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Hu D, Krivitski NM, Salehpour F, Rivas L, Chahal Y, Aragon M. Active Circulating Blood Volume During Hemodialysis: A Bench Model. ASAIO J 2022; 68:972-977. [PMID: 35383581 DOI: 10.1097/mat.0000000000001709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Intradialytic hypotension due to excessive fluid removal is a common complication of hemodialysis. A bench model was constructed to evaluate quantification of active circulating blood volume (ACBV). The model included a central pump representing the heart and compartments to represent the central and peripheral circulation. A blood oxygenator was used to simulate lung volume and two containers represented fast and slow circulation compartments. A separate dialysis circuit with a blood pump and two ultrasound flow-dilution probes was incorporated. Vascular access was simulated with both a shunt (fistula or graft) and a central venous catheter. Hypertonic saline (5%) was circulated in the system. A bolus of isotonic saline was introduced in the dialysis circuit, which dispersed through the physiologic model. ACBV was measured by comparing the baseline dilution curve to the curve as it returned to the probes. To evaluate the sensitivity of this technique, we investigated changing cardiac output, central venous volume, shunt flow, vascular access type, and HD pump flow. Overall percentage error (mean ± SD) across all tests (n = 15 conditions, each in triplicate) was 2.6% ± 7.4%. This study demonstrates the ability to accurately measure ACBV on the bench.
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Affiliation(s)
- Dean Hu
- From the Outset Medical, San Jose, California
| | | | | | - Logan Rivas
- From the Outset Medical, San Jose, California
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2
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Davenport A. Peri-dialytic hypoglycaemia with haemodialysis and on-line post-dilutional haemodiafiltration. Ther Apher Dial 2022; 26:1148-1155. [PMID: 35261192 DOI: 10.1111/1744-9987.13835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/04/2022] [Accepted: 03/06/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION We wished to determine whether peri-dialytic hypoglycaemia is a clinical risk in contemporary dialysis patients using glucose containing dialysate. METHODS We measured blood glucose pre- and post-haemodialysis or haemodiafiltration, using 5.5 mmol/L glucose dialysate, and body composition by bioimpedance. RESULTS 239 patients were studied, mean age 65±15.4 years, 59.4% male, 46.4% diabetes, 81.6% treated by haemodiafiltration, Five haemodiafiltration patients (2.1%) had hypoglycaemia, with 82 (33%) a blood glucose <5.5 mmol/L, with fewer diabetics (19.8 vs 74.7%, p=0.001, and %body fat 27.7(20.6-32.6) vs 34.7(26.6-42.8)%, p=0.001. Low post-dialysis blood glucose was negatively associated with glycated haemoglobin (OR 0.94 (0.84-0.97), p=0.004), weight (OR 0.94 (0.89-0.98), p=0.009), and % body fat (OR 0.92 (0.86-0.98), p=0.013). CONCLUSIONS Although hypoglycaemia occurred in 2%, 33% had a blood glucose below dialysate glucose. Low post-dialysis glucose was associated with lower glycated haemoglobin and body fat, suggesting nutritional status is important in determining the risk of peri-dialytic hypoglycaemia.
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Affiliation(s)
- Andrew Davenport
- UCL Department of Renal Medicine Royal Free Hospital University College London Rowland Hill Street London NW3 2PF
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3
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Krenn S, Schmiedecker M, Schneditz D, Hödlmoser S, Mayer CC, Wassertheurer S, Omic H, Schernhammer E, Wabel P, Hecking M. Feasibility of Dialysate Bolus-Based Absolute Blood Volume Estimation in Maintenance Hemodialysis Patients. Front Med (Lausanne) 2022; 9:801089. [PMID: 35223900 PMCID: PMC8866453 DOI: 10.3389/fmed.2022.801089] [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: 10/24/2021] [Accepted: 01/04/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Absolute blood volume (ABV) is a critical component of fluid status, which may inform target weight prescriptions and hemodynamic vulnerability of dialysis patients. Here, we utilized the changes in relative blood volume (RBV), monitored by ultrasound (BVM) upon intradialytic 240 mL dialysate fluid bolus-infusion 1 h after hemodialysis start, to calculate the session-specific ABV. With the main goal of assessing clinical feasibility, our sub-aims were to (i) standardize the BVM-data read-out; (ii) determine optimal time-points for ABV-calculation, "before-" and "after-bolus"; (iii) assess ABV-variation. METHODS We used high-level programming language and basic descriptive statistics in a retrospective study of routinely measured BVM-data from 274 hemodialysis sessions in 98 patients. RESULTS Regarding (i) and (ii), we automatized the processing of RBV-data, and determined an algorithm to select the adequate RBV-data points for ABV-calculations. Regarding (iii), we found in 144 BVM-curves from 75 patients, that the average ABV ± standard deviation was 5.2 ± 1.5 L and that among those 51 patients who still had ≥2 valid estimates, the average intra-patient standard deviation in ABV was 0.8 L. Twenty-seven of these patients had an average intra-patient standard deviation in ABV <0.5 L. CONCLUSIONS We demonstrate feasibility of ABV-calculation by an automated algorithm after dialysate bolus-administration, based on the BVM-curve. Based on our results from this simple "abridged" calculation approach with routine clinical measurements, we encourage the use of multi-compartment modeling and comparison with reference methods of ABV-determination. Hopes are high that clinicians will be able to use ABV to inform target weight prescription, improving hemodynamic stability.
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Affiliation(s)
- Simon Krenn
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Epidemiology, Center for Public Health, Medical University of Vienna, Vienna, Austria.,AIT Austrian Institute of Technology, Center for Health & Bioresources, Medical Signal Analysis, Vienna, Austria
| | - Michael Schmiedecker
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Daniel Schneditz
- Division of Physiology, Otto Loewi Research Center, Medical University of Graz, Graz, Austria
| | - Sebastian Hödlmoser
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Epidemiology, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Christopher C Mayer
- AIT Austrian Institute of Technology, Center for Health & Bioresources, Medical Signal Analysis, Vienna, Austria
| | - Siegfried Wassertheurer
- AIT Austrian Institute of Technology, Center for Health & Bioresources, Medical Signal Analysis, Vienna, Austria
| | - Haris Omic
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Eva Schernhammer
- Department of Epidemiology, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | | | - Manfred Hecking
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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4
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Kron S, Schneditz D, Keane DF, Leimbach T, Kron J. An improved method to estimate absolute blood volume based on dialysate dilution. Artif Organs 2021; 45:E359-E363. [PMID: 33908065 DOI: 10.1111/aor.13970] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/09/2021] [Accepted: 04/12/2021] [Indexed: 12/01/2022]
Abstract
Online hemodiafiltration machines equipped with a blood volume monitor and the possibility to rapidly infuse exact amounts of ultrapure dialysate into the extracorporeal circulation can be used to determine absolute blood volume in clinical practice. The aim of the present study was to evaluate the reproducibility of such measurements. Intra-individual reproducibility was evaluated in four measurements taken in hourly intervals within the same dialysis treatment. Ten patients were studied. Absolute blood volumes measured at the beginning and after 1 hour of dialysis were significantly different (80.6 ± 14.5 and 63.9 ± 14.3 mL/kg, P < .001) and highly reproducible between the last three measurements (63.9 ± 14.3, 61.4 ± 13.8, and 60.9 ± 13.9 mL/kg, P = n.s.). Measurement of absolute blood volume after 1 hour of treatment is more precise than earlier measurements and might be better suited for guidance of ultrafiltration.
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Affiliation(s)
- Susanne Kron
- Department of Nephrology and Internal Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Daniel Schneditz
- Division of Physiology, Otto Loewi Research Center, Medical University of Graz, Graz, Austria
| | - David F Keane
- Department of Renal Medicine, Leeds Teaching Hospitals, Leeds, UK
| | - Til Leimbach
- KfH Kidney Center Berlin-Köpenick, Berlin, Germany
| | - Joachim Kron
- KfH Kidney Center Berlin-Köpenick, Berlin, Germany
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5
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Haider T, Diaz-Canestro C, Pentz B, Montero D. Intravascular albumin loss is strongly associated with plasma volume withdrawal in dialysis patients. Hemodial Int 2020; 25:86-93. [PMID: 32996274 DOI: 10.1111/hdi.12881] [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: 12/04/2019] [Revised: 08/10/2020] [Accepted: 09/14/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Low circulating albumin closely predicts mortality in end-stage renal disease (ESRD) patients. The cause(s) of hypoalbuminemia (hALB) in ESRD patients remains to be elucidated. The aim of the present study was to determine the role of plasma volume (PV) withdrawal in the reduction of total circulating albumin and essential blood solutes induced by hemodialysis (HD). METHODS PV determined with high-precision automated carbon monoxide-rebreathing, total circulating as well as concentration of plasma albumin and electrolytes were assessed prior to and after 4-hour HD in 10 ESRD patients. FINDINGS Baseline PV ranged from 3.5 to 6.2 l. After HD, PV was decreased by 689 ± 566 mL (-16%) (P = 0.004). Total circulating albumin was largely reduced after HD (170.8 ± 35.1 vs. 146.1 ± 48.9 g, P = 0.008), while albumin concentration was unaltered. According to a strong linear relationship (r = 0.91, P < 0.001), one-third of total circulating albumin is lost from the intravascular compartment for every liter of PV removed. Similar results were found regarding Na+ and Ca2+ electrolytes. DISCUSSION Total circulating albumin, but not albumin concentration, is substantially reduced by HD in proportion to the amount of PV removed from the circulation. This study highlights the potential contributing role of PV withdrawal to hALB in ESRD patients.
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Affiliation(s)
- Thomas Haider
- University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Candela Diaz-Canestro
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Brandon Pentz
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - David Montero
- University Heart Center, University Hospital Zurich, Zurich, Switzerland.,Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada.,Cumming School of Medicine, Calgary, Alberta, Canada
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6
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Yang J, Wang T, Zhao L, Rajasekhar VK, Joshi S, Andreou C, Pal S, Hsu HT, Zhang H, Cohen IJ, Huang R, Hendrickson RC, Miele MM, Pei W, Brendel MB, Healey JH, Chiosis G, Kircher MF. Gold/alpha-lactalbumin nanoprobes for the imaging and treatment of breast cancer. Nat Biomed Eng 2020; 4:686-703. [PMID: 32661307 PMCID: PMC8255032 DOI: 10.1038/s41551-020-0584-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 06/11/2020] [Indexed: 02/03/2023]
Abstract
Theranostic agents should ideally be renally cleared and biodegradable. Here, we report the synthesis, characterization and theranostic applications of fluorescent ultrasmall gold quantum clusters that are stabilized by the milk metalloprotein alpha-lactalbumin. We synthesized three types of these nanoprobes that together display fluorescence across the visible and near-infrared spectra when excited at a single wavelength through optical colour coding. In live tumour-bearing mice, the near-infrared nanoprobe generates contrast for fluorescence, X-ray computed tomography and magnetic resonance imaging, and exhibits long circulation times, low accumulation in the reticuloendothelial system, sustained tumour retention, insignificant toxicity and renal clearance. An intravenously administrated near-infrared nanoprobe with a large Stokes shift facilitated the detection and image-guided resection of breast tumours in vivo using a smartphone with modified optics. Moreover, the partially unfolded structure of alpha-lactalbumin in the nanoprobe helps with the formation of an anti-cancer lipoprotein complex with oleic acid that triggers the inhibition of the MAPK and PI3K-AKT pathways, immunogenic cell death and the recruitment of infiltrating macrophages. The biodegradability and safety profile of the nanoprobes make them suitable for the systemic detection and localized treatment of cancer.
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Affiliation(s)
- Jiang Yang
- Center for Molecular Imaging and Nanotechnology (CMINT), Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Tai Wang
- Chemical Biology Program, Sloan Kettering Institute, New York, NY, USA
| | - Lina Zhao
- CAS Key Laboratory for Biomedical Effects of Nanomaterials and Nanosafety, Institute of High Energy Physics, Chinese Academy of Sciences, Beijing, China
| | | | - Suhasini Joshi
- Chemical Biology Program, Sloan Kettering Institute, New York, NY, USA
| | - Chrysafis Andreou
- Center for Molecular Imaging and Nanotechnology (CMINT), Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Suchetan Pal
- Center for Molecular Imaging and Nanotechnology (CMINT), Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hsiao-Ting Hsu
- Center for Molecular Imaging and Nanotechnology (CMINT), Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hanwen Zhang
- Center for Molecular Imaging and Nanotechnology (CMINT), Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ivan J Cohen
- Center for Molecular Imaging and Nanotechnology (CMINT), Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Louis V. Gerstner Jr Graduate School of Biomedical Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ruimin Huang
- Center for Molecular Imaging and Nanotechnology (CMINT), Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ronald C Hendrickson
- Proteomics and Microchemistry Core Laboratory, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Matthew M Miele
- Proteomics and Microchemistry Core Laboratory, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Wenbo Pei
- Chemical Biology Program, Sloan Kettering Institute, New York, NY, USA
| | - Matthew B Brendel
- Molecular Cytology Core Laboratory, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - John H Healey
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gabriela Chiosis
- Chemical Biology Program, Sloan Kettering Institute, New York, NY, USA
- Breast Cancer Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Moritz F Kircher
- Center for Molecular Imaging and Nanotechnology (CMINT), Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Molecular Pharmacology Program, Sloan Kettering Institute, New York, NY, USA.
- Department of Radiology, Weill Cornell Medical College, New York, NY, USA.
- Department of Imaging, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA.
- Department of Radiology, Brigham & Women's Hospital and Harvard Medical School, Boston, MA, USA.
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7
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Kron S, Schneditz D, Leimbach T, Kron J. Feedback control of absolute blood volume: A new technical approach in hemodialysis. Hemodial Int 2020; 24:344-350. [PMID: 32115891 DOI: 10.1111/hdi.12826] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 02/06/2020] [Accepted: 02/17/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The success of automatic feedback control systems to improve hemodynamic stability by preventing relative blood volume from dropping beyond a critical value during dialysis is limited. The aim of this study was to use one of these systems for control of absolute rather than relative blood volume to prevent volume-dependent morbid events. METHODS Dialysis was delivered by a machine providing feedback control of ultrafiltration rates, relative blood volume monitoring, and accurate bolus infusion of 240 mL of dialysate to measure absolute blood volume at the beginning of dialysis. Critical relative blood volume required by the control algorithm was calculated from absolute blood volume at the beginning and a critical absolute blood volume of 67 mL/kg. FINDINGS In 40 stable patients, ultrafiltration was guided by blood volume using the feedback algorithm of the integrated program. Blood volume was maintained in a narrow range above the prespecified minimal value of 67 mL/kg. At the end of dialysis, absolute blood volume ranged from 67.5 to 72.5 mL/kg (69.4 ± 1.3 mL/kg). No volume-dependent intradialytic morbid event occurred. DISCUSSION A feedback control system for relative blood volume-controlled ultrafiltration can be used for control of absolute blood volume. A prescribed target of absolute blood volume can be converted into relative blood volume, and this can subsequently be reached automatically with the integrated feedback system of the dialysis machine. Intradialytic morbid events could be considerably reduced. The whole procedure could be completely automated without altering the hardware of the dialysis device.
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Affiliation(s)
- Susanne Kron
- Department of Nephrology and Internal Intensive Care Medicine, Charite Universitätsmedizin Berlin, Berlin, Germany
| | - Daniel Schneditz
- Division of Physiology, Otto Loewi Research Center, Medical University of Graz, Graz, Austria
| | - Til Leimbach
- KfH Kidney Center Berlin-Köpenick, Berlin, Germany
| | - Joachim Kron
- KfH Kidney Center Berlin-Köpenick, Berlin, Germany
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8
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Grant CJ, Huang SHS, McIntyre CW. Hepato-splanchnic circulatory stress: An important effect of hemodialysis. Semin Dial 2019; 32:237-242. [PMID: 30937954 DOI: 10.1111/sdi.12782] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The gastro-intestinal tract is being increasingly recognized as the site of key pathophysiological processes in the hemodialysis patient. Intestinal dysbiosis, increased intraluminal toxin production, and increased intestinal permeability are commonly observed processes which contribute to the pathogenesis of cardiovascular disease and thus elevated mortality. The acute circulatory effects of dialysis itself may contribute significantly to the development of gastrointestinal dysfunction as a result of both local and distant effects. Additionally, the liver, a relatively unknown entity in this process, has a substantial role as a functional barrier between the portal and systemic circulation and in the metabolism of pathogenic gut-derived uremic toxins. Here we summarize the evidence for acute gastro-intestinal and hepatic effects of hemodialysis and identify gaps in knowledge to date which require further study.
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Affiliation(s)
- Claire J Grant
- The Lilibeth Caberto Kidney Clinical Research Unit, Western University, London, Ontario, Canada
| | - Shih-Han S Huang
- The Lilibeth Caberto Kidney Clinical Research Unit, Western University, London, Ontario, Canada.,Department of Medical Biophysics, Western University, London, Ontario, Canada.,Division of Nephrology, London Health Sciences Centre, London, Ontario, Canada
| | - Chris W McIntyre
- The Lilibeth Caberto Kidney Clinical Research Unit, Western University, London, Ontario, Canada.,Department of Medical Biophysics, Western University, London, Ontario, Canada.,Division of Nephrology, London Health Sciences Centre, London, Ontario, Canada
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Maarek JMI, Rubinstein EH, Guo Y, Lane CJ, Campese VM, Holschneider DP. Measurement of Cardiac Output and Blood Volume During Hemodialysis with Fluorescent Dye Dilution Technique. Ann Biomed Eng 2016; 45:580-591. [PMID: 27539225 DOI: 10.1007/s10439-016-1711-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 08/10/2016] [Indexed: 11/24/2022]
Abstract
Intradialytic hypotensive events (IDH) accompanied by deleterious decreases of the cardiac output complicate up to 25% of hemodialysis treatments. Monitoring options available to track hemodynamic changes during hemodialysis have been found ineffective to anticipate the occurrence of IDH. We have assembled opto-electronic instrumentation that uses the fluorescence of a small bolus of indocyanine green dye injected in the hemodialysis circuit to estimate cardiac output and blood volume based on indicator dilution principles in patients receiving hemodialysis. The instrument and technique were tested in 24 adult end-stage renal failure subjects during 64 hemodialysis sessions. A single calibration factor could be used across subjects and across time. Intra-subject variability of the measurements over time was <10%. Stroke volume index (SVI) (mean ± SEM = 34 ± 1 vs. 39 ± 2 mL m-2) and central blood volume (CBV) index (783 ± 36 vs. 881 ± 33 mL m-2) were lower at the beginning of the sessions in which IDH eventually occurred. Cardiac index, SVI, and CBV index decreased with hemodialysis in all treatment sessions but the decrease was more intense in the IDH sessions. We conclude that hemodynamic monitoring can be implemented in patients receiving hemodialysis with minimal disruption of the treatment and could help understand intradialytic hypotension.
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Affiliation(s)
- Jean Michel I Maarek
- Department of Biomedical Engineering, University of Southern California, DRB 140, University Park, Los Angeles, CA, 90089-1111, USA.
| | - Eduardo H Rubinstein
- Department of Anesthesiology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Yumei Guo
- Department of Psychiatry & the Behavioral Sciences, University of Southern California, Los Angeles, CA, USA
| | - Christianne J Lane
- Southern California Clinical & Translational Science Institute, University of Southern California, Los Angeles, CA, USA
| | - Vito M Campese
- Division of Nephrology and Hypertension Center, Department of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Daniel P Holschneider
- Department of Biomedical Engineering, University of Southern California, DRB 140, University Park, Los Angeles, CA, 90089-1111, USA.,Department of Psychiatry & the Behavioral Sciences, University of Southern California, Los Angeles, CA, USA
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10
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Schneditz D, Ribitsch W, Schilcher G, Uhlmann M, Chait Y, Stadlbauer V. Concordance of absolute and relative plasma volume changes and stability of Fcells in routine hemodialysis. Hemodial Int 2016; 20:120-8. [PMID: 26246366 PMCID: PMC4937455 DOI: 10.1111/hdi.12338] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Central hematocrit (H) measurements are currently used to track the degree of ultrafiltration-induced hemoconcentration with the aim to detect and prevent excessive intravascular fluid depletion during hemodialysis (HD). Failure to maintain hemodynamic stability is commonly attributed to the misinterpretation of H caused by an unaccountable increase in Fcells , the ratio of whole-body hematocrit to H. It was the aim to examine Fcells under everyday conditions in a group of stable HD patients. Absolute plasma volume (Vp ) and H were concomitantly measured during routine HD in the extracorporeal system in hourly intervals by noninvasive and continuous technology (CritLine-Instrument-III) and indocyanine green dye dilution to derive relative plasma volumes from Vp and H (RPVp , RPVH ), respectively, and to calculate Fcells . Thirteen patients were studied during two midweek treatments (n = 26). Both absolute Vp (P < 0.05) and relative plasma volumes RPVH (P < 0.001) decreased during HD. Vp at any time point was positively correlated to RPVH (r = 0.52). Moreover, relative plasma volumes RPVH and RPVp determined by independent techniques were identical and showed negligible bias (-0.2%) but considerable limits of agreement (-15.6% to +15.3%). Fcells was stable and in the range of 0.9 ± 0.05 throughout HD and not different from the value assumed at the beginning of HD. Although Fcells remains constant in patients on routine dialysis and relative plasma volumes (RPVH and RPVp ) determined by independent techniques are therefore comparable, the variability of experimental conditions during dialysis and the limited accuracy of absolute volume measurements using available technology continues to complicate the ultrafiltration control problem.
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Affiliation(s)
- Daniel Schneditz
- Institute of Physiology, Medical University of Graz, Graz, Austria
| | - Werner Ribitsch
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Gernot Schilcher
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Matthias Uhlmann
- Institute of Physiology, Medical University of Graz, Graz, Austria
| | - Yossi Chait
- Department of Mechanical & Industrial Engineering, University of Massachusetts, Amherst, MA, USA
| | - Vanessa Stadlbauer
- Division of Gastroenterology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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11
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Increased Hepato-Splanchnic Vasoconstriction in Diabetics during Regular Hemodialysis. PLoS One 2015; 10:e0145411. [PMID: 26713734 PMCID: PMC4695079 DOI: 10.1371/journal.pone.0145411] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 12/03/2015] [Indexed: 11/19/2022] Open
Abstract
Background and Objectives Ultrafiltration (UF) of excess fluid activates numerous compensatory mechanisms during hemodialysis (HD). The increase of both total peripheral and splanchnic vascular resistance is considered essential in maintaining hemodynamic stability. The aim of this study was to evaluate the extent of UF-induced changes in hepato-splanchnic blood flow and resistance in a group of maintenance HD patients during regular dialysis. Design, Setting, Participants, & Measurements Hepato-splanchnic flow resistance index (RI) and hepato-splanchnic perfusion index (QI) were measured in 12 chronic HD patients using a modified, non-invasive Indocyaningreen (ICG) dilution method. During a midweek dialysis session we determined RI, QI, ICG disappearance rate (kICG), plasma volume (Vp), hematocrit (Hct), mean arterial blood pressure (MAP) and heart rate (HR) at four times in hourly intervals (t1 to t4). Dialysis settings were standardized and all patient studies were done in duplicate. Results In the whole study group mean UF volume was 1.86 ± 0.46 L, Vp dropped from 3.65 ± 0.77L at t1 to 3.40 ± 0.78L at t4, and all patients remained hemodynamically stable. In all patients RI significantly increased from 12.40 ± 4.21 mmHg∙s∙m2/mL at t1 to 14.94 ± 6.36 mmHg∙s∙m2/mL at t4 while QI significantly decreased from 0.61 ± 0.22 at t1 to 0.52 ± 0.20 L/min/m2 at t4, indicating active vasoconstriction. In diabetic subjects, however, RI was significantly larger than in non-diabetics at all time points. QI was lower in diabetic subjects. Conclusions In chronic HD-patients hepato-splanchnic blood flow substantially decreases during moderate UF as a result of an active splanchnic vasoconstriction. Our data indicate that diabetic HD-patients are particularly prone to splanchnic ischemia and might therefore have an increased risk for bacterial translocation, endotoxemia and systemic inflammation.
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12
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Kron J, Schneditz D, Leimbach T, Aign S, Kron S. A simple and feasible method to determine absolute blood volume in hemodialysis patients in clinical practice. Blood Purif 2014; 38:180-7. [PMID: 25531533 DOI: 10.1159/000368157] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 09/02/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND We developed a simple method to determine the absolute blood volume (V) during hemodialysis in everyday clinical practice and examined its relationship with volume overload, clinical relevance, and accuracy. METHODS The increase in relative blood volume (RBVpost - RBVpre) measured before and after infusion of 240 ml of ultra-pure dialysate using the bolus function of a commercial online hemodiafiltration machine incorporating a relative blood volume monitor was applied to determine absolute blood volume. The specific blood volume (Vs, blood volume per kg body mass at dry weight, in ml/kg) was compared to volume status as assessed by bioimpedance analysis and clinical criteria. RESULTS The blood volume measured in 30 stable hemodialysis patients was 6.51 ± 1.70 l at the beginning, corresponding to a specific blood volume of 80.1 ± 12.8 ml/kg, and dropped to 5.84 ± 1.61 l or 72.0 ± 12.1 ml/kg at the end of the dialysis session, respectively. Specific blood volume correlated with volume status assessed both clinically and by bioimpedance analysis. Intradialytic morbid events occurred only in treatments where specific blood volume fell below 65 ml/kg. The reproducibility of the technique was better than 4% and the in vitro accuracy corresponds to a resolution in Vs of better than 1 ml/kg. CONCLUSION Absolute blood volume can be easily measured at the beginning of the dialysis session using the current dialysis technology. Information about V and Vs could be a promising tool to avoid intradialytic morbid events. This technique could be completely automated without altering the hardware of currently available online dialysis devices. Therefore, it is recommended that this technique be integrated into all hemodiafiltration machines.
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Affiliation(s)
- Joachim Kron
- KfH Kidney Center Berlin-Köpenick, Berlin, Germany
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