevalent intradialytic complications, particularly intradialytic hypotension prevention.
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Affiliation(s)
- Stefano Stuard
- FME Global Medical Office, 61352 Bad Homburg, Germany; (M.P.); (O.A.)
| | | | | | | | | | - Marija Bojic
- FME Global Medical Office, 75400 Zvornik, Bosnia and Herzegovina;
| | | | | | | | | | | | - Alon Antebi
- FME Global Medical Office, Ra’anana 4366411, Israel;
| | - Pedro Ponce
- FME Global Medical Office, 1750-233 Lisboa, Portugal;
| | - Mamdouh Nada
- FME Global Medical Office, Riyadh 12472, Saudi Arabia;
| | | | | | - Tomas Jirka
- FME Global Medical Office, 16000 Praha, Czech Republic;
| | - Kira Enden
- FME Global Medical Office, 00380 Helsinki, Finland;
| | | | | | - Martin Pachmann
- FME Global Medical Office, 61352 Bad Homburg, Germany; (M.P.); (O.A.)
| | - Otto Arkossy
- FME Global Medical Office, 61352 Bad Homburg, Germany; (M.P.); (O.A.)
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Vongchaiudomchoke T, Aviphan K, Sanyakeun N, Wachiraphansakul N, Sawangduan V, Nochaiwong S, Ruengorn C, Noppakun K. Randomized Trial on the Effects of Dialysate Potassium Concentration on Intradialytic Hypertension. Kidney Int Rep 2023; 8:1323-1331. [PMID: 37441490 PMCID: PMC10334342 DOI: 10.1016/j.ekir.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 03/08/2023] [Accepted: 04/04/2023] [Indexed: 07/15/2023] Open
Abstract
Introduction Intradialytic hypertension is not an uncommon condition during chronic hemodialysis. It is associated with unfavorable cardiovascular outcomes, including hospitalization and mortality. Several small studies have demonstrated the contradictory effects of different dialysate potassium concentrations on intradialytic blood pressure. This study is a randomized crossover trial aiming to evaluate the effects of different dialysate potassium concentrations on intradialytic hypertension. Methods A 24-week, 2-treatment, 4-sequence, multicenter, double-blinded, randomized, crossover study was conducted at Maharaj Nakorn Chiang Mai Hospital and Lampang Hospital in Thailand among stable patients receiving chronic hemodialysis who experienced intradialytic hypertension >30% of their sessions over the past 3 months. Each participant was randomly assigned to 1 of 4 treatment sequences. During each intervention period, patients were dialyzed with dialysate potassium of either 2 mmol/l (D-K2) or 3 mmol/l (D-K3) for 4 weeks according to their preassigned sequence, separated by a 2-week washout period. The primary outcome was the incidence of intradialytic hypertension. Results Forty eligible patients were recruited. The mean age was 61.4 ± 14.2 years and the mean systolic blood pressure (SBP) was 146.6 ± 11.2 mm Hg. Of the 40 patients, 95.5% had hypertension and their average number of antihypertensive drugs was 2.8 ± 1.9. A total of 1380 dialysis sessions were included in the analysis (695 sessions for D-K2 and 685 sessions for D-K3). The incidence of intradialytic hypertension was not significantly different between different dialysate potassium concentrations (D-K2 54.7% vs. D-K3 53.1%, P = 0.788). The changes in SBP, diastolic blood pressure (DBP), and mean arterial pressure (MAP) were not different between the 2 dialysate potassium groups. Conclusion Dialysate potassium concentration of 2 or 3 mmol/l did not affect the incidence of intradialytic hypertension in patients receiving chronic hemodialysis who frequently developed intradialytic hypertension.
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Affiliation(s)
| | - Kanawat Aviphan
- Department of Internal Medicine, Lampang Hospital, Lampang, Thailand
| | - Nopparat Sanyakeun
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | | | | | - Surapon Nochaiwong
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
- Pharmacoepidemiology and Statistics Research Center, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Chidchanok Ruengorn
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
- Pharmacoepidemiology and Statistics Research Center, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Kajohnsak Noppakun
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Pharmacoepidemiology and Statistics Research Center, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
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Canaud B, Kooman J, Maierhofer A, Raimann J, Titze J, Kotanko P. Sodium First Approach, to Reset Our Mind for Improving Management of Sodium, Water, Volume and Pressure in Hemodialysis Patients, and to Reduce Cardiovascular Burden and Improve Outcomes. FRONTIERS IN NEPHROLOGY 2022; 2:935388. [PMID: 37675006 PMCID: PMC10479686 DOI: 10.3389/fneph.2022.935388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 06/07/2022] [Indexed: 09/08/2023]
Abstract
New physiologic findings related to sodium homeostasis and pathophysiologic associations require a new vision for sodium, fluid and blood pressure management in dialysis-dependent chronic kidney disease patients. The traditional dry weight probing approach that has prevailed for many years must be reviewed in light of these findings and enriched by availability of new tools for monitoring and handling sodium and water imbalances. A comprehensive and integrated approach is needed to improve further cardiac health in hemodialysis (HD) patients. Adequate management of sodium, water, volume and hemodynamic control of HD patients relies on a stepwise approach: the first entails assessment and monitoring of fluid status and relies on clinical judgement supported by specific tools that are online embedded in the HD machine or devices used offline; the second consists of acting on correcting fluid imbalance mainly through dialysis prescription (treatment time, active tools embedded on HD machine) but also on guidance related to diet and thirst management; the third consist of fine tuning treatment prescription to patient responses and tolerance with the support of innovative tools such as artificial intelligence and remote pervasive health trackers. It is time to come back to sodium and water imbalance as the root cause of the problem and not to act primarily on their consequences (fluid overload, hypertension) or organ damage (heart; atherosclerosis, brain). We know the problem and have the tools to assess and manage in a more precise way sodium and fluid in HD patients. We strongly call for a sodium first approach to reduce disease burden and improve cardiac health in dialysis-dependent chronic kidney disease patients.
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Affiliation(s)
- Bernard Canaud
- School of Medicine, Montpellier University, Montpellier, France
- Global Medical Office, Freseenius Medical Care (FMC)-France, Fresnes, France
| | - Jeroen Kooman
- Maastricht University Maastricht Medical Center (UMC), Maastricht University, Maastricht, Netherlands
| | - Andreas Maierhofer
- Global Research Development, Fresenius Medical Care (FMC) Deutschland GmbH, Bad Homburg, Germany
| | - Jochen Raimann
- Research Division, Renal Research Institute, New York, NY, United States
| | - Jens Titze
- Cardiovascular and Metabolic Disease Programme, Duke-National University Singapore (NUS) Medical School, Singapore, Singapore
| | - Peter Kotanko
- Research Division, Renal Research Institute, New York, NY, United States
- Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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Jaques DA, Davenport A. Serum sodium variation is a major determinant of peridialytic blood pressure trends in haemodialysis outpatients. Sci Rep 2021; 11:7882. [PMID: 33846430 PMCID: PMC8042038 DOI: 10.1038/s41598-021-86960-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 03/22/2021] [Indexed: 11/18/2022] Open
Abstract
Intradialytic hypotension (IDH) and peridialytic blood pressure (BP) trends are associated with morbidity and mortality in haemodialysis (HD) patients. We aimed to characterise the respective influence of volume status and small solutes variation on peridialytic systolic BP (SBP) trends during HD. We retrospectively analysed the relative peridialytic SBP decrease in 647 prevalent outpatients attending for their mid-week session with corresponding pre- and post-HD bioelectrical impedance analysis. Mean SBP decreased by 10.5 ± 23.6 mmHg. Factors positively associated with the relative decrease in SBP were: serum sodium (Na) decrease, body mass index, serum albumin, dialysis vintage, ultrafiltration rate and urea Kt/V (p < 0.05 for all). Antihypertensive medications and higher dialysate calcium were negatively associated with the relative decrease in SBP (p < 0.05 for both). Age had a quadratic relationship with SBP trends (p < 0.05). Pre-HD volume status measured by extracellular to total body water ratio was not associated with SBP variation (p = 0.216). Peridialytic SBP trends represent a continuum with serum Na variation being a major determinant while volume status has negligible influence. Middle-aged and overweight patients are particularly prone to SBP decline. Tailoring Na and calcium dialysate concentrations could influence haemodynamic stability during HD and improve patient experience and outcomes.
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Affiliation(s)
- David A Jaques
- Division of Nephrology, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland. .,UCL Department of Nephrology, Royal Free Hospital, University College London, London, UK.
| | - Andrew Davenport
- UCL Department of Nephrology, Royal Free Hospital, University College London, London, UK
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Furaz Czerpak K, Gruss Vergara E, Barril Cuadrado G, Pérez Fernández E, Benavides N, de la Flor J, Mendez Á, Martín R. Usefulness of ABPM and bioimpedance for the treatment and control of hypertension in patients on chronic haemodialysis. Nefrologia 2021; 41:17-26. [PMID: 36165357 DOI: 10.1016/j.nefroe.2020.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 06/11/2020] [Indexed: 06/16/2023] Open
Abstract
INTRODUCTION Hypertension is very common in haemodialysis (HD) patients, and is associated with increased morbidity and mortality rates. The goals of our research were to: 1. Measure blood pressure (BP) during HD sessions; 2. Study BP in between HD sessions with 44-h Ambulatory Blood Pressure Monitoring (ABPM); 3. Evaluate changes in treatment after the ABPM; 4. Perform bioimpedance spectroscopy (BIS) on all patients and, in those hyper-hydrated or hypertensive according to ABPM, assess for changes in BP after adjusting the dry weight; 5. Identify factors associated with average systolic and diastolic BP measured by ABPM. MATERIAL AND METHODS Prospective observational study, which included 100 patients from our dialysis unit. We measured BP before and after the HD sessions for two weeks and then, mid-week, we attached the ABPM device to the patients for 44 h. Before starting the following dialysis session, we performed BIS. A second ABPM was performed on hyper-hydrated patients and patients hypertensive according to ABPM to evaluate changes in BP values. RESULTS According to the ABPM, 65% of patients had daytime BP > 135/85 mmHg, 90% night-time BP > 120/70 mmHg and 76% average BP > 130/80 mmHg; 11% had a dipper pattern, 51% non-dipper and 38% riser. The average systolic and diastolic BP readings were 4.7 mmHg (3.8%) and 1.1 mmHg (1.64%) higher on the second day. The dose of antihypertensive medication had to be lowered in 6% of patients, 9% had to stop taking it, 28% needed increased doses and 17% had to add a new drug. The pre-HD diastolic BP best matched the ABPM. After performing the bioimpedance and adjusting dry weight, there was a statistically significant decrease in all BP values. The univariate analysis showed that the average systolic BP was higher in patients with a high-calcium dialysis bath, more antihypertensive drugs and higher doses of EPO. The multivariate analysis showed significant association for EPO and number of drugs (p < 0.01). The average diastolic BP was higher in younger patients and patients with lower Charlson index, lower body mass index and less diuresis, those on higher doses of EPO and non-diabetics. The linear regression study showed age (p < 0.005), body mass index (p < 0.03) and EPO (p < 0.03) as significant variables. CONCLUSIONS Our study shows: 1. The variability of hypertension criteria according to use of BP values from during the HD session or ABPM; 2. The variability of BP in the interdialysis period; 3. That the pre-dialysis diastolic BP best corresponds with the ABPM. 4. That the use of both BIS and ABPM improves the control of BP; 5. That the dose of EPO is the most important factor associated with hypertension in our patients.
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Affiliation(s)
- Karina Furaz Czerpak
- Centro de Diálisis Los Llanos, Fundación Renal Íñigo Álvarez de Toledo (FRIAT), Madrid, Spain.
| | | | | | - Elia Pérez Fernández
- Departamento de Estadística, Hospital Universitario Fundación de Alcorcón, Madrid, Spain
| | - Nardeth Benavides
- Centro de Diálisis Los Llanos, Fundación Renal Íñigo Álvarez de Toledo (FRIAT), Madrid, Spain
| | - José de la Flor
- Centro de Diálisis Los Llanos, Fundación Renal Íñigo Álvarez de Toledo (FRIAT), Madrid, Spain
| | - Ángel Mendez
- Centro de Diálisis Los Llanos, Fundación Renal Íñigo Álvarez de Toledo (FRIAT), Madrid, Spain
| | - Roberto Martín
- Centro de Diálisis Los Llanos, Fundación Renal Íñigo Álvarez de Toledo (FRIAT), Madrid, Spain
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Furaz Czerpak K, Gruss Vergara E, Barril Cuadrado G, Pérez Fernández E, Benavides N, de la Flor J, Mendez Á, Martín R. Usefulness of ABPM and bioimpedance for the treatment and control of hypertension in patients on chronic haemodialysis. Nefrologia 2020; 41:17-26. [PMID: 32950283 DOI: 10.1016/j.nefro.2020.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 05/31/2020] [Accepted: 06/11/2020] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION Hypertension is very common in haemodialysis (HD) patients, and is associated with increased morbidity and mortality rates. The goals of our research were to: 1. Measure blood pressure (BP) during HD sessions; 2. Study BP in between HD sessions with 44-hour Ambulatory Blood Pressure Monitoring (ABPM); 3. Identify differences between the BP recorded during HD and with the ABPM; 4. Evaluate changes in treatment after the ABPM; 5. Perform bioimpedance spectroscopy (BIS) on all patients and, in those hyper-hydrated or hypertensive according to ABPM, assess for changes in BP after adjusting the dry weight; 6. Identify factors associated with average systolic and diastolic BP measured by ABPM. MATERIAL AND METHODS Prospective observational study, which included 100 patients from our dialysis unit. We measured BP before and after the HD sessions for two weeks and then, mid-week, we attached the ABPM device to the patients for 44 hours. Before starting the following dialysis session, we performed BIS. A second ABPM was performed on hyper-hydrated patients and patients hypertensive according to ABPM to evaluate changes in BP values. RESULTS According to the ABPM, 65% of patients had daytime BP > 135/85 mmHg, 90% night-time BP > 120/70 mmHg and 76% average BP > 130/80 mmHg; 11% had a dipper pattern, 51% non-dipper and 38% riser. The average systolic and diastolic BP readings were 4.7 mmHg (3.8%) and 1.1 mmHg (1.64%) higher on the second day. The dose of antihypertensive medication had to be lowered in 6% of patients, 9% had to stop taking it, 28% needed increased doses and 17% had to add a new drug. The pre-HD diastolic BP best matched the ABPM. After performing the bioimpedance and adjusting dry weight, there was a statistically significant decrease in all BP values. The univariate analysis showed that the average systolic BP was higher in patients with a high-calcium dialysis bath, more antihypertensive drugs and higher doses of EPO. The multivariate analysis showed significant association for EPO and number of drugs (p < 0.01). The average diastolic BP was higher in younger patients and patients with lower Charlson index, lower body mass index and less diuresis, those on higher doses of EPO and non-diabetics. The linear regression study showed age (p < 0.005), body mass index (p < 0.03) and EPO (p < 0.03) as significant variables. CONCLUSIONS Our study shows: 1. The variability of hypertension criteria according to use of BP values from during the HD session or ABPM; 2. The variability of BP in the interdialysis period; 3. That the pre-dialysis diastolic BP best corresponds with the ABPM. 4. That the use of both BIS and ABPM improves the control of BP; 5. That the dose of EPO is the most important factor associated with hypertension in our patients.
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Affiliation(s)
- Karina Furaz Czerpak
- Centro de Diálisis Los Llanos, Fundación Renal Íñigo Álvarez de Toledo (FRIAT), Madrid, España.
| | | | | | - Elia Pérez Fernández
- Departamento de Estadística. Hospital Universitario Fundación de Alcorcón, Madrid, España
| | - Nardeth Benavides
- Centro de Diálisis Los Llanos, Fundación Renal Íñigo Álvarez de Toledo (FRIAT), Madrid, España
| | - José de la Flor
- Centro de Diálisis Los Llanos, Fundación Renal Íñigo Álvarez de Toledo (FRIAT), Madrid, España
| | - Ángel Mendez
- Centro de Diálisis Los Llanos, Fundación Renal Íñigo Álvarez de Toledo (FRIAT), Madrid, España
| | - Roberto Martín
- Centro de Diálisis Los Llanos, Fundación Renal Íñigo Álvarez de Toledo (FRIAT), Madrid, España
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7
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Peyronel F, Parenti E, Fenaroli P, Benigno GD, Rossi GM, Maggiore U, Fiaccadori E. Integrated strategies to prevent intradialytic hypotension: research protocol of the DialHypot study, a prospective randomised clinical trial in hypotension-prone haemodialysis patients. BMJ Open 2020; 10:e036893. [PMID: 32641335 PMCID: PMC7348655 DOI: 10.1136/bmjopen-2020-036893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION In patients on maintenance haemodialysis (HD), intradialytic hypotension (IDH) is a clinical problem that nephrologists and dialysis nurses face daily in their clinical routine. Despite the technological advances in the field of HD, the incidence of hypotensive events occurring during a standard dialytic treatment is still very high. Frequently recurring hypotensive episodes during HD sessions expose patients not only to severe immediate complications but also to a higher mortality risk in the medium term. Various strategies aimed at preventing IDH are currently available, but there is lack of conclusive data on more integrated approaches combining different interventions. METHODS AND ANALYSIS This is a prospective, randomised, open-label, crossover trial (each subject will be used as his/her own control) that will be performed in two distinct phases, each of which is divided into several subphases. In the first phase, 27 HD sessions for each patient will be used, and will be aimed at the validation of a new ultrafiltration (UF) profile, designed with an ascending/descending shape, and a standard dialysate sodium concentration. In the second phase, 33 HD sessions for each patient will be used and will be aimed at evaluating the combination of different UF and sodium profiling strategies through individualised dialysate sodium concentration. ETHICS AND DISSEMINATION The trial protocol has been reviewed and approved by the local Institutional Ethics Committee (Comitato Etico AVEN, prot. 43391 22.10.19). The results of the trial will be presented at local and international conferences and submitted for publication to a peer-reviewed journal. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT03949088).
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Affiliation(s)
- Francesco Peyronel
- Unità Operativa di Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
- Scuola di Specializzazione in Nefrologia, Università degli Studi di Parma Dipartimento di Medicina e Chirurgia, Parma, Emilia-Romagna, Italy
| | - Elisabetta Parenti
- Unità Operativa di Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
| | - Paride Fenaroli
- Unità Operativa di Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
- Scuola di Specializzazione in Nefrologia, Università degli Studi di Parma Dipartimento di Medicina e Chirurgia, Parma, Emilia-Romagna, Italy
| | - Giuseppe Daniele Benigno
- Unità Operativa di Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
- Scuola di Specializzazione in Nefrologia, Università degli Studi di Parma Dipartimento di Medicina e Chirurgia, Parma, Emilia-Romagna, Italy
| | - Giovanni Maria Rossi
- Unità Operativa di Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
| | - Umberto Maggiore
- Unità Operativa di Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
- Scuola di Specializzazione in Nefrologia, Università degli Studi di Parma Dipartimento di Medicina e Chirurgia, Parma, Emilia-Romagna, Italy
| | - Enrico Fiaccadori
- Unità Operativa di Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
- Scuola di Specializzazione in Nefrologia, Università degli Studi di Parma Dipartimento di Medicina e Chirurgia, Parma, Emilia-Romagna, Italy
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Doulton TWR, Swift PA, Murtaza A, Dasgupta I. Uncertainties in BP management in dialysis patients. Semin Dial 2020; 33:223-235. [PMID: 32285984 DOI: 10.1111/sdi.12880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 03/12/2020] [Indexed: 12/21/2022]
Abstract
Hypertension in dialysis patients is extremely common. In this article, we review the current evidence for blood pressure (BP) goals in hemodialysis patients, and consider the effectiveness of interventions by which BP may be lowered, including manipulation of dietary and dialysate sodium; optimization of extracellular water; prolongation of dialysis time; and antihypertensive medication. Although two meta-analyses suggest lowering BP using antihypertensive drugs might be beneficial in reducing cardiovascular events and mortality, there are insufficient rigorously designed trials in hypertensive hemodialysis populations to determine preferred antihypertensive drug classes. We suggest aiming for predialysis systolic BP between 130 and 159 mm Hg, while at the same time acknowledge the significant limitations of the data upon which it is based. We conclude by summarizing current knowledge as regards management of hypertension in the peritoneal dialysis population and make recommendations for future research in this field.
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Affiliation(s)
- Timothy W R Doulton
- Department of Renal Medicine, East Kent Hospitals University NHS Foundation Trust, Canterbury, Kent, UK
| | - Pauline A Swift
- Department of Nephrology, Epsom and St Helier University Hospitals NHS Trust, Carshalton, Surrey, UK
| | - Asam Murtaza
- Renal Unit, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Indranil Dasgupta
- Renal Unit, University Hospitals Birmingham NHS Trust, Birmingham, UK.,Warwick Medical School, University of Warwick, Warwick, UK
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9
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Ettema EM, Kuipers J, van Faassen M, Groen H, van Roon AM, Lefrandt JD, Westerhuis R, Kema IP, van Goor H, Gansevoort RT, Gaillard CAJM, Franssen CFM. Effect of plasma sodium concentration on blood pressure regulators during hemodialysis: a randomized crossover study. BMC Nephrol 2018; 19:214. [PMID: 30134847 PMCID: PMC6106825 DOI: 10.1186/s12882-018-0997-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 08/01/2018] [Indexed: 12/21/2022] Open
Abstract
Background Intradialytic hypotension is a common complication of hemodialysis. The Hemocontrol biofeedback system, improving intradialytic hemodynamic stability, is associated with an initial transient increase in plasma sodium levels. Increases in sodium could affect blood pressure regulators. Methods We investigated whether Hemocontrol dialysis affects vasopressin and copeptin levels, endothelial function, and sympathetic activity in twenty-nine chronic hemodialysis patients. Each patient underwent one standard hemodialysis and one Hemocontrol hemodialysis. Plasma sodium, osmolality, nitrite and nitrate (NOx), endothelin-1, angiopoietins-1 and 2, and methemoglobin as measures of endothelial function, plasma catecholamines as indices of sympathetic activity and plasma vasopressin and copeptin levels were measured six times during each modality. Blood pressure, heart rate, blood volume, and heart rate variability were repeatedly monitored. Generalized Estimating Equations was used to compare the course of the parameters during the two treatment modalities. Results Plasma sodium and osmolality were significantly higher during the first two hours of Hemocontrol hemodialysis. Overall, mean arterial pressure (MAP) was higher during Hemocontrol dialysis. Neither the measures of endothelial function and sympathetic activity nor copeptin levels differed between the two dialysis modalities. In contrast, plasma vasopressin levels were significantly higher during the first half of Hemocontrol dialysis. The intradialytic course of vasopressin was associated with the course of MAP. Conclusions A transient intradialytic increase in plasma sodium did not affect indices of endothelial function or sympathetic activity compared with standard hemodialysis, but coincided with higher plasma vasopressin levels. The beneficial effect of higher intradialytic sodium levels on hemodynamic stability might be mediated by vasopressin. Trial registration ClinicalTrials.gov. Identifier: NCT03578510. Date of registration: July 5th, 2018. Retrospectively registered.
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Affiliation(s)
- Esmée M Ettema
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, PO box 30, 001 9700, RB, Groningen, The Netherlands.
| | | | - Martijn van Faassen
- Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Henk Groen
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Arie M van Roon
- Department of Vascular Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Joop D Lefrandt
- Department of Vascular Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Ido P Kema
- Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Harry van Goor
- Department of Pathology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ron T Gansevoort
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, PO box 30, 001 9700, RB, Groningen, The Netherlands
| | - Carlo A J M Gaillard
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, PO box 30, 001 9700, RB, Groningen, The Netherlands
| | - Casper F M Franssen
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, PO box 30, 001 9700, RB, Groningen, The Netherlands
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10
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Davenport A. Negative Dialysate to Sodium Gradient Does not Lead to Intracellular Volume Expansion Post Hemodialysis. Int J Artif Organs 2018. [DOI: 10.1177/039139881003301002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction Intradialytic hypotension remains the most common complication of routine outpatient hemodialysis treatments. There is debate as to the optimum dialysate sodium concentration, with hypotonic dialysates potentially causing intracellular swelling and hypertonic ones intracellular dehydration. Methods Multi-frequency bioimpedance was used to assess extracellular and intracellular fluid volumes in 53 adult hemodialysis patients. Dialysate sodium was checked by ion electrophoresis. Results The mean decrease in extracellular volume and intracellular volumes were 1.01 ±0.09 and 0.88 ±0.18 kg, respectively. The median dialysate to sodium gradient was −3 mmol/L (−1 to −6), with a median dialysate sodium of 136 mmol/L (136–138). There was no association between changes in body fluid composition and sodium concentrations, or gradients. The mean difference between dialysate sodium prescribed and delivered was 2.4 ±0.8 mmol/L. Conclusions In this study we were unable to demonstrate a relationship between predialysis serum sodium and the dialysate sodium prescribed and changes in extracellular or intracellular fluid volumes. However this study showed that using a negative sodium gradient, patients can be successfully ultrafiltrated without setting up intracompartmental fluid gradients. The caveat is that the prescribed dialysate to serum sodium gradient may differ from the actual gradient.
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Affiliation(s)
- Andrew Davenport
- Center for Nephrology, University College London Medical School, Royal Free Campus, Rowland Hill Street, London – United Kingdom
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11
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Sandhu E, Crawford C, Davenport A. Weight Gains and Increased Blood Pressure in Outpatient Hemodialysis Patients Due to Change in Acid Dialysate Concentrate Supplier. Int J Artif Organs 2018. [DOI: 10.1177/039139881203500903] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Eleanor Sandhu
- UCL Centre for Nephrology, Royal Free Hospital, University College London, Medical School, London - United Kingdom
| | - Colley Crawford
- UCL Centre for Nephrology, Royal Free Hospital, University College London, Medical School, London - United Kingdom
| | - Andrew Davenport
- UCL Centre for Nephrology, Royal Free Hospital, University College London, Medical School, London - United Kingdom
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12
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Davenport A, Cox C, Thuraisingham R. The Importance of Dialysate Sodium Concentration in Determining Interdialytic Weight Gains in Chronic Hemodialysis Patients: The PanThames Renal Audit. Int J Artif Organs 2018; 31:411-7. [DOI: 10.1177/039139880803100506] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background and Objectives There is controversy as to the optimum dialysate sodium to be used for hemodialysis patients, with reports of hypertension and increased interdialytic weight gains with high sodium dialysates and intradialytic hypotension and cramps with low sodium dialysates. Methods We analyzed the effect of different dialysate sodium concentrations during a one-week period in an audit of 2187 established patients regularly receiving dialysis three times a week. Patients were given general dietary advice to restrict dietary sodium intake, but no systematic assessment of dietary sodium intake was undertaken. Results The prescription of a dialysate sodium concentration of 140 mmol/L and >140 mmol/L, was associated with greater interdialytic weight gains, 3.5% and 4.1% respectively, compared to 2.8% and 2.7% for those using dialysate sodium concentrations of 137 and 136 mmol/L, respectively (p<0.05). The mean pulse pressure was greater patients dialyzing using a sodium of 140 mmol/L, compared to 136 mmol/L, 70 (13) vs 63 (15) mmHg (p<0.011). In addition, 13.5% of patients using the highest sodium dialysate suffered symptomatic intradialytic hypotension requiring intravenous fluid resuscitation, compared to 2.7% who used the lowest sodium concentrate (p<0.05). Conclusions This analysis would support the use of lower dialysate sodium concentrations to aid in reducing interdialytic weight gains and subsequent intradialytic hypotension.
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Affiliation(s)
- A. Davenport
- UCL Center for Nephrology, Royal Free & University College Medical School, London - United Kingdom
| | - C. Cox
- Audit, Information & Analysis Unit for London, Kent, Surrey, Sussex, Essex, Beds & Herts, London - United Kingdom
| | - R. Thuraisingham
- Department of Nephrology, Barts and The London NHS Trust, London - United Kingdom
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13
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Roy A, De S. State-of-the-Art Materials and Spinning Technology for Hemodialyzer Membranes. SEPARATION AND PURIFICATION REVIEWS 2016. [DOI: 10.1080/15422119.2016.1256323] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Anirban Roy
- Department of Chemical Engineering, Indian Institute of Technology, Kharagpur, West Bengal, India
| | - Sirshendu De
- Department of Chemical Engineering, Indian Institute of Technology, Kharagpur, West Bengal, India
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14
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Torres da Costa e Silva V, Costalonga EC, Oliveira APL, Hung J, Caires RA, Hajjar LA, Fukushima JT, Soares CM, Bezerra JS, Oikawa L, Yu L, Burdmann EA. Evaluation of Intermittent Hemodialysis in Critically Ill Cancer Patients with Acute Kidney Injury Using Single-Pass Batch Equipment. PLoS One 2016; 11:e0149706. [PMID: 26938932 PMCID: PMC4777515 DOI: 10.1371/journal.pone.0149706] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 02/04/2016] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Data on renal replacement therapy (RRT) in cancer patients with acute kidney injury (AKI) in the intensive care unit (ICU) is scarce. The aim of this study was to assess the safety and the adequacy of intermittent hemodialysis (IHD) in critically ill cancer patients with AKI. METHODS AND FINDINGS In this observational prospective cohort study, 149 ICU cancer patients with AKI were treated with 448 single-pass batch IHD procedures and evaluated from June 2010 to June 2012. Primary outcomes were IHD complications (hypotension and clotting) and adequacy. A multiple logistic regression was performed in order to identify factors associated with IHD complications (hypotension and clotting). Patients were 62.2 ± 14.3 years old, 86.6% had a solid cancer, sepsis was the main AKI cause (51%) and in-hospital mortality was 59.7%. RRT session time was 240 (180-300) min, blood/dialysate flow was 250 (200-300) mL/min and UF was 1000 (0-2000) ml. Hypotension occurred in 25% of the sessions. Independent risk factors (RF) for hypotension were dialysate conductivity (each ms/cm, OR 0.81, CI 0.69-0.95), initial mean arterial pressure (each 10 mmHg, OR 0.49, CI 0.40-0.61) and SOFA score (OR 1.16, CI 1.03-1.30). Clotting and malfunctioning catheters (MC) occurred in 23.8% and 29.2% of the procedures, respectively. Independent RF for clotting were heparin use (OR 0.57, CI 0.33-0.99), MC (OR 3.59, CI 2.24-5.77) and RRT system pressure increase over 25% (OR 2.15, CI 1.61-4.17). Post RRT blood tests were urea 71 (49-104) mg/dL, creatinine 2.71 (2.10-3.8) mg/dL, bicarbonate 24.1 (22.5-25.5) mEq/L and K 3.8 (3.5-4.1) mEq/L. CONCLUSION IHD for critically ill patients with cancer and AKI offered acceptable hemodynamic stability and provided adequate metabolic control.
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Affiliation(s)
| | - Elerson C. Costalonga
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Ana Paula Leandro Oliveira
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - James Hung
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Renato Antunes Caires
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Ludhmila Abrahão Hajjar
- Intensive Care Unit Department, Sao Paulo State Cancer Institute, University of Sao Paulo School Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Julia T. Fukushima
- Intensive Care Unit Department, Sao Paulo State Cancer Institute, University of Sao Paulo School Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Cilene Muniz Soares
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Juliana Silva Bezerra
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Luciane Oikawa
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Luis Yu
- LIM 12, Division of Nephrology, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Emmanuel A. Burdmann
- LIM 12, Division of Nephrology, University of Sao Paulo Medical School, Sao Paulo, Brazil
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Locatelli F, La Milia V, Violo L, Del Vecchio L, Di Filippo S. Optimizing haemodialysate composition. Clin Kidney J 2015; 8:580-9. [PMID: 26413285 PMCID: PMC4581377 DOI: 10.1093/ckj/sfv057] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 06/17/2015] [Indexed: 11/25/2022] Open
Abstract
Survival and quality of life of dialysis patients are strictly dependent on the quality of the haemodialysis (HD) treatment. In this respect, dialysate composition, including water purity, plays a crucial role. A major aim of HD is to normalize predialysis plasma electrolyte and mineral concentrations, while minimizing wide swings in the patient's intradialytic plasma concentrations. Adequate sodium (Na) and water removal is critical for preventing intra- and interdialytic hypotension and pulmonary edema. Avoiding both hyper- and hypokalaemia prevents life-threatening cardiac arrhythmias. Optimal calcium (Ca) and magnesium (Mg) dialysate concentrations may protect the cardiovascular system and the bones, preventing extraskeletal calcifications, severe secondary hyperparathyroidism and adynamic bone disease. Adequate bicarbonate concentration [HCO3−] maintains a stable pH in the body fluids for appropriate protein and membrane functioning and also protects the bones. An adequate dialysate glucose concentration prevents severe hyperglycaemia and life-threating hypoglycaemia, which can lead to severe cardiovascular complications and a worsening of diabetic comorbidities.
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Affiliation(s)
- Francesco Locatelli
- Nephrology and Dialysis Department , 'Alessandro Manzoni' Hospital , Lecco , Italy
| | - Vincenzo La Milia
- Nephrology and Dialysis Department , 'Alessandro Manzoni' Hospital , Lecco , Italy
| | - Leano Violo
- Nephrology and Dialysis Department , 'Alessandro Manzoni' Hospital , Lecco , Italy
| | - Lucia Del Vecchio
- Nephrology and Dialysis Department , 'Alessandro Manzoni' Hospital , Lecco , Italy
| | - Salvatore Di Filippo
- Nephrology and Dialysis Department , 'Alessandro Manzoni' Hospital , Lecco , Italy
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16
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Basile C, Lomonte C. A neglected issue in dialysis practice: haemodialysate. Clin Kidney J 2015; 8:393-9. [PMID: 26251705 PMCID: PMC4515893 DOI: 10.1093/ckj/sfv038] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 03/25/2015] [Accepted: 04/30/2015] [Indexed: 01/09/2023] Open
Abstract
The intended function of dialysate fluid is to correct the composition of uraemic blood to physiologic levels, both by reducing the concentration of uraemic toxins and correcting electrolyte and acid-base abnormalities. This is accomplished principally by formulating a dialysate whose constituent concentrations are set to approximate normal values in the body. Sodium balance is the cornerstone of intradialysis cardiovascular stability and good interdialytic blood pressure control; plasma potassium concentration and its intradialytic kinetics certainly play a role in the genesis of cardiac arrhythmias; calcium is related to haemodynamic stability, mineral bone disease and also cardiac arrhythmias; the role of magnesium is still controversial; lastly, acid buffering by means of base supplementation is one of the major roles of dialysis. In conclusion, learning about the art and the science of fashioning haemodialysates is one of the best ways to further the understanding of the pathophysiologic processes underlying myriad acid-base, fluid, electrolyte as well as blood pressure abnormalities of the uraemic patient on maintenance haemodialysis.
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Affiliation(s)
- Carlo Basile
- Division of Nephrology , Miulli General Hospital , Acquaviva delle Fonti , Italy
| | - Carlo Lomonte
- Division of Nephrology , Miulli General Hospital , Acquaviva delle Fonti , Italy
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17
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Mc Causland FR, Waikar SS. Association of Predialysis Calculated Plasma Osmolarity With Intradialytic Blood Pressure Decline. Am J Kidney Dis 2015; 66:499-506. [PMID: 25975966 DOI: 10.1053/j.ajkd.2015.03.028] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 03/06/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND The rapid reduction in plasma osmolality during hemodialysis (HD) may induce temporary gradients that promote the movement of water from the extracellular to the intracellular compartment, predisposing to the development of intradialytic hypotension (IDH). STUDY DESIGN Observational cohort study. SETTING & PARTICIPANTS 3,142 prevalent patients receiving thrice-weekly HD from a single dialysis provider organization. PREDICTOR Predialysis calculated plasma osmolarity (calculated after the 2-day interval as 2 × serum sodium + serum urea nitrogen/2.8 + serum glucose/18). OUTCOME Magnitude of systolic blood pressure (SBP) decline (predialysis SBP - nadir intradialytic SBP) and risk of IDH (SBP decline > 35 or nadir SBP < 90 mm Hg). MEASUREMENTS Unadjusted and multivariable-adjusted generalized linear models were fit to estimate the association of calculated osmolarity with intradialytic SBP decline and the odds of developing IDH. RESULTS Mean age of participants was 62.6±15.2 (SD) years, 57.1% were men, and 61.0% had diabetes. Mean predialysis calculated osmolarity during follow-up was 306.4 ± 9.5 mOsm/L. After case-mix adjustment, each 10-mOsm/L increase in predialysis calculated osmolarity was associated with 1.48 (95% CI, 0.86-2.09) mm Hg (P < 0.001) greater decline in intradialytic SBP and 10% greater odds of IDH (OR, 1.10; 95% CI, 1.05-1.15). In adjusted models, lower predialysis sodium and higher serum urea nitrogen and serum glucose levels were associated with greater decline in intradialytic SBP. LIMITATIONS Measured serum osmolality, timing of changes in intradialytic osmolality, dialysate osmolality, and dialysate temperature were not available. CONCLUSIONS Higher predialysis calculated osmolarity is associated with greater decline in intradialytic SBP and greater risk of IDH in maintenance HD patients. Strategies to minimize rapid shifts in osmolality should be tested prospectively to minimize excess SBP decline in susceptible patients.
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Affiliation(s)
- Finnian R Mc Causland
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Sushrut S Waikar
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
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18
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Saikumar JH, Kovesdy CP. Bicarbonate Therapy in End-Stage Renal Disease: Current Practice Trends and Implications. Semin Dial 2015; 28:370-6. [PMID: 25845518 DOI: 10.1111/sdi.12373] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Management of metabolic acidosis covers the entire spectrum from oral bicarbonate therapy and dietary modifications in chronic kidney disease to delivery of high doses of bicarbonate-based dialysate during maintenance haemodialysis (MHD). Due to the gradual depletion of the body's buffers and rapid repletion during MHD, many potential problems arise as a result of our current treatment paradigms. Several studies have given rise to conflicting data about the adverse effects of our current practice patterns in MHD. In this review, we will describe the pathophysiology and consequences of metabolic acidosis and its therapy in CKD and ESRD, and discuss current evidence supporting a more individualized approach for bicarbonate therapy in MHD.
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Affiliation(s)
- Jagannath H Saikumar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee.,Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee
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19
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Beladi Mousavi SS, Tamadon MR. Vasopressin and prevention of hypotension during hemodialysis. IRANIAN RED CRESCENT MEDICAL JOURNAL 2014; 16:e20219. [PMID: 25763221 PMCID: PMC4329956 DOI: 10.5812/ircmj.20219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Revised: 07/12/2014] [Accepted: 09/23/2014] [Indexed: 11/16/2022]
Abstract
CONTEXT The occurrence of intradialytic hypotension (IDH) during hemodialysis (HD) continues to be a main problem in patients with ESRD (end-stage kidney disease). It also negatively affects health-related quality of life. We aimed to determine vasopressin effect in decreasing IDH. EVIDENCE ACQUISITION We reviewed clinical and experimental literature in a variety of sources, including PubMed, Current Content, Scopus, Embase, and Iranmedex regarding the possible effect of vasopressin administration in prevention of hypotension during HD to clarify its mechanism, efficacy, and safety. RESULTS Although arginine vasopressin is widely recognized for its anti-diuretic properties, it is also a well-recognized vasoconstrictor. It has been shown that the vasopressin release (as it would normally be expected) does not increase in the majority of HD patients with recurrent dialysis hypotension. In addition, it has also been reported that vasopressin secretion (due to the osmotic stimulation) is the most important mechanism in blood pressure control in ESRD patients receiving hypertonic solution for IDH. Therefore, it is suggested that vasopressin administration may improve hemodynamic stability among ESRD patients during HD. There are few clinical trials about this issue, suggesting that administration of exogenous vasopressin may be significantly associated with a decreased incidence of IDH as well as cardiovascular stability in ESRD patients in need of volume removal during HD. CONCLUSIONS Vasopressin insufficiency may have an important role in the pathogenesis of hemodynamic instability during HD and administration of exogenous vasopressin is significantly associated with a lower incidence of IDH.
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Affiliation(s)
| | - Mohamad Reza Tamadon
- Department of Internal Medicine, Faculty of Medicine, Semnan University of Medical Sciences, Semnan, IR Iran
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20
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Courivaud C, Davenport A. Measurement and Interpretation of Serum Sodium in End-Stage Kidney Disease Patients. Semin Dial 2014; 27:542-4. [DOI: 10.1111/sdi.12265] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Cecile Courivaud
- Department of Nephrology; Dialysis and Renal Transplantation Besançon University Hospital; Besancon France
| | - Andrew Davenport
- Centre for Nephrology; Royal Free Hospital; University College London Medical School; London United Kingdom
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21
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Silva BC, Freitas GR, Silva VB, Abensur H, Luders C, Pereira BJ, de Oliveira RB, Castro MC, Moysés RM, Elias RM. Hemodynamic Behavior During Hemodialysis: Effects of Dialysate Concentrations of Bicarbonate and Potassium. ACTA ACUST UNITED AC 2014; 39:490-6. [DOI: 10.1159/000368459] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2014] [Indexed: 11/19/2022]
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22
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Wańkowicz Z. The role of technological progress vs. accidental discoveries and clinical experience. Med Sci Monit 2013; 19:984-92. [PMID: 24226207 PMCID: PMC3843571 DOI: 10.12659/msm.889710] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
The 50th anniversary of dialysotherapy celebrated by nephrologists around the world in 2012 provided an opportunity for discussion on the role of clinical experience in relation to technological progress in the evolution of dialysis, especially of recently observed inadequate decrease in mortality/morbidity rates of patients on chronic dialysis. My report, based on almost 50 years of career in nephrology, refers the evolution of dialysis, from catharsis to modern dialysotherapy with special attention devoted to nowadays gravely underestimated role of clinical experience and personalized professional care for patients.
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Analytical solution of multicompartment solute kinetics for hemodialysis. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2013; 2013:654726. [PMID: 24307914 PMCID: PMC3836297 DOI: 10.1155/2013/654726] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 08/05/2013] [Accepted: 08/26/2013] [Indexed: 11/26/2022]
Abstract
Objective. To provide an exact solution for variable-volume multicompartment kinetic models with linear volume change, and to apply this solution to a 4-compartment diffusion-adjusted regional blood flow model for both urea and creatinine kinetics in hemodialysis. Methods. A matrix-based approach applicable to linear models encompassing any number of compartments is presented. The procedure requires the inversion of a square matrix and the computation of its eigenvalues λ, assuming they are all distinct. This novel approach bypasses the evaluation of the definite integral to solve the inhomogeneous ordinary differential equation. Results. For urea two out of four eigenvalues describing the changes of concentrations in time are about 105 times larger than the other eigenvalues indicating that the 4-compartment model essentially reduces to the 2-compartment regional blood flow model. In case of creatinine, however, the distribution of eigenvalues is more balanced (a factor of 102 between the largest and the smallest eigenvalue) indicating that all four compartments contribute to creatinine kinetics in hemodialysis. Interpretation. Apart from providing an exact analytic solution for practical applications such as the identification of relevant model and treatment parameters, the matrix-based approach reveals characteristic details on model symmetry and complexity for different solutes.
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Mc Causland FR, Brunelli SM, Waikar SS. Dialysis dose and intradialytic hypotension: results from the HEMO study. Am J Nephrol 2013; 38:388-96. [PMID: 24192428 DOI: 10.1159/000355958] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 09/20/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND Intradialytic hypotension (IDH) is common and is associated with increased morbidity and mortality in chronic hemodialysis patients. A higher dialysis 'dose' may generate transient intradialytic osmotic gradients, predisposing to intracellular fluid shifts and resulting in hypotension. STUDY DESIGN We performed a post hoc analysis of the HEMO study, a multicenter trial that randomized chronic hemodialysis patients to high versus standard Kt/V and higher versus lower membrane flux. In order to achieve dose targets, per protocol, adjustments were made in membrane efficiency, blood flow or dialysate flow before changing session length. Detailed hemodynamic and urea kinetic modeling data were abstracted from 1,825 individuals. The primary outcome was the occurrence of hypotensive events necessitating clinical intervention (saline infusion, lowering of ultrafiltration rate or reduced blood flow). RESULTS Intradialytic hypotensive events occurred more frequently in the higher-Kt/V group (18.3 vs. 16.8%; p < 0.001). Participants randomized to higher-target Kt/V had a greater adjusted risk of IDH than those randomized to standard Kt/V [odds ratio (OR) 1.12; 95% confidence interval (CI) 1.01-1.25]. Higher vs. lower dialyzer mass transfer-area coefficient for urea and rate of urea removal were associated with greater adjusted odds of IDH (OR 1.15; 95% CI 1.04-1.27 and OR 1.05; 95% CI 1.04-1.06 per mg/dl/h, respectively). CONCLUSIONS Higher dialysis dose, at relatively constrained treatment times, may associate with an increased risk of IDH. These findings support the possibility that rapidity of intradialytic reductions in plasma osmolality may play an important role in mediating hemodynamic instability during dialysis.
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Tentori F, Karaboyas A, Robinson BM, Morgenstern H, Zhang J, Sen A, Ikizler TA, Rayner H, Fissell RB, Vanholder R, Tomo T, Port FK. Association of dialysate bicarbonate concentration with mortality in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 2013; 62:738-46. [PMID: 23707043 PMCID: PMC3832240 DOI: 10.1053/j.ajkd.2013.03.035] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 03/21/2013] [Indexed: 11/11/2022]
Abstract
BACKGROUND Most hemodialysis patients worldwide are treated with bicarbonate dialysis using sodium bicarbonate as the base. Few studies have assessed outcomes of patients treated with different dialysate bicarbonate levels, and the optimal concentration remains uncertain. STUDY DESIGN The Dialysis Outcomes and Practice Patterns Study (DOPPS) is an international prospective cohort study. SETTING & PARTICIPANTS This study included 17,031 patients receiving thrice-weekly in-center hemodialysis from 11 DOPPS countries (2002-2011). PREDICTOR Dialysate bicarbonate concentration. OUTCOMES All-cause and cause-specific mortality and first hospitalization, using Cox regression to estimate the effects of dialysate bicarbonate concentration, adjusting for potential confounders. MEASUREMENTS Demographics, comorbid conditions, laboratory values, and prescriptions were abstracted from medical records. RESULTS Mean dialysate bicarbonate concentration was 35.5 ± 2.7 (SD) mEq/L, ranging from 32.2 ± 2.3 mEq/L in Germany to 37.0 ± 2.6 mEq/L in the United States. Prescription of high dialysate bicarbonate concentration (≥38 mEq/L) was most common in the United States (45% of patients). Approximately 50% of DOPPS facilities used a single dialysate bicarbonate concentration. 3,913 patients (23%) died during follow-up. Dialysate bicarbonate concentration was associated positively with mortality (adjusted HR, 1.08 per 4 mEq/L higher [95% CI, 1.01-1.15]; HR for dialysate bicarbonate ≥38 vs 33-37 mEq/L, 1.07 [95% CI, 0.97-1.19]). Results were consistent across levels of pre-dialysis session serum bicarbonate and between facilities that used a single dialysate bicarbonate concentration and those that prescribed different concentrations to individual patients. The association of dialysis bicarbonate concentration with mortality was stronger in patients with longer dialysis vintage. LIMITATIONS Due to the observational nature of the present study, we cannot rule out that the reported associations may be biased by unmeasured confounders. CONCLUSIONS High dialysate bicarbonate concentrations, especially prolonged exposure, may contribute to adverse outcomes, likely through the development of postdialysis metabolic alkalosis. Additional studies are warranted to identify the optimal dialysate bicarbonate concentration.
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Affiliation(s)
- Francesca Tentori
- Arbor Research Collaborative for Health, Ann Arbor, MI; Vanderbilt University Medical Center, Nashville, TN.
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Abeleda KL, Bennett PN, Ockerby C. Standardising dialysate potassium does not increase patient risk. J Ren Care 2013; 39:151-6. [PMID: 23902229 DOI: 10.1111/j.1755-6686.2013.12024.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Rapid intradialytic potassium shifts during haemodialysis have been associated with increased mortality and morbidity. Standardising dialysate potassium to 2 mmol/l may decrease the potassium shift. OBJECTIVE To examine the effect of standardising dialysate potassium to 2 mmol/l for all chronic dialysis treatments. DESIGN Pre- and post-intervention comparison of monthly serum potassium. PARTICIPANTS Ninety-seven individuals, of whom 56 patients could be matched across both data collection periods. METHODS Serum potassium data were categorised based on a target range 3.5-6.0 mmol/l. Overall pre- and post-intervention mean scores were compared using a paired samples t-test. Data for patients routinely prescribed dialysate potassium 1 mmol/l pre-intervention (n = 6) underwent paired samples t-test to compare their mean serum potassium pre- and post-intervention. RESULTS There was no statistically significant change in serum potassium post-intervention. The majority of patients remained within the target range, including the subset of patients who had a history of high serum potassium during the pre-intervention period. CONCLUSIONS A standard potassium dialysate of 2 mmol/l may reduce intradialytic serum potassium shifts and may assist in standardising safer work practices.
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Mc Causland FR, Waikar SS, Brunelli SM. The relevance of dietary sodium in hemodialysis. Nephrol Dial Transplant 2012; 28:797-802. [PMID: 23129821 DOI: 10.1093/ndt/gfs452] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Since the earliest days of hemodialysis, dietary sodium restriction has been recommended as a therapeutic means to mitigate problems of extracellular volume overload, hypertension and inter-dialytic weight gain. Recently, there has been a proliferation of human subjects' research examining the potential effects of dietary sodium curtailment. Herein we examine the available evidence with respect to the effects of dietary sodium restriction on clinically relevant endpoints among hemodialysis patients.
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Affiliation(s)
- Finnian R Mc Causland
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Shah A, Davenport A. Does a reduction in dialysate sodium improve blood pressure control in haemodialysis patients? Nephrology (Carlton) 2012; 17:358-63. [PMID: 22300276 DOI: 10.1111/j.1440-1797.2012.01576.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION There has been debate as to the value of lower sodium dialysates to control blood pressure in haemodialysis patients, as sodium is predominantly removed by ultrafiltration. METHODS Re-audit of clinical practice following reduction in dialysate sodium concentration. RESULTS Overall dialysate sodium concentration decreased from 138.9 ± 1.7 to 137.8 ± 1.7 mmol/L (mean ± standard deviation), resulting in a reduction in pre- and post-dialysis mean arterial pressure (MAP) of 4 mmHg (from 100.6 ± 15.6 to 97.1 ± 15.6, P < 0.01 and from 91.7 ± 15.6 to 87.1 ± 14.6, P < 0.001 respectively), yet fewer patients were prescribed antihypertensives (49.6 vs 60.6%), and less antihypertensive medications/patient (mean 0.86 vs 1.05), ultrafiltration requirements (2.8% vs 3.2% body weight, P < 0.001), and symptomatic intradialytic hypotension (0.19 vs 0.28 episodes per week, P < 0.001). A multivariable model showed that for a dialysate sodium of 136 mmol/L, younger patients had higher MAP than older patients (0.35 mmHg lower MAP/year older; but with a dialysate sodium of 140 mmol/L, there was minimal association of MAP with age (0.07 mmHg higher MAP/year older). CONCLUSION Change in clinical practice, amounting to a modest reduction in dialysate sodium was associated with a reduction not only in pre- and post-dialysis blood pressures, but also ultrafiltration requirements and symptomatic intradialytic hypotension. However, this effect on blood pressure was most marked for older patients and women, within minimal effects for younger patients, and lesser effects for men, suggesting that dialysate sodium reduction alone may help improve blood pressure control, but requires additional factors such as dietary sodium restriction to be effective in younger male patients.
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Affiliation(s)
- Anoop Shah
- Centre for Nephrology, Royal Free Hospital, University College London Medical School, London, UK
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Locatelli F, Stefoni S, Petitclerc T, Colì L, Di Filippo S, Andrulli S, Fumeron C, Frascà GM, Sagripanti S, Savoldi S, Serra A, Stallone C, Aucella F, Gesuete A, Scarlatella A, Quarello F, Mesiano P, Ahrenholz P, Winkler R, Mandart L, Fort J, Tielemans C, Navino C. Effect of a plasma sodium biofeedback system applied to HFR on the intradialytic cardiovascular stability. Results from a randomized controlled study. Nephrol Dial Transplant 2012; 27:3935-42. [PMID: 22561583 PMCID: PMC3484730 DOI: 10.1093/ndt/gfs091] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Intradialytic hypotension (IDH) is still a major clinical problem for haemodialysis (HD) patients. Haemodiafiltration (HDF) has been shown to be able to reduce the incidence of IDH. Methods Fifty patients were enrolled in a prospective, randomized, crossover international study focussed on a variant of traditional HDF, haemofiltration with endogenous reinfusion (HFR). After a 1-month run-in period on HFR, the patients were randomized to two treatments of 2 months duration: HFR (Period A) or HFR-Aequilibrium (Period B), followed by a 1-month HFR wash-out period and then switched to the other treatment. HFR-Aequilibrium (HFR-Aeq) is an evolution of the haemofiltration with endogenous reinfusion (HFR) dialysis therapy, with dialysate sodium concentration and ultrafiltration rate profiles elaborated by an automated procedure. The primary end point was the frequency of IDH. Results Symptomatic hypotension episodes were significantly lower on HFR-Aeq versus HFR (23 ± 3 versus 31 ± 4% of sessions, respectively, P l= l0.03), as was the per cent of clinical interventions (17 ± 3% of sessions with almost one intervention on HFR-Aeq versus 22 ± 2% on HFR, P <0.01). In a post-hoc analysis, the effect of HFR-Aeq was greater on more unstable patients (35 ± 3% of sessions with hypotension on HFR-Aeq versus 71 ± 3% on HFR, P <0.001). No clinical or biochemical signs of Na/water overload were registered during the treatment with HFR-Aeq. Conclusions HFR-Aeq, a profiled dialysis supported by the Natrium sensor for the pre-dialysis Na+ measure, can significantly reduce the burden of IDH. This could have an important impact in every day dialysis practice.
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Affiliation(s)
- Francesco Locatelli
- Department of Nephrology, Dialysis and Renal Transplant, Alessandro Manzoni Hospital, Lecco, Italy.
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Vanholder R. The ultimate salt war? Uraemic toxins are all that count in dialysis patients. Nephrol Dial Transplant 2012; 27:62-6. [DOI: 10.1093/ndt/gfr637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Mc Causland FR, Tilley BS, Waikar SS. Dialysate Sodium and the Milieu Intérieur. Clin J Am Soc Nephrol 2011; 7:5-7. [DOI: 10.2215/cjn.12101111] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Stockinger J, Ribitsch W, Schneditz D. Volume excess in chronic haemodialysis patients--effects of treatment frequency and treatment spacing. Nephrol Dial Transplant 2011; 28:170-5. [PMID: 22167596 DOI: 10.1093/ndt/gfr673] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The main objective of this study was to theoretically quantify the fluctuations of fluid volume excess for different modes of intermittent ultrafiltration schedules and to compare the prediction for the typical and asymmetric thrice-weekly schedule to clinical, physiological and biophysical markers of volume expansion in a group of stable haemodialysis patients. METHODS Overall volume excess (V(OVE)) was described as the sum of a time-independent (V(0)) and a time-dependent component (V). An exact relationship was developed to relate V to variable treatment frequency, treatment spacing and net volume accumulation rate. In a single-centre haemodialysis population, body mass profiling was combined with volume state evaluation by bioimpedance analysis, N-terminal pro-B-type natriuretic peptide (NT-pro BNP) levels, clinical signs, a volume questionnaire and blood pressure levels. RESULTS In 23 patients following the typical thrice-weekly schedule, the time-averaged volume excess (V) during the whole week (1.1 ± 0.5 L) was significantly larger than that during the midweek interval (0.9 ± 0.4 L) (P < 0.002) by a factor comparable to that of 1.21 obtained from the theoretical analysis. V(OVE) was 1.3 ± 1.7 L and significantly related to pre- (P < 0.001) and post-dialysis levels of NT-pro BNP (P < 0.001). CONCLUSION Asymmetric treatment spacing such as with the typical thrice-weekly treatment schedule leads to a significant increase in time-averaged volume excess. The theoretical analysis allows for comparison of time-averaged volume excess in treatments varying with regard to treatment frequency and regularity and could be helpful to prescribe post-treatment volume (target weight) for such variable treatment modes.
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Affiliation(s)
- Jakob Stockinger
- Institute of Physiology, Medical University of Graz, Graz, Austria
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Javed F, Savkin AV, Chan GSH, Mackie JD, Lovell NH. Recent advances in the monitoring and control of haemodynamic variables during haemodialysis: a review. Physiol Meas 2011; 33:R1-R31. [DOI: 10.1088/0967-3334/33/1/r1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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35
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Colì L, La Manna G, Comai G, Ursino M, Ricci D, Piccari M, Locatelli F, Di Filippo S, Cristinelli L, Bacchi M, Balducci A, Aucella F, Panichi V, Ferrandello FP, Tarchini R, Lambertini D, Mura C, Marinangeli G, Di Loreto E, Quarello F, Forneris G, Tancredi M, Morosetti M, Palombo G, Di Luca M, Martello M, Emiliani G, Bellazzi R, Stefoni S. Automatic Adaptive System Dialysis for Hemodialysis-Associated Hypotension and Intolerance: A Noncontrolled Multicenter Trial. Am J Kidney Dis 2011; 58:93-100. [DOI: 10.1053/j.ajkd.2011.01.030] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2010] [Accepted: 02/27/2011] [Indexed: 11/11/2022]
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Gabutti L, Salvadé I, Lucchini B, Soldini D, Burnier M. Haemodynamic consequences of changing potassium concentrations in haemodialysis fluids. BMC Nephrol 2011; 12:14. [PMID: 21470404 PMCID: PMC3079606 DOI: 10.1186/1471-2369-12-14] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Accepted: 04/06/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A rapid decrease of serum potassium concentrations during haemodialysis produces a significant increase in blood pressure parameters at the end of the session, even if effects on intra-dialysis pressure are not seen. Paradoxically, in animal models potassium is a vasodilator and decreases myocardial contractility. The purpose of this trial is to study the precise haemodynamic consequences induced by acute changes in potassium concentration during haemodialysis. METHODS In 24 patients, 288 dialysis sessions, using a randomised single blind crossover design, we compared six dialysate sequences with different potassium profiles. The dialysis sessions were divided into 3 tertiles, casually modulating potassium concentration in the dialysate between the value normally used K and the two cut-off points K+1 and K-1 mmol/l. Haemodynamics were evaluated in a non-invasive manner using a finger beat-to-beat monitor. RESULTS Comparing K-1 and K+1, differences were found within the tertiles regarding systolic (+5.3, +6.6, +2.3 mmHg, p < 0.05, < 0.05, ns) and mean blood pressure (+4.3, +6.4, -0.5 mmHg, p < 0.01, < 0.01, ns), as well as peripheral resistance (+212, +253, -4 dyne.sec.cm-5, p < 0.05, < 0.05, ns). The stroke volume showed a non-statistically-significant inverse trend (-3.1, -5.2, -0.2 ml). 18 hypotension episodes were recorded during the course of the study. 72% with K-1, 11% with K and 17% with K+1 (p < 0.01 for comparison K-1 vs. K and K-1 vs. K+1). CONCLUSIONS A rapid decrease in the concentration of serum potassium during the initial stage of the dialysis-obtained by reducing the concentration of potassium in the dialysate-translated into a decrease of systolic and mean blood pressure mediated by a decrease in peripheral resistance. The risk of intra-dialysis hypotension inversely correlates to the potassium concentration in the dialysate. TRIAL REGISTRATION NUMBER NCT01224314.
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Affiliation(s)
- Luca Gabutti
- Division of Nephrology, Ospedale Carità, Via Ospedale, 6600 Locarno, Switzerland.
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37
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LeBoeuf A, Mac-Way F, Utescu MS, De Serres SA, Douville P, Desmeules S, Lebel M, Agharazii M. Impact of dialysate calcium concentration on the progression of aortic stiffness in patients on haemodialysis. Nephrol Dial Transplant 2011; 26:3695-701. [DOI: 10.1093/ndt/gfr138] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Urea kinetics and intermittent dialysis prescription in small animals. Vet Clin North Am Small Anim Pract 2011; 41:193-225. [PMID: 21251518 DOI: 10.1016/j.cvsm.2010.12.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Hemodialysis improves survival for animals with acute kidney injury beyond what would be expected with conventional management of the same animals. Clinical evidence and experience in human patients suggest a role for earlier intervention with renal replacement to avoid the morbidity of uremia and to promote better metabolic stability and recovery. For a large population of animal patients, it is the advanced standard for the management of acute and chronic uremia, life-threatening poisoning, and fluid overload for which there is no alternative therapy.
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Abstract
Intradialytic hypertension is not a rare complication of dialysis, with a prevalence of 5-15% among hemodialysis patients, and it seems to be associated with adverse outcomes. This complex phenomenon is not well understood, and many uncertainties exist regarding its pathophysiologic mechanisms and appropriate treatment strategies. Mechanisms that might be involved in the pathogenesis of intradialytic hypertension include extracellular volume overload, increased cardiac output, changes in electrolyte levels (particularly sodium), activation of the renin-angiotensin-aldosterone system, overactivity of the sympathetic nervous system, and endothelial cell dysfunction. Most current treatment strategies are based only on expert opinion and not on the results of randomized clinical trials, as very little data on the therapy of intradialytic hypertension are available. The most important treatment is adequate sodium and water removal, but reducing sympathetic hyperactivity and reducing endothelin-1 levels should also be considered. Well-designed, randomized clinical trials are urgently needed to better understand the pathophysiologic mechanisms of this complex phenomenon and to improve its diagnosis, prognosis and treatment.
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Affiliation(s)
- Francesco Locatelli
- Department of Nephrology, Dialysis and Renal Transplant, Alessandro Manzoni Hospital, Via dell'Eremo 9/11, 23900 Lecco, Italy.
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40
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The Artificial Kidney. Artif Organs 2009. [DOI: 10.1007/978-1-84882-283-2_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Gabutti L, Bianchi G, Soldini D, Marone C, Burnier M. Haemodynamic consequences of changing bicarbonate and calcium concentrations in haemodialysis fluids. Nephrol Dial Transplant 2008; 24:973-81. [PMID: 18842671 PMCID: PMC2644633 DOI: 10.1093/ndt/gfn541] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background. In a previous study we demonstrated that mild metabolic alkalosis resulting from standard bicarbonate haemodialysis induces hypotension. In this study, we have further investigated the changes in systemic haemodynamics induced by bicarbonate and calcium, using non-invasive procedures. Methods. In a randomized controlled trial with a single-blind, crossover design, we sequentially changed the dialysate bicarbonate and calcium concentrations (between 26 and 35 mmol/l for bicarbonate and either 1.25 or 1.50 mmol/l for calcium). Twenty-one patients were enrolled for a total of 756 dialysis sessions. Systemic haemodynamics was evaluated using pulse wave analysers. Bioimpedance and BNP were used to compare the fluid status pattern. Results. The haemodynamic parameters and the pre-dialysis BNP using either a high calcium or bicarbonate concentration were as follows: systolic blood pressure (+5.6 and −4.7 mmHg; P < 0.05 for both), stroke volume (+12.3 and +5.2 ml; P < 0.05 and ns), peripheral resistances (−190 and −171 dyne s cm−5; P < 0.05 for both), central augmentation index (+1.1% and −2.9%; ns and P < 0.05) and BNP (−5 and −170 ng/l; ns and P < 0.05). The need of staff intervention was similar in all modalities. Conclusions. Both high bicarbonate and calcium concentrations in the dialysate improve the haemodynamic pattern during dialysis. Bicarbonate reduces arterial stiffness and ameliorates the heart tolerance for volume overload in the interdialytic phase, whereas calcium directly increases stroke volume. The slight hypotensive effect of alkalaemia should motivate a probative reduction of bicarbonate concentration in dialysis fluid for haemodynamic reasons, only in the event of failure of classical tools to prevent intradialytic hypotension.
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Affiliation(s)
- Luca Gabutti
- Division of Nephrology, Ospedale la Carità, Locarno, Switzerland.
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ROSENBAUM BP, ASH SR, WONG RJ, THOMPSON RP, CARR DJ. Prediction of hemodialysis sorbent cartridge urea nitrogen capacity and sodium release from in vitro tests. Hemodial Int 2008; 12:244-53. [DOI: 10.1111/j.1542-4758.2008.00261.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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43
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Flanigan MJ. Opinion: How Should Dialysis Fluid Be Individualized for the Chronic Hemodialysis Patient? Semin Dial 2008; 21:226-9. [DOI: 10.1111/j.1525-139x.2008.00428.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Santos SFF, Peixoto AJ. Revisiting the dialysate sodium prescription as a tool for better blood pressure and interdialytic weight gain management in hemodialysis patients. Clin J Am Soc Nephrol 2008; 3:522-30. [PMID: 18199846 PMCID: PMC6631087 DOI: 10.2215/cjn.03360807] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Hypertension and chronic volume overload are complications often seen in hemodialysis patients. Current hemodialysis practices adopt a standard dialysate sodium prescription that is typically higher than the plasma sodium concentration of most patients. As a general rule, hemodialysis patients have stable predialysis plasma sodium concentrations, and each patient has a fixed "osmolar set point." Hypertonic dialysate sodium prescriptions, including sodium modeling, predispose to positive sodium balance and lead to higher blood pressure and increased interdialytic weight gain. Conversely, lowering or individualizing dialysate sodium reduces thirst, interdialytic weight gain, and blood pressure in non-hypotension prone dialysis patients. Optimization of the dialysate sodium prescription is an important step in achieving sodium balance and improving blood pressure control in hypertensive hemodialysis patients.
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Affiliation(s)
- Sergio F. F. Santos
- Division of Nephrology, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil; and
| | - Aldo J. Peixoto
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut and Medical Service and Renal Section, VA Connecticut Healthcare System, West Haven, Connecticut
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MOLINA VILA P, SÁNCHEZ PÉREZ P, GARRIGÓS ALMERICH E, PERIS DOMINGO A. Marked improvement in bone metabolism parameters after increasing the dialysate calcium concentration from 2.5 to 3 mEq/L in nonhypercalcemic hemodialysis patients. Hemodial Int 2008; 12:73-9. [DOI: 10.1111/j.1542-4758.2008.00244.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Scholze A, Jankowski V, Henning L, Haass W, Wittstock A, Suvd-Erdene S, Zidek W, Tepel M, Jankowski J. Phenylacetic acid and arterial vascular properties in patients with chronic kidney disease stage 5 on hemodialysis therapy. Nephron Clin Pract 2007; 107:c1-6. [PMID: 17622769 DOI: 10.1159/000105137] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2006] [Accepted: 03/20/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Phenylacetic acid (PAA) is a recently described uremic toxin that inhibits inducible nitric oxide synthase expression and plasma membrane calcium ATPase and may therefore also be involved in remodeling of arteries. Such vascular effects have not been evaluated yet in patients with chronic kidney disease stage 5. METHOD We prospectively measured the plasma concentrations of PAA using nuclear magnetic resonance spectroscopy in 50 patients with chronic kidney disease stage 5 (37 men, 13 women) on maintenance hemodialysis. Arterial vascular properties were quantified by the reflective index obtained from digital photoplethysmography. RESULTS During the hemodialysis session the plasma PAA concentration was reduced from 3.38 +/- 0.24 mmol/l (mean +/- SEM; median, 2.85 mmol/l; interquartile range, 2.02-4.52 mmol/l) to 2.25 +/- 0.11 mmol/l (median, 2.06 mmol/l; interquartile range, 1.62-2.86 mmol/l; n = 50; p < 0.001). There was a significant correlation between the PAA concentration and the reflective index before the start of the hemodialysis session. CONCLUSION The study demonstrates an association of PAA and arterial vascular properties in patients with chronic kidney disease stage 5.
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Affiliation(s)
- Alexandra Scholze
- Medizinische Klinik IV, Nephrologie, Charité Campus Benjamin Franklin, Berlin, Germany
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Abstract
Dialysis fluid is produced by the blending of treated water with electrolytes at the patients bed side. Its preparation and composition are important elements of treatment optimisation since many of the constituents play a role in patient well-being. Ideally the composition of the dialysis fluid should match that of plasma, but due to differences between patients, as well as the increasing number of elderly patients receiving treatment, have resulted in a move towards individualisation of the electrolyte and buffer composition to patient needs. Such individualisation is facilitated by the availability of technology, however it is not yet possible to individualise minor electrolytes, such as K(+), Ca(2+) and Mg(2+). Early dialysis treatments were frequently accompanied by pyrogen reactions arising from bacterial contamination of the dialysis fluid. Today the focus is on the stimulation of mononuclear cells by bacterial fragments contributing to chronic inflammation associated with long-term haemodialysis therapy, and which has led to suggestions regarding the desirability of using ultra-pure dialysis fluid to prevent or to delay complications associated with their presence.
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Affiliation(s)
- Nicholas A Hoenich
- School of Clinical Medical Sciences, Newcastle University, Framlington Place, Newcastle upon Tyne NE2 4HH, UK.
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48
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Abstract
The dialysate calcium (Ca) concentration for hemodialysis (HD) patients can be adjusted to manage more optimally the body's Ca and phosphate balance, and thus improve bone metabolism as well as reduce accelerated arteriosclerosis and cardiovascular mortality. The appropriate dialysate Ca concentration allowing this balance should be prescribed to each individual patient depending on a multitude of variable factors relating to Ca load. A lower dialysate Ca concentration of 1.25 to 1.3 mmol/L will permit the use of vitamin D supplements and Ca-based phosphate binders in clinical practice, with much less risk of Ca loading and resultant hypercalcemia and calcification. Low Ca baths are useful in the setting of adynamic bone disease where an increase in bone turnover is required. However, low Ca levels in the dialysate may also predispose to cardiac arrhythmias and hemodynamically unstable dialysis sessions with intradialytic hypotension. Higher Ca dialysate is useful to sustain normal serum Ca levels where patients are not taking Ca-based binders or if Ca supplements are not able to normalize serum levels. Suppression of hyperparathyroidism is also effective with dialysate Ca of 1.75 mmol/L, but hypercalcemia, metastatic calcification, and oversuppression of parathyroid hormone are risks. Dialysate Ca of 1.5 mmol/L may be a compromise between bone protection and reduction in cardiovascular risk for conventional HD and is a common concentration used throughout the world. The increase in longer, more frequent dialysis such as short-daily and nocturnal HD, however, provides another challenge with regard to optimal dialysate Ca levels and higher levels of 1.75 mmol/L are probably indicated in this setting. Difficulties in determining the ideal dialysate Ca occur because of the complex pathophysiology of bone and mineral metabolism in HD patients and there needs to be a balance between dialysis prescription and other treatment modalities. To optimize management of the abnormal Ca balance, other aspects of this disorder need to be more fully clarified and, with evolving medications for phosphate control and treatment of secondary hyperparathyroidism, as well as the emergence of a multitude of different HD regimes, further studies are required to make definitive recommendations. At present, we need to maintain flexibility with HD treatments and so dialysate Ca needs to be individualized to meet the specific requirements of patients by optimizing management of renal bone disease and simultaneously reducing metastatic calcification and cardiovascular disease.
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Affiliation(s)
- Nigel Toussaint
- Department of Nephrology, Monash Medical Centre, Clayton, Vic., Australia
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Sam R, Vaseemuddin M, Leong WH, Rogers BE, Kjellstrand CM, Ing TS. Composition and clinical use of hemodialysates. Hemodial Int 2006; 10:15-28. [PMID: 16441823 DOI: 10.1111/j.1542-4758.2006.01170.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A thorough knowledge and understanding of the principles underlying the preparation and the clinical application of hemodialysates can help us provide exemplary patient care to individuals having end-stage renal disease. It is prudent to be conversant with the following: (a) how each ingredient in a dialysate works, (b) the clinical circumstances under which the concentration of an ingredient can be altered, and (c) the special situations in which unconventional ingredients can be introduced into a dialysate. The potential to enrich dialysates with appropriate ingredients (such as iron compounds) is limited only by the boundaries of our imagination.
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Affiliation(s)
- Ramin Sam
- Department of Medicine, John H. Stroger Hospital of Cook County and School of Medicine, University of Illinois at Chicago, USA
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50
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Abstract
The value of bioimpedance in hemodialysis remains under debate. However, when appropriately used, bioimpedance can provide measures of body hydration characterized by a small error, a high sensitivity to changes in water volume, and, above all, a linear relationship over a wide range of volume changes. These features make it very useful to measure body hydration in hemodialysis patients.
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Affiliation(s)
- D Schneditz
- Institute of Physiology, Center for Physiologic Medicine, Medical University of Graz, Graz, Austria.
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