1
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Tanaka T, Kawakubo Y, Shigematsu T, Nishimura H. The Changes in Relative Blood Volume during Dialysis Are Characterized by Ultrafiltration Rate and Predialysis Blood Test Values. Blood Purif 2024; 53:505-510. [PMID: 38310862 DOI: 10.1159/000536073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 12/29/2023] [Indexed: 02/06/2024]
Abstract
INTRODUCTION Continuous monitoring of relative blood volume (percentage BV) in hemodialysis (HD) is critical for determining dry weight and preventing intradialytic hypotension. However, the cause of the BV variation remains unknown. This research aimed to examine factors that influence the percentage BV. METHODS We devised a formula based on coefficients ("a," "τ," and "b") to predict changes in percentage BV. "a" denotes a significant decrease in percentage BV in the early stages of HD. "τ" represents the transition from early to late phase of HD. "b" denotes the slope of the decrease in percentage BV in the late phase of HD. We measured the percentage BV in 18 patients with end-stage renal disease. The coefficients were estimated by fitting experimental data from patients using a least squares optimization algorithm. A correlation analysis of these parameters and patient predialysis data was performed. RESULTS Ultrafiltration rate (UFR) was found to be negatively correlated with "b" (r = -0.851, p < 0.01). However, UFR was not significantly related to "a." Predialysis serum total protein level was negatively correlated with "a" (r = -0.531, p = 0.042). Predialysis serum albumin and predialysis sodium were not significantly correlated with "a" and "τ." Plasma osmolarity did not have a significant relationship with "a" and "τ." DISCUSSION/CONCLUSION UFR influenced the decrease in percentage BV in the late phase but did not influence the decrease of percentage BV in the early phase. "a" was associated with predialysis serum total protein level but not with plasma osmolality or predialysis sodium. This implies that colloid oncotic pressure is important for plasma refilling immediately after dialysis begins. During the change of percentage BV, the decrease in the early phase of dialysis was not related to UFR, but related to other parameters, especially predialysis total protein level. A decrease in the late phase of dialysis is related to UFR.
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Affiliation(s)
- Tomoyuki Tanaka
- Department of Clinical Engineering, Faculty of Health Care, Jikei University of Health Care Sciences, Osaka, Japan
| | - Yoshifumi Kawakubo
- Department of Clinical Engineering, Faculty of Health Care, Jikei University of Health Care Sciences, Osaka, Japan
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2
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Yildiz AB, Vehbi S, Covic A, Burlacu A, Covic A, Kanbay M. An update review on hemodynamic instability in renal replacement therapy patients. Int Urol Nephrol 2023; 55:929-942. [PMID: 36308664 DOI: 10.1007/s11255-022-03389-w] [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: 05/24/2022] [Accepted: 10/15/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hemodynamic instability in patients undergoing kidney replacement therapy (KRT) is one of the most common and essential factors influencing mortality, morbidity, and the quality of life in this patient population. METHOD Decreased cardiac preload, reduced systemic vascular resistance, redistribution of fluids, fluid overload, inflammatory factors, and changes in plasma osmolality have all been implicated in the pathophysiology of hemodynamic instability associated with KRT. RESULT A cascade of these detrimental mechanisms may ultimately cause intra-dialytic hypotension, reduced tissue perfusion, and impaired kidney rehabilitation. Multiple parameters, including dialysate composition, temperature, posture during dialysis sessions, physical activity, fluid administrations, dialysis timing, and specific pharmacologic agents, have been studied as possible management modalities. Nevertheless, a clear consensus is not reached. CONCLUSION This review includes a thorough investigation of the literature on hemodynamic instability in KRT patients, providing insight on interventions that may potentially minimize factors leading to hemodynamic instability.
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Affiliation(s)
- Abdullah B Yildiz
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Sezan Vehbi
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Andreea Covic
- Department of Nephrology, Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Alexandru Burlacu
- Department of Nephrology, Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Adrian Covic
- Department of Nephrology, Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Mehmet Kanbay
- Division of Nephrology, Department of Medicine, Koc University School of Medicine, 34010, Istanbul, Turkey.
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3
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Wang CH, Negoianu D, Zhang H, Casper S, Hsu JY, Kotanko P, Raimann J, Dember LM. Dynamics of Plasma Refill Rate and Intradialytic Hypotension During Hemodialysis: Retrospective Cohort Study With Causal Methodology. KIDNEY360 2023; 4:e505-e514. [PMID: 36790867 PMCID: PMC10278774 DOI: 10.34067/kid.0000000000000082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/18/2023] [Indexed: 02/16/2023]
Abstract
Key Points Directly studying plasma refill rate (PRR) during hemodialysis (HD) can offer insight into physiologic mechanisms that change throughout HD. PRR at the start and during HD is associated with intradialytic hypotension, independent of ultrafiltration rate. A rising PRR during HD may be an early indicator of compensatory mechanisms for impending circulatory instability. Background Attaining the optimal balance between achieving adequate volume removal while preserving organ perfusion is a challenge for patients receiving maintenance hemodialysis (HD). Current strategies to guide ultrafiltration are inadequate. Methods We developed an approach to calculate the plasma refill rate (PRR) throughout HD using hematocrit and ultrafiltration data in a retrospective cohort of patients receiving maintenance HD at 17 dialysis units from January 2017 to October 2019. We studied whether (1 ) PRR is associated with traditional risk factors for hemodynamic instability using logistic regression, (2 ) low starting PRR is associated with intradialytic hypotension (IDH) using Cox proportional hazard regression, and (3 ) time-varying PRR throughout HD is associated with hypotension using marginal structural modeling. Results During 180,319 HD sessions among 2554 patients, PRR had high within-patient and between-patient variability. Female sex and hypoalbuminemia were associated with low PRR at multiple time points during the first hour of HD. Low starting PRR has a higher hazard of IDH, whereas high starting PRR was protective (hazard ratio [HR], 1.26, 95% confidence interval [CI], 1.18 to 1.35 versus HR, 0.79, 95% CI, 0.73 to 0.85, respectively). However, when accounting for time-varying PRR and time-varying confounders, compared with a moderate PRR, while a consistently low PRR was associated with increased risk of hypotension (odds ratio [OR], 1.09, 95% CI, 1.02 to 1.16), a consistently high PRR had a stronger association with hypotension within the next 15 minutes (OR, 1.38, 95% CI, 1.30 to 1.45). Conclusions We present a straightforward technique to quantify plasma refill that could easily integrate with devices that monitor hematocrit during HD. Our study highlights how examining patterns of plasma refill may enhance our understanding of circulatory changes during HD, an important step to understand how current technology might be used to improve hemodynamic instability.
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Affiliation(s)
- Christina H. Wang
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dan Negoianu
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Sabrina Casper
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Jesse Y. Hsu
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter Kotanko
- Renal Research Institute, New York, New York
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Laura M. Dember
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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4
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Schneditz D, Niemczyk L, Wojtecka A, Szamotulska K, Niemczyk S. Comparable Hemodilution with Hypertonic Glucose in Patients with and without Type-2 Diabetes Mellitus during Hemodialysis. Nutrients 2023; 15:nu15030536. [PMID: 36771243 PMCID: PMC9920628 DOI: 10.3390/nu15030536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/12/2023] [Accepted: 01/16/2023] [Indexed: 01/22/2023] Open
Abstract
(1) Background: It was examined whether glucose-induced changes in the relative blood volume are suitable to identify subjects with and without type-2 diabetes mellitus (T2D) during hemodialysis. (2) Methods: The relative blood volume was continuously recorded during hemodialysis and perturbed by the infusion of glucose comparable to the dose used for intravenous glucose tolerance tests. Indices of glucose metabolism were determined by the homeostatic model assessment (HOMA). Body composition was measured by a bioimpedance analysis. The magnitude and the time course of hemodilution were described by a modified gamma variate model and five model parameters. (3) Results: A total of 34 subjects were studied, 14 with and 20 without T2D. The magnitude of the hemodilution and the selected model parameters correlated with measures of anthropometry, body mass index, absolute and relative fat mass, volume excess, baseline insulin concentration, and HOMA indices such as insulin resistance and glucose disposition in a continuous analysis, but were not different in a dichotomous analysis of patients with and without T2D. (4) Conclusions: Even though the parameters of the hemodilution curve were correlated with measures of impaired glucose metabolism and body composition, the distinction between subjects with and without T2D was not possible using glucose-induced changes in the relative blood volume during hemodialysis.
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Affiliation(s)
- Daniel Schneditz
- Otto Loewi Research Center, Division of Physiology, Medical University of Graz, 8010 Graz, Austria
- Correspondence: ; Tel.: +43-316-385-7385
| | - Longin Niemczyk
- Department of Nephrology, Dialysis and Internal Diseases, Medical University of Warsaw, 02-097 Warsaw, Poland
| | - Anna Wojtecka
- Department of Internal Diseases, Nephrology and Dialysis, Military Institute of Medicine, 04-141 Warsaw, Poland
| | - Katarzyna Szamotulska
- Department of Epidemiology and Biostatistics, National Research Institute of Mother and Child, 01-211 Warsaw, Poland
| | - Stanisław Niemczyk
- Department of Internal Diseases, Nephrology and Dialysis, Military Institute of Medicine, 04-141 Warsaw, Poland
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5
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Álvarez-Nadal M, Martín-Capón I, Viera-Ramírez ER, Fernández-Lucas M. Impact of dialysate sodium concentration on vascular refilling. Hemodial Int 2021; 26:30-37. [PMID: 34180118 DOI: 10.1111/hdi.12957] [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: 02/05/2021] [Revised: 05/31/2021] [Accepted: 06/10/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Although relationship between dialysate sodium concentration and hemodynamic stability has been well studied over the years, outcomes of absolute blood volume (ABV) maintenance and vascular refilling volume (Vref ) modifications were not included, as its analysis has not been easily accessible to direct investigation. However, recent studies report a simple and feasible methodology to assess ABV and Vref during hemodialysis (HD) treatments. It is the aim of this study to analyze whether sodium concentration in dialysate modifies ABV drop and Vref . METHODS The study was performed in 19 patients under HD. During three different sessions, sodium concentration in dialysate was randomized to three different profiles: low sodium concentration (LNa, 138 mEq/L), neutral sodium concentration (NNa, 140 mEq/L), and high sodium concentration (HNa, 143 mEq/L). ABV and Vref were calculated using Kron et al methodology. RESULTS Predialysis values of the measured parameters showed similar results for the three profiles. Sodium concentration showed an effect on ABV drop, Vref, and vascular refilling fraction (Fref ). Pair-wise comparison revealed mean ABV decreased 0.21 L less when using HNa profile versus LNa profile (p = 0.027), a mean Vref increase of 0.39 L (p = 0.038), and a mean Fref increase of 9.94% (p = 0.048). CONCLUSIONS This study shows that the use of HNa profiles increases Vref and Fref and reduces ABV drop during dialysis treatments when compared to LNa profiles.
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Affiliation(s)
- Marta Álvarez-Nadal
- Department of Nephrology, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Irene Martín-Capón
- Department of Nephrology, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | | | - Milagros Fernández-Lucas
- Department of Nephrology, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain.,Universidad de Alcalá, Madrid, Spain
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6
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Ertuglu LA, Demiray A, Basile C, Afsar B, Covic A, Kanbay M. Sodium and ultrafiltration profiling in hemodialysis: A long-forgotten issue revisited. Hemodial Int 2021; 25:433-446. [PMID: 34133065 DOI: 10.1111/hdi.12952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 04/21/2021] [Accepted: 05/16/2021] [Indexed: 12/16/2022]
Abstract
Sodium and ultrafiltration profiling are method of dialysis in which dialysate sodium concentration and ultrafiltration rate are altered during the course of the dialysis session. Sodium and ultrafiltration profiling have been used, commonly simultaneously, to improve hemodynamic stability during hemodialysis. Sodium profiling is particularly effective in decreasing the incidence of intradialytic hypotension, while ultrafiltration profiling is suggested to decrease subclinical repeated end organ ischemia during dialysis. However, complications such as increased interdialytic weight gain and thirst due to sodium excess have prevented widespread use of sodium profiling. Evidence suggest that different sodium profiling techniques may lead to different clinical results, and preferring sodium balance neutral sodium profiling may mitigate adverse effects related to sodium overload. However, evidence is lacking on the long-term clinical outcomes of different sodium profiling methods. Optimal method of sodium profiling as well as the utility of sodium/ultrafiltration profiling in routine practice await further clinical investigation.
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Affiliation(s)
- Lale A Ertuglu
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Atalay Demiray
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Carlo Basile
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
| | - Baris Afsar
- Division of Nephrology, Department of Internal Medicine, Suleyman Demirel University School of Medicine, Isparta, Turkey
| | - Adrian Covic
- Department of Nephrology, Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Mehmet Kanbay
- Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
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7
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Douvris A, Zeid K, Hiremath S, Bagshaw SM, Wald R, Beaubien-Souligny W, Kong J, Ronco C, Clark EG. Mechanisms for hemodynamic instability related to renal replacement therapy: a narrative review. Intensive Care Med 2019; 45:1333-1346. [PMID: 31407042 PMCID: PMC6773820 DOI: 10.1007/s00134-019-05707-w] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 07/17/2019] [Indexed: 02/07/2023]
Abstract
Hemodynamic instability related to renal replacement therapy (HIRRT) is a frequent complication of all renal replacement therapy (RRT) modalities commonly used in the intensive care unit. HIRRT is associated with increased mortality and may impair kidney recovery. Our current understanding of the physiologic basis for HIRRT comes primarily from studies of end-stage kidney disease patients on maintenance hemodialysis in whom HIRRT is referred to as ‘intradialytic hypotension’. Nonetheless, there are many studies that provide additional insights into the underlying mechanisms for HIRRT specifically in critically ill patients. In particular, recent evidence challenges the notion that HIRRT is almost entirely related to excessive ultrafiltration. Although excessive ultrafiltration is a key mechanism, multiple other RRT-related mechanisms may precipitate HIRRT and this could have implications for how HIRRT should be managed (e.g., the appropriate response might not always be to reduce ultrafiltration, particularly in the context of significant fluid overload). This review briefly summarizes the incidence and adverse effects of HIRRT and reviews what is currently known regarding the mechanisms underpinning it. This includes consideration of the evidence that exists for various RRT-related interventions to prevent or limit HIRRT. An enhanced understanding of the mechanisms that underlie HIRRT, beyond just excessive ultrafiltration, may lead to more effective RRT-related interventions to mitigate its occurrence and consequences.
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Affiliation(s)
- Adrianna Douvris
- The Ottawa Hospital, Department of Medicine and Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, 1967 Riverside Drive, Ottawa, ON K1H 7W9 Canada
| | - Khalid Zeid
- Faculty of Medicine, University of Ottawa, Ottawa, ON Canada
| | - Swapnil Hiremath
- The Ottawa Hospital, Department of Medicine and Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, 1967 Riverside Drive, Ottawa, ON K1H 7W9 Canada
| | - Sean M. Bagshaw
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB Canada
| | - Ron Wald
- St. Michael’s Hospital, University Health Network, University of Toronto, Toronto, ON Canada
| | | | - Jennifer Kong
- The Ottawa Hospital, Department of Medicine and Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, 1967 Riverside Drive, Ottawa, ON K1H 7W9 Canada
| | - Claudio Ronco
- Department of Medicine, Università degli Studi di Padova and International Renal Research Institute, St. Bortolo Hospital, Vicenza, Italy
| | - Edward G. Clark
- The Ottawa Hospital, Department of Medicine and Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, 1967 Riverside Drive, Ottawa, ON K1H 7W9 Canada
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8
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Hanafusa N, Tsuchiya K, Nitta K. Dialysate sodium concentration: The forgotten salt shaker. Semin Dial 2018; 31:563-568. [DOI: 10.1111/sdi.12749] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Norio Hanafusa
- Department of Blood Purification; Tokyo Women’s Medical University; Tokyo Japan
| | - Ken Tsuchiya
- Department of Blood Purification; Tokyo Women’s Medical University; Tokyo Japan
| | - Kosaku Nitta
- Department of Nephrology; Tokyo Women’s Medical University; Tokyo Japan
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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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Douvris A, Malhi G, Hiremath S, McIntyre L, Silver SA, Bagshaw SM, Wald R, Ronco C, Sikora L, Weber C, Clark EG. Interventions to prevent hemodynamic instability during renal replacement therapy in critically ill patients: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:41. [PMID: 29467008 PMCID: PMC5822560 DOI: 10.1186/s13054-018-1965-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Accepted: 01/24/2018] [Indexed: 01/09/2023]
Abstract
Background Hemodynamic instability related to renal replacement therapy (HIRRT) may increase the risk of death and limit renal recovery. Studies in end-stage renal disease populations on maintenance hemodialysis suggest that some renal replacement therapy (RRT)-related interventions (e.g., cool dialysate) may reduce the occurrence of HIRRT, but less is known about interventions to prevent HIRRT in critically ill patients receiving RRT for acute kidney injury (AKI). We sought to evaluate the effectiveness of RRT-related interventions for reducing HIRRT in such patients across RRT modalities. Methods A systematic review of publications was undertaken using MEDLINE, MEDLINE in Process, EMBASE, and Cochrane’s Central Registry for Randomized Controlled Trials (RCTs). Studies that assessed any intervention’s effect on HIRRT (the primary outcome) in critically ill patients with AKI were included. HIRRT was variably defined according to each study’s definition. Two reviewers independently screened abstracts, identified articles for inclusion, extracted data, and evaluated study quality using validated assessment tools. Results Five RCTs and four observational studies were included (n = 9; 623 patients in total). Studies were small, and the quality was mostly low. Interventions included dialysate sodium modeling (n = 3), ultrafiltration profiling (n = 2), blood volume (n = 2) and temperature control (n = 3), duration of RRT (n = 1), and slow blood flow rate at initiation (n = 1). Some studies applied more than one strategy simultaneously (n = 5). Interventions shown to reduce HIRRT from three studies (two RCTs and one observational study) included higher dialysate sodium concentration, lower dialysate temperature, variable ultrafiltration rates, or a combination of strategies. Interventions not found to have an effect included blood volume and temperature control, extended duration of intermittent RRT, and slower blood flow rates during continuous RRT initiation. How HIRRT was defined and its frequency of occurrence varied widely across studies, including those involving the same RRT modality. Pooled analysis was not possible due to study heterogeneity. Conclusions Small clinical studies suggest that higher dialysate sodium, lower temperature, individualized ultrafiltration rates, or a combination of these strategies may reduce the risk of HIRRT. Overall, for all RRT modalities, there is a paucity of high-quality data regarding interventions to reduce the occurrence of HIRRT in critically ill patients. Electronic supplementary material The online version of this article (10.1186/s13054-018-1965-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Adrianna Douvris
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Gurpreet Malhi
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Swapnil Hiremath
- Division of Nephrology, Department of Medicine and Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Lauralyn McIntyre
- Division of Critical Care, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada.,Centre for Transfusion Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Samuel A Silver
- Division of Nephrology, Queen's University, Kingston, ON, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Ron Wald
- Division of Nephrology, St. Michael's Hospital, Toronto, ON, Canada
| | - Claudio Ronco
- International Renal Research Institute and Department of Nephrology, St. Bortolo Hospital, Vicenza, Italy
| | - Lindsey Sikora
- Health Sciences Library, University of Ottawa, Ottawa, ON, Canada
| | - Catherine Weber
- Division of Nephrology, McGill University, Montreal, Quebec, Canada
| | - Edward G Clark
- Division of Nephrology, Department of Medicine and Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada. .,The Ottawa Hospital - Riverside Campus, 1967 Riverside Drive, Ottawa, ON, K1H 7W9, Canada.
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11
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Donati G, Ursino M, Spazzoli A, Natali N, Schillaci R, Conte D, Angeletti A, Croci Chiocchini AL, Capelli I, Baraldi O, La Manna G. Sodium Prescription in the Prevention of Intradialytic Hypotension: New Insights into an Old Concept. Blood Purif 2017; 45:61-70. [DOI: 10.1159/000480221] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 08/10/2017] [Indexed: 11/19/2022]
Abstract
Background: Sodium prescription in patients with intradialytic hypotension remains a challenge for the attending nephrologist, as it increases dialysate conductivity in hypotension-prone patients, thereby adding to dietary sodium levels. Methods: New sodium prescription strategies are now available, including the use of a mathematical model to compute the sodium mass to be removed during dialysis as a physiological controller. Results: This review describes the sodium load of patients with end-stage renal disease on chronic hemodialysis (HD) and discusses 2 strategies to remove excess sodium in patients prone to intradialytic hypotension, namely, Profiled HD and the hemodiafiltration Aequilibrium System. Conclusion: The Profiled HD and Aequilibrium System trial both proved effective in counteracting intradialytic hypotension.
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12
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Larkin JW, Reviriego-Mendoza MM, Usvyat LA, Kotanko P, Maddux FW. To cool, or too cool: Is reducing dialysate temperature the optimal approach to preventing intradialytic hypotension? Semin Dial 2017; 30:501-508. [DOI: 10.1111/sdi.12628] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
| | | | - Len A. Usvyat
- Fresenius Medical Care North America; Waltham MA USA
| | - Peter Kotanko
- Renal Research Institute; New York NY USA
- Icahn School of Medicine at Mount Sinai; New York NY USA
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13
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Lynch KE, Ghassemi F, Flythe JE, Feng M, Ghassemi M, Celi LA, Brunelli SM. Sodium modelling to reduce intradialytic hypotension during haemodialysis for acute kidney injury in the intensive care unit. Nephrology (Carlton) 2017; 21:870-7. [PMID: 26590371 DOI: 10.1111/nep.12677] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 11/17/2015] [Accepted: 11/18/2015] [Indexed: 11/26/2022]
Abstract
AIM Intradialytic hypotension often complicates haemodialysis for patients with acute kidney injury (AKI) and may impact renal recovery. Sodium modelling is sometimes used as prophylaxis against intradialytic hypotension in the chronic haemodialysis population, but there is little evidence for its use among critically ill patients with AKI. METHODS A retrospective cohort with AKI requiring intermittent haemodialysis in the intensive care unit from 2001 to 2008 was used to study the association of prophylactic sodium modelling and multiple outcomes. Outcomes included a composite of in-hospital death or dialysis dependence at hospital discharge, as well as intradialytic hypotension, ultrafiltration goal achievement and net ultrafiltration volume. Associations were estimated using logistic regression, mixed linear models and generalized estimating equations adjusting for demographic and clinical characteristics. RESULTS One hundred and ninety-one individuals who underwent 892 sessions were identified; sodium modelling was prescribed in 27.1% of the sessions. In adjusted analyses, sodium modelling was not significantly associated with intradialytic hypotension (P = 0.67) or with the ultrafiltration goal achievement (P = 0.06). Sodium modelling during the first dialysis session was numerically associated with lower risk for the composite of in-hospital death or dialysis dependence: adjusted odds ratio (95% confidence interval) 0.39 (0.15-1.02; P = 0.06); however, this association did not reach statistical significance. CONCLUSION We did not observe statistically significant associations between sodium modelling and improved outcomes among AKI patients receiving intermittent dialysis in the intensive care unit. However, suggestive findings warrant further study.
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Affiliation(s)
- Katherine E Lynch
- Division of Nephrology, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Fatimah Ghassemi
- Harvard-Massachusetts Institute of Technology Division of Health Sciences and Technology, Cambridge, MA, USA
| | - Jennifer E Flythe
- Division of Nephrology and Hypertension, University of North Carolina Kidney Center, Chapel Hill, NC, USA
| | - Mengling Feng
- Harvard-Massachusetts Institute of Technology Division of Health Sciences and Technology, Cambridge, MA, USA.,Institute for Infocomm Research, Agency for Science, Technology and Research, Singapore, Singapore
| | - Marzyeh Ghassemi
- Harvard-Massachusetts Institute of Technology Division of Health Sciences and Technology, Cambridge, MA, USA.,The Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Leo Anthony Celi
- Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard-Massachusetts Institute of Technology Division of Health Sciences and Technology, Cambridge, MA, USA
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14
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Bourdenx JP, Fartoux L. Place des « outils embarqués » (BVM et BTM) dans la prise en charge de la surcharge hydro-sodée. Nephrol Ther 2016; 12:S17-S19. [DOI: 10.1016/s1769-7255(17)30023-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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15
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Kron S, Schneditz D, Leimbach T, Aign S, Kron J. Vascular refilling is independent of volume overload in hemodialysis with moderate ultrafiltration requirements. Hemodial Int 2016; 20:484-91. [DOI: 10.1111/hdi.12417] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Susanne Kron
- Department of Nephrology; Charité Universitätsmedizin Berlin; Berlin Germany
| | - Daniel Schneditz
- Institute of Physiology, Medical University of Graz; Graz Austria
| | - Til Leimbach
- KfH Kidney Center Berlin-Köpenick; Berlin Germany
| | - Sabine Aign
- KfH Kidney Center Berlin-Köpenick; Berlin Germany
| | - Joachim Kron
- KfH Kidney Center Berlin-Köpenick; Berlin Germany
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16
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Blood Volume Changes Induced By Low-Intensity Intradialytic Exercise in Long-Term Hemodialysis Patients. ASAIO J 2016; 62:190-6. [PMID: 26720736 DOI: 10.1097/mat.0000000000000320] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Intradialytic exercise-induced blood volume (BV) reduction may cause intradialytic hypotension in hemodialysis (HD) patients. However, BV recovery time after intradialytic exercise remains unknown. Hemodialysis patients were recruited, and their relative BV change (%ΔBV) were measured with intradialytic exercise (n = 12). After confirming the linearity of %ΔBV for 30 min, patients exercised using a stationary cycle in the supine position. The target exercise intensity was a 10% increase in heart rate (HR), corresponding to relatively low-intensity exercise. Baseline %ΔBV (assumed baseline) were calculated for the 30 min before exercise using linear regression analysis. The mean intradialytic exercise start and end times after HD initiation were 93.0 ± 8.4 and 116.4 ± 8.3 min, respectively, a mean exercise duration of 23.5 ± 2.6 min. Percentage change in blood volume declined rapidly upon exercise initiation and gradually increased above the assumed baseline throughout HD. At the end of HD, %ΔBV in the exercise group was significantly higher than the assumed baseline (measured - assumed baseline %ΔBV: 2.17 ± 0.62%; p = 0.02). Intradialytic exercise with low intensity in the supine position attenuated ultrafiltration-induced BV reduction at the end of HD. Therefore, intradialytic exercise may prevent intradialytic hypotension during later HD, although its intensity was relatively low level.
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17
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Kinetics of Plasma Refilling During Hemodialysis Sessions with Different Initial Fluid Status. ASAIO J 2015; 61:350-6. [DOI: 10.1097/mat.0000000000000206] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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18
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Effects of sodium on measuring relative blood volume during hemodialysis differ by techniques. ASAIO J 2014; 59:612-6. [PMID: 24172266 DOI: 10.1097/mat.0b013e3182a4b45e] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Recording the relative blood volume is a standard feature of modern dialysis devices, enabling feedback guidance of ultrafiltration and dialysate conductivity. Technically, the process is based on optical or ultrasonic methods. On the grounds of clinical evidence suggesting a malfunction of the optical hemoglobin (Hb)-dependent absorbance method in the presence of sodium changes, we compared the system with the ultrasonic method. Six patients underwent hemodialysis with a step sodium profile (140, 150, 130, and 140 mmol/L, hourly switch), with two dialysis devices featuring the optical and the ultrasonic blood volume detector, respectively. The ultrasonic system recorded a decreasing blood volume throughout the treatment. With the optical method, changes in dialysate sodium led to inverse deviations of the blood volume curve. In another treatment without profile administering, a bolus of hypertonic sodium led to the detection of a rapid 8.7% reduction in blood volume with the optical method, which was not observed with the ultrasonic device. Blood volume monitors using the optical absorbance device are influenced by osmotic changes. An increase in osmolality produces a paradox drop in the measured blood volume and vice versa rendering the monitor inappropriate for use in sodium profiling.
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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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Davenport A. Using dialysis machine technology to reduce intradialytic hypotension. Hemodial Int 2011; 15 Suppl 1:S37-42. [DOI: 10.1111/j.1542-4758.2011.00600.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Andrew Davenport
- UCL Centre for Nephrology; Royal Free Hospital, University College London Medical School; London; UK
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21
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Jung A, Korohoda P, Krisper P, Schneditz D. Relationship between kinetics of albumin-bound bilirubin and water-soluble urea in extracorporeal blood purification. Nephrol Dial Transplant 2011; 27:1200-6. [DOI: 10.1093/ndt/gfr413] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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22
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Evolution of volume sensitivity during hemodialysis and ultrafiltration. Clin Auton Res 2011; 21:353-60. [DOI: 10.1007/s10286-011-0122-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Accepted: 03/21/2011] [Indexed: 10/18/2022]
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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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