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Yang IN, Liu CF, Chien CC, Wang HY, Wang JJ, Shen YT, Chen CC. Personalized prediction of intradialytic hypotension in clinical practice: Development and evaluation of a novel AI dashboard incorporating risk factors from previous and current dialysis sessions. Int J Med Inform 2024; 190:105538. [PMID: 38968689 DOI: 10.1016/j.ijmedinf.2024.105538] [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: 04/11/2023] [Revised: 10/18/2023] [Accepted: 07/01/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND Intradialytic hypotension (IDH) is one of the most common and critical complications of hemodialysis. Despite many proven factors associated with IDH, accurately predicting it before it occurs for individual patients during dialysis sessions remains a challenge. PURPOSE To establish artificial intelligence (AI) predictive models for IDH, which consider risk factors from previous and ongoing dialysis to optimize model performance. We then implement a novel digital dashboard with the best model for continuous monitoring of patients' status undergoing hemodialysis. The AI dashboard can display the real-time probability of IDH for each patient in the hemodialysis center providing an objective reference for care members for monitoring IDH and treating it in advance. METHODS Eight machine learning (ML) algorithms, including Logistic Regression (LR), Random Forest (RF), Support Vector Machine (SVM), K Nearest Neighbor (KNN), Light Gradient Boosting Machine (LightGBM), Multilayer Perception (MLP), eXtreme Gradient Boosting (XGBoost), and NaiveBayes, were used to establish the predictive model of IDH to determine if the patient will acquire IDH within 60 min. In addition to real-time features, we incorporated several features sourced from previous dialysis sessions to improve the model's performance. The electronic medical records of patients who had undergone hemodialysis at Chi Mei Medical Center between September 1, 2020 and December 31, 2020 were included in this research. Impact evaluation of AI assistance was conducted by IDH rate. RESULTS The results showed that the XGBoost model had the best performance (accuracy: 0.858, sensitivity: 0.858, specificity: 0.858, area under the curve: 0.936) and was chosen for AI dashboard implementation. The care members were delighted with the dashboard providing real-time scientific probabilities for IDH risk and historic predictive records in a graphic style. Other valuable functions were appended in the dashboard as well. Impact evaluation indicated a significant decrease in IDH rate after the application of AI assistance. CONCLUSION This AI dashboard provides high-quality results in IDH risk prediction during hemodialysis. High-risk patients for IDH will be recognized 60 min earlier, promoting individualized preventive interventions as part of the treatment plan. Our approachis believed to promise an excellent way for IDH management.
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Affiliation(s)
- I-Ning Yang
- Division of Nephrology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan; Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chung-Feng Liu
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan.
| | - Chih-Chiang Chien
- Division of Nephrology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Hsien-Yi Wang
- Division of Nephrology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan; Department of Sport Management, College of Leisure and Recreation Management, Chia Nan University of Pharmacy and Science, Tainan City, Taiwan
| | - Jhi-Joung Wang
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
| | - Yu-Ting Shen
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Chia-Chun Chen
- Department of Information Systems, Chi Mei Medical Center, Liouying Tainan, Taiwan.
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Callum J, Skubas NJ, Bathla A, Keshavarz H, Clark EG, Rochwerg B, Fergusson D, Arbous S, Bauer SR, China L, Fung M, Jug R, Neill M, Paine C, Pavenski K, Shah PS, Robinson S, Shan H, Szczepiorkowski ZM, Thevenot T, Wu B, Stanworth S, Shehata N. Use of Intravenous Albumin: A Guideline From the International Collaboration for Transfusion Medicine Guidelines. Chest 2024; 166:321-338. [PMID: 38447639 PMCID: PMC11317816 DOI: 10.1016/j.chest.2024.02.049] [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: 11/21/2023] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Albumin is used commonly across a wide range of clinical settings to improve hemodynamics, to facilitate fluid removal, and to manage complications of cirrhosis. The International Collaboration for Transfusion Medicine Guidelines developed guidelines for the use of albumin in patients requiring critical care, undergoing cardiovascular surgery, undergoing kidney replacement therapy, or experiencing complications of cirrhosis. STUDY DESIGN AND METHODS Cochairs oversaw the guideline development process and the panel included researchers, clinicians, methodologists, and a patient representative. The evidence informing this guideline arises from a systematic review of randomized clinical trials and systematic reviews, in which multiple databases were searched (inception through November 23, 2022). The panel reviewed the data and formulated the guideline recommendations using Grading of Recommendations Assessment, Development, and Evaluation methodology. The guidelines were revised after public consultation. RESULTS The panel made 14 recommendations on albumin use in adult critical care (three recommendations), pediatric critical care (one recommendation), neonatal critical care (two recommendations), cardiovascular surgery (two recommendations), kidney replacement therapy (one recommendation), and complications of cirrhosis (five recommendations). Of the 14 recommendations, two recommendations had moderate certainty of evidence, five recommendations had low certainty of evidence, and seven recommendations had very low certainty of evidence. Two of the 14 recommendations suggested conditional use of albumin for patients with cirrhosis undergoing large-volume paracentesis or with spontaneous bacterial peritonitis. Twelve of 14 recommendations did not suggest albumin use in a wide variety of clinical situations where albumin commonly is transfused. INTERPRETATION Currently, few evidence-based indications support the routine use of albumin in clinical practice to improve patient outcomes. These guidelines provide clinicians with actionable recommendations on the use of albumin.
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Affiliation(s)
- Jeannie Callum
- Department of Pathology and Molecular Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada.
| | - Nikolaos J Skubas
- Department of Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | | | | | - Edward G Clark
- Division of Nephrology, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Bram Rochwerg
- Department of Medicine and Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Dean Fergusson
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Sesmu Arbous
- Department of Critical Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH
| | - Louise China
- Department of Hepatology and Institute for Liver and Digestive Health, The Royal Free NHS Trust and University College London, London, England
| | - Mark Fung
- Department of Pathology and Laboratory Medicine, University of Vermont Medical Center, Burlington, VT
| | - Rachel Jug
- University of Cincinnati College of Medicine, Cincinnati, OH
| | | | - Cary Paine
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| | - Katerina Pavenski
- Department of Laboratory Medicine and Pathobiology, Mount Sinai Hospital, Toronto, ON, Canada
| | - Prakesh S Shah
- Institute of Health Policy, Management, and Evaluation, Mount Sinai Hospital, Toronto, ON, Canada; Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada
| | - Susan Robinson
- Department of Clinical Haematology, Guy's and St Thomas' NHS Foundation Trust, London, England
| | - Hua Shan
- Department of Pathology, Stanford University School of Medicine, Palo Alto, CA
| | | | - Thierry Thevenot
- Service d'Hépatologie, Centre Hospitalier Régional et Universitaire de Besançon, Besançon, France
| | - Bovey Wu
- Department of Internal Medicine, Graduate Medical Education, Loma Linda University, Loma Linda, CA
| | - Simon Stanworth
- NHS Blood and Transplant, Oxford, England; Radcliffe Department of Medicine, University of Oxford, Oxford, England; John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Nadine Shehata
- Department of Medicine, University of Toronto, Mount Sinai Hospital, Toronto, ON, Canada; Transfusion Medicine Laboratory, Mount Sinai Hospital, Toronto, ON, Canada
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Prasad R, Vignesh S, Yadav RR, Sharma S, Hasani P, Yadav T, Israrahmed A, Lal H. Direct Percutaneous Thrombolysis (DPT): A novel method of salvaging Thrombosed Native Arteriovenous Fistula. J Vasc Access 2024; 25:1158-1163. [PMID: 36750968 DOI: 10.1177/11297298231153196] [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] [Indexed: 02/09/2023] Open
Abstract
INTRODUCTION Thrombosed arteriovenous fistulas (AVFs) are either treated by thrombectomy or pharmaco-mechanical thrombolysis with or without percutaneous balloon angioplasty. In this study, we have described an effective and economical technique of salvaging these fistulae using a 20-22-gauge spinal needle and urokinase and have named it direct percutaneous thrombolysis (DPT). MATERIALS AND METHOD This prospective study comprised of 148 patients out of which 120 patients presented with AVF thrombosis and were divided into two groups; those with no obvious stenosis on ultrasound (n = 38) and second with venous stenosis (n = 82). Remaining 28 patients developed thrombosis post angioplasty for venous stenosis. Percutaneous injection of urokinase into the thrombus was done under ultrasound guidance, followed by balloon angioplasty if there was associated stenosis. RESULTS In 38 patients who didn't have any stenosis, 32 AVFs were successfully thrombolysed by DPT, with technical success of 84.2%. Remaining six patients required angioplasty because of chronic nature of clot. In 82 patients who had venous stenosis, 80 cases were treated successfully by DPT followed by angioplasty with technical success of 97.5%. In third group (n = 28), who developed thrombosis post angioplasty, 100% success rate was noted. The mean length of thrombus was 31.4 ± 4.6 mm and mean diameter of thrombosed vein was 10.5 ± 1.2 mm. There were no major complications encountered during the procedure. Minor complications were seen in 19 patients which included prolonged oozing from puncture site and local hematoma formation. CONCLUSION Ultrasound guided DPT with urokinase is a safe and economical option for salvaging thrombosed AVF without vascular stenosis that does not need angioplasty.
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Affiliation(s)
- Raghunandan Prasad
- Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Selvamurugan Vignesh
- Department of Imaging Sciences & Interventional Radiology, Meenakshi Mission Hospital & Research Centre, Madurai, Tamil Nadu, India
| | - Rajanikant R Yadav
- Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Srishti Sharma
- Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Prerna Hasani
- Department of Radiology, Bhailal Amin Hospital, Vadodara, Gujarat, India
| | - Tanya Yadav
- Department of Radiodiagnosis, Narayana Super Speciality Hospital, Gurugram, Haryana, India
| | - Amrin Israrahmed
- Division of Intervention Radiology, Medanta Hospital, Lucknow, Uttar Pradesh, India
| | - Hira Lal
- Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Kolben Y, Gork I, Peled D, Amitay S, Moshel P, Goldstein N, Ben Ishay A, Fons M, Tabi M, Eisenkraft A, Gepner Y, Nachman D. Continuous Monitoring of Advanced Hemodynamic Parameters during Hemodialysis Demonstrated Early Variations in Patients Experiencing Intradialytic Hypotension. Biomedicines 2024; 12:1177. [PMID: 38927384 PMCID: PMC11200556 DOI: 10.3390/biomedicines12061177] [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: 04/03/2024] [Revised: 05/18/2024] [Accepted: 05/23/2024] [Indexed: 06/28/2024] Open
Abstract
Intradialytic hypotension (IDH) is a severe complication of hemodialysis (HD) with a significant impact on morbidity and mortality. In this study, we used a wearable device for the continuous monitoring of hemodynamic vitals to detect hemodynamic changes during HD and attempted to identify IDH. End-stage kidney disease patients were continuously monitored 15 min before starting the session and until 15 min after completion of the session, measuring heart rate (HR), noninvasive cuffless systolic and diastolic blood pressure (SBP and DBP), stroke volume (SV), cardiac output (CO), and systemic vascular resistance (SVR). Data were analyzed retrospectively and included comparing BP measured by the wearable devices (recorded continuously every 5 s) and the cuff-based devices. A total of 98 dialysis sessions were included in the final analysis, and IDH was identified in 22 sessions (22.5%). Both SBP and DBP were highly correlated (r > 0.62, p < 0.001 for all) between the wearable device and the cuff-based measurements. Based on the continuous monitoring, patients with IDH had earlier and more profound reductions in SBP and DBP during the HD treatment. In addition, nearly all of the advanced vitals differed between groups. Further studies should be conducted in order to fully understand the potential of noninvasive advanced continuous monitoring in the prediction and prevention of IDH events.
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Affiliation(s)
- Yotam Kolben
- Heart Institute, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel; (Y.K.); (S.A.); (P.M.); (D.N.)
| | - Ittamar Gork
- Department of Nephrology and Hypertension, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel;
| | - David Peled
- Department of Health Promotion, School of Public Health, Faculty of Medicine and Health, Sylvan Adams Sports Institute, Tel Aviv University, Tel Aviv 6997801, Israel; (D.P.); (Y.G.)
| | - Shani Amitay
- Heart Institute, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel; (Y.K.); (S.A.); (P.M.); (D.N.)
| | - Peleg Moshel
- Heart Institute, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel; (Y.K.); (S.A.); (P.M.); (D.N.)
| | - Nir Goldstein
- Biobeat Technologies Ltd., Petah Tikva 4937213, Israel; (N.G.); (A.B.I.); (M.F.); (M.T.)
| | - Arik Ben Ishay
- Biobeat Technologies Ltd., Petah Tikva 4937213, Israel; (N.G.); (A.B.I.); (M.F.); (M.T.)
| | - Meir Fons
- Biobeat Technologies Ltd., Petah Tikva 4937213, Israel; (N.G.); (A.B.I.); (M.F.); (M.T.)
| | - Michael Tabi
- Biobeat Technologies Ltd., Petah Tikva 4937213, Israel; (N.G.); (A.B.I.); (M.F.); (M.T.)
| | - Arik Eisenkraft
- Biobeat Technologies Ltd., Petah Tikva 4937213, Israel; (N.G.); (A.B.I.); (M.F.); (M.T.)
- Institute for Research in Military Medicine, Faculty of Medicine, The Hebrew University of Jerusalem and the Israel Defense Force Medical Corps, Jerusalem 9112102, Israel
| | - Yftach Gepner
- Department of Health Promotion, School of Public Health, Faculty of Medicine and Health, Sylvan Adams Sports Institute, Tel Aviv University, Tel Aviv 6997801, Israel; (D.P.); (Y.G.)
| | - Dean Nachman
- Heart Institute, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel; (Y.K.); (S.A.); (P.M.); (D.N.)
- Institute for Research in Military Medicine, Faculty of Medicine, The Hebrew University of Jerusalem and the Israel Defense Force Medical Corps, Jerusalem 9112102, Israel
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Al Nusair H, Hamdan W, Garma J, Eid A, Alnjadat R, Al-Nsair N, Fonbuena M, Davao C. The Implementation of a Modified Fluid Assessment Tool to Improve the Clinical Assessment, Detection, and Management of Blood Pressure Control and Fluid Alterations Among Hemodialysis Patients. Int J Nephrol Renovasc Dis 2023; 16:261-268. [PMID: 38107557 PMCID: PMC10723595 DOI: 10.2147/ijnrd.s440990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/29/2023] [Indexed: 12/19/2023] Open
Abstract
Background Fluid overload is a common complication of the care of End-stage Renal Disease patients that may lead to prolonged hospitalization and mortality. This warrants an effective and systemic approach to early recognition and management to improve patient outcomes. Aim This study aims to evaluate the effect of a modified fluid assessment tool to improve accurate clinical assessments, detection, and management of blood pressure control and fluid alteration among hemodialysis patients. Methods In this retrospective study, data were collected from forty-three dialysis patients who were seen and followed up from a dialysis unit of an acute care hospital during 8 weeks of standard care. A modified assessment tool was used to systematically highlight the appropriateness of the patient set dry weight using intradialytic weight gain (IWDG) and patient blood pressure. Paired sample t-test and repeated measure ANOVA within-group analysis were applied to compare the mean difference score for IDWG and the mean arterial pressure within the study group, respectively. Result A total of 43 patients were enrolled (mean age, 59.07) (ranges 27-88 years) (SD - 14.30); 51.16% female; 79% Emirati Nationals, with Chronic Kidney Disease. A repeated measure ANOVA analysis showed a significant difference in the mean arterial pressure within the study group based on time, over six measurements (p = 0.001). However, the difference between the pre- and post-intra-dialytic weight gain mean scores yields insignificant results (p = 0.346). Conclusion The implementation of a modified assessment tool improved blood pressure control, increased staff and physician involvement in assessing patient dry weight facilitated through fluid status evaluation, methodical assessment of dry weight, and precise fluid removal calculation, enhancing overall blood pressure and fluid management in HD patients.
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Affiliation(s)
- Hussam Al Nusair
- Dialysis Department, Sheikh Khalifa General Hospital, Umm Al Quwain, United Arab Emirates
| | - Wael Hamdan
- Dialysis Department, Sheikh Khalifa General Hospital, Umm Al Quwain, United Arab Emirates
| | - Joy Garma
- Dialysis Department, Sheikh Khalifa General Hospital, Umm Al Quwain, United Arab Emirates
| | - Ahmed Eid
- Dialysis Department, Sheikh Khalifa General Hospital, Umm Al Quwain, United Arab Emirates
| | - Rafi Alnjadat
- Applied Health Sciences, Al-Balqa Applied University, Irbid, Jordan
| | - Nezam Al-Nsair
- College of Nursing, Xavier University, Cincinnati, OH, USA
| | - Mariezl Fonbuena
- Dialysis Department, Sheikh Khalifa General Hospital, Umm Al Quwain, United Arab Emirates
| | - Christin Davao
- Dialysis Department, Sheikh Khalifa General Hospital, Umm Al Quwain, United Arab Emirates
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Hong D, Chang H, He X, Zhan Y, Tong R, Wu X, Li G. Construction of an Early Alert System for Intradialytic Hypotension before Initiating Hemodialysis Based on Machine Learning. KIDNEY DISEASES (BASEL, SWITZERLAND) 2023; 9:433-442. [PMID: 37901708 PMCID: PMC10601920 DOI: 10.1159/000531619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 06/05/2023] [Indexed: 10/31/2023]
Abstract
Introduction Intradialytic hypotension (IDH) is prevalent and associated with high hospitalization and mortality rates. The purpose of this study was to explore the risk factors for IDH and use artificial intelligence to establish an early alert system before hemodialysis sessions to identify patients at high risk of IDH. Materials and Methods We obtained data on 314,534 hemodialysis sessions conducted at Sichuan Provincial People's Hospital from the renal disease treatment information system. IDH was defined as a systolic blood pressure drop ≥20 mm Hg, a mean arterial pressure drop ≥10 mm Hg during dialysis, or the occurrence of clinical hypotensive events requiring nursing intervention. After pre-processing, the data were randomly divided into training (80%) and testing (20%) sets. Four interpolation methods, three feature selection methods, and 18 machine learning algorithms were used to construct predictive models. The area under the receiver operating characteristic curve (AUC) was the main indicator for evaluating the performance of the models, while Shapley Additive ExPlanation was used to explain the contribution of each variable to the best predictive model. Results A total of 3,906 patients and 314,534 dialysis sessions were included, of which 142,237 cases showed IDH (incidence rate, 45.2%). Nineteen parameters were identified through artificial intelligence feature screening. They included age, pre-dialysis weight, dry weight, pre-dialysis blood pressure, heart rate, prescribed ultrafiltration, blood cell counts (neutrophil, lymphocyte, monocyte, eosinophil, lymphocyte, and platelet counts), hematocrit, serum calcium, creatinine, urea, glucose, and uric acid. Random forest, gradient boosting, and logistic regression were the three best models, and the AUCs were 0.812 (95% confidence interval [CI], 0.811-0.813), 0.748 (95% CI, 0.747-0.749), and 0.743 (95% CI, 0.742-0.744), respectively. Conclusion Our dialysis software-based artificial intelligence alert system can be used to predict IDH occurrence, enabling the initiation of relevant interventions.
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Affiliation(s)
- Daqing Hong
- Department of Nephrology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Huan Chang
- Department of Pharmacy, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Xin He
- Department of Nephrology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Department of Nephrology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Ya Zhan
- Department of Nephrology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Department of Nephrology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Rongsheng Tong
- Department of Pharmacy, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Xingwei Wu
- Department of Pharmacy, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Guisen Li
- Department of Nephrology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
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Husain-Syed F, Takeuchi T, Neyra JA, Ramírez-Guerrero G, Rosner MH, Ronco C, Tolwani AJ. Acute kidney injury in neurocritical care. Crit Care 2023; 27:341. [PMID: 37661277 PMCID: PMC10475203 DOI: 10.1186/s13054-023-04632-1] [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: 04/18/2023] [Accepted: 08/30/2023] [Indexed: 09/05/2023] Open
Abstract
Approximately 20% of patients with acute brain injury (ABI) also experience acute kidney injury (AKI), which worsens their outcomes. The metabolic and inflammatory changes associated with AKI likely contribute to prolonged brain injury and edema. As a result, recognizing its presence is important for effectively managing ABI and its sequelae. This review discusses the occurrence and effects of AKI in critically ill adults with neurological conditions, outlines potential mechanisms connecting AKI and ABI progression, and highlights AKI management principles. Tailored approaches include optimizing blood pressure, managing intracranial pressure, adjusting medication dosages, and assessing the type of administered fluids. Preventive measures include avoiding nephrotoxic drugs, improving hemodynamic and fluid balance, and addressing coexisting AKI syndromes. ABI patients undergoing renal replacement therapy (RRT) are more susceptible to neurological complications. RRT can negatively impact cerebral blood flow, intracranial pressure, and brain tissue oxygenation, with effects tied to specific RRT methods. Continuous RRT is favored for better hemodynamic stability and lower risk of dialysis disequilibrium syndrome. Potential RRT modifications for ABI patients include adjusted dialysate and blood flow rates, osmotherapy, and alternate anticoagulation methods. Future research should explore whether these strategies enhance outcomes and if using novel AKI biomarkers can mitigate AKI-related complications in ABI patients.
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Affiliation(s)
- Faeq Husain-Syed
- Division of Nephrology, University of Virginia School of Medicine, 1300 Jefferson Park Avenue, Charlottesville, VA, 22908, USA
- Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus-Liebig-University Giessen, Klinikstrasse 33, 35392, Giessen, Germany
| | - Tomonori Takeuchi
- Division of Nephrology, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
- Department of Health Policy and Informatics, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo Ku, Tokyo, 113-8510, Japan
| | - Javier A Neyra
- Division of Nephrology, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Gonzalo Ramírez-Guerrero
- Critical Care Unit, Carlos Van Buren Hospital, San Ignacio 725, Valparaíso, Chile
- Dialysis and Renal Transplant Unit, Carlos Van Buren Hospital, San Ignacio 725, Valparaíso, Chile
- Department of Medicine, Universidad de Valparaíso, Hontaneda 2653, Valparaíso, Chile
| | - Mitchell H Rosner
- Division of Nephrology, University of Virginia School of Medicine, 1300 Jefferson Park Avenue, Charlottesville, VA, 22908, USA
| | - Claudio Ronco
- Department of Medicine (DIMED), Università di Padova, Via Giustiniani, 2, 35128, Padua, Italy
- International Renal Research Institute of Vicenza, Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Via Rodolfi, 37, 36100, Vicenza, Italy
| | - Ashita J Tolwani
- Division of Nephrology, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL, 35294, USA.
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8
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Gervasoni F, Bellocchio F, Rosenberger J, Arkossy O, Ion Titapiccolo J, Kovarova V, Larkin J, Nikam M, Stuard S, Tripepi GL, Usvyat LA, Winter A, Neri L, Zoccali C. Development and validation of AI-based triage support algorithms for prevention of intradialytic hypotension. J Nephrol 2023; 36:2001-2011. [PMID: 37707692 DOI: 10.1007/s40620-023-01741-6] [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: 02/15/2023] [Accepted: 07/19/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Intradialytic hypotension remains one of the most recurrent complications of dialysis sessions. Inadequate management can lead to adverse outcomes, highlighting the need to develop personalized approaches for the prevention of intradialytic hypotension. Here, we sought to develop and validate two AI-based risk models predicting the occurrence of symptomatic intradialytic hypotension at different time points. METHODS The models were built using the XGBoost algorithm and they predict the occurrence of intradialytic hypotension in the next dialysis session and in the next month. The initial dataset, obtained from routinely collected data in the EuCliD® Database, was split to perform model derivation, training and validation. Model performance was evaluated by concordance statistic and calibration charts; the importance of features was assessed with the Shapley Additive Explanation (SHAP) methodology. RESULTS The final dataset included 1,249,813 dialysis sessions, and the incidence rate of intradialytic hypotension was 10.07% (95% CI 10.02-10.13). Our models retained good discrimination (AUC around 0.8) and a suitable calibration yielding to the selection of three classification thresholds identifying four distinct risk groups. Variables providing the most significant impact on risk estimates were blood pressure dynamics and other metrics mirroring hemodynamic instability over time. CONCLUSIONS Recurrent symptomatic intradialytic hypotension could be reliably and accurately predicted using routinely collected data during dialysis treatment and standard clinical care. Clinical application of these prediction models would allow for personalized risk-based interventions for preventing and managing intradialytic hypotension.
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Affiliation(s)
| | | | - Jaroslav Rosenberger
- FMC-Dialysis Services Slovakia, Kosice, Slovakia
- Medical Faculty, University of PJ Safarik, Kosice, Slovakia
| | - Otto Arkossy
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | | | | | | | - Milind Nikam
- Fresenius Medical Care, Singapore, 307684, Singapore
| | - Stefano Stuard
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | | | | | - Anke Winter
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Luca Neri
- Fresenius Medical Care Italia SpA, Palazzo Pignano, Italy.
| | - Carmine Zoccali
- Renal Research Institute, New York, USA
- Associazione Ipertensione Nefrologia e Trapianto Renale (IPNET) c/o Nefrologia e CNR, Grande Ospedale Metropolitano, Reggio Calabria, Italy
- Biologia E Genetica Molecolare (BIOGEM) Research Center, Ariano Irpino, Avellino, Italy
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Hamrahian SM, Vilayet S, Herberth J, Fülöp T. Prevention of Intradialytic Hypotension in Hemodialysis Patients: Current Challenges and Future Prospects. Int J Nephrol Renovasc Dis 2023; 16:173-181. [PMID: 37547077 PMCID: PMC10404053 DOI: 10.2147/ijnrd.s245621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 07/25/2023] [Indexed: 08/08/2023] Open
Abstract
Intradialytic hypotension, defined as rapid decrease in systolic blood pressure of greater than or equal to 20 mmHg or in mean arterial pressure of greater than or equal to 10 mmHg that results in end-organ ischemia and requires countermeasures such as ultrafiltration reduction or saline infusion to increase blood pressure to improve patient's symptoms, is a known complication of hemodialysis and is associated with several potential adverse outcomes. Its pathogenesis is complex and involves both patient-related factors such as age and comorbidities, as well as factors related to the dialysis prescription itself. Key factors include the need for volume removal during hemodialysis and a suboptimal vascular response which compromises the ability to compensate for acute intravascular volume loss. Inadequate vascular refill, incorrect assessment or unaccounted changes of target weight, acute illnesses and medication interference are further potential contributors. Intradialytic hypotension can lead to compromised tissue perfusion and end-organ damage, both acutely and over time, resulting in repetitive injuries. To address these problems, a careful assessment of subjective symptoms, minimizing interdialytic weight gains, individualizing dialysis prescription and adjusting the dialysis procedure based on patients' risk factors can mitigate negative outcomes.
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Affiliation(s)
| | - Salem Vilayet
- Department of Medicine - Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA
| | - Johann Herberth
- Department of Medicine - Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA
- Medicine Services, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
| | - Tibor Fülöp
- Department of Medicine - Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA
- Medicine Services, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
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10
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Mao Y, Xu L, Xu J, Tang Y, Liu T. Application Value of Limb Ischemic Preconditioning in Preventing Intradialytic Hypotension during Maintenance Hemodialysis. Kidney Blood Press Res 2023; 48:535-544. [PMID: 37497943 PMCID: PMC10614484 DOI: 10.1159/000531855] [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: 01/12/2023] [Accepted: 06/26/2023] [Indexed: 07/28/2023] Open
Abstract
INTRODUCTION The aim of this study was to investigate the efficacy and safety of limb ischemia preconditioning (LIPC) in the treatment of intradialytic hypotension (IDH) in patients with maintenance hemodialysis (MHD). METHODS This was a single-center, prospective, and randomized controlled case study. A total of 38 patients with MHD who met the inclusion criteria from September 2021 to August 2022 were selected from the Blood Purification Center of our hospital. They were randomly divided into the LIPC group (n = 19) and the control group (n = 19). For patients in the LIPC group, the femoral artery blood flow was blocked with an LIPC instrument for 5 min (pressurized to 200 mm Hg) before each dialysis, and they were reperfused for 5 min. The cycle was repeated five times, with a total of 50 min for 12 weeks. The control group was pressurized to 20 mm Hg with an LIPC instrument, and the rest was the same as the LIPC group. The blood pressure of 0 h, 1 h, 2 h, 3 h, 4 h, and body weight before and after hemodialysis were measured in the two groups during hemodialysis, the incidence of IDH and the changes of serum troponin I (TNI) and creatine kinase isoenzyme MB (CK-MB) levels before and after the intervention were observed, and the ultrafiltration volume and ultrafiltration rate were recorded. RESULTS At the 8th and 12th week after intervention, the MAP in the LIPC group was higher than that in the control group (103.28 ± 12.19 mm Hg vs. 93.18 ± 11.11 mm Hg, p = 0.04; 101.81 ± 11.36 mm Hg vs. 91.81 ± 11.92 mm Hg, p = 0.047). The incidence of IDH in the LIPC group was lower than that in the control group (36.5% vs. 43.1%, p = 0.01). The incidence of clinical treatment in IDH patients in the LIPC group was lower than that in the control group (6.3% vs. 12.4%, p = 0.00). The incidence of early termination of hemodialysis in the LIPC group was lower than that in the control group (1.6% vs. 3.8%, p = 0.01). The levels of TNI and CK-MB in the LIPC group after the intervention were lower than those in the control group (322.30 ± 13.72 ng/dL vs. 438.50 ± 24.72 ng/dL, p = 0.00; 159.78 ± 8.48 U/dL vs. 207.00 ± 8.70 U/dL, p = 0.00). The changes of MAP before and after the intervention were negatively correlated with the changes of TNI and CK-MB before and after the intervention (r = -0.473, p = 0.04; r = -0.469, p = 0.04). There were no differences in dry body mass and ultrafiltration rate between the two groups before and after the LIPC intervention (p > 0.05). Multiple linear regression analysis shows that TNI is the main influencing factor of ΔMAP. No LIPC-related adverse events were found during the study period. CONCLUSION LIPC can effectively reduce the incidence of IDH in patients with MHD and may be associated with the alleviation of myocardial damage.
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Affiliation(s)
- Yaqin Mao
- Division of Nephrology, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, China,
- Graduate School, Dalian Medical University, Dalian, China,
| | - Linfang Xu
- Blood Purification Center, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, China
| | - Juntian Xu
- Division of Nephrology, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, China
- Graduate School, Dalian Medical University, Dalian, China
| | - Yushang Tang
- Division of Nephrology, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, China
- Blood Purification Center, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, China
| | - Tongqiang Liu
- Division of Nephrology, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, China
- Blood Purification Center, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, China
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11
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Inoue H, Oya M, Aizawa M, Wagatsuma K, Kamimae M, Kashiwagi Y, Ishii M, Wakabayashi H, Fujii T, Suzuki S, Hattori N, Tatsumoto N, Kawakami E, Asanuma K. Predicting dry weight change in Hemodialysis patients using machine learning. BMC Nephrol 2023; 24:196. [PMID: 37386392 PMCID: PMC10308746 DOI: 10.1186/s12882-023-03248-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 06/19/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Machine Learning has been increasingly used in the medical field, including managing patients undergoing hemodialysis. The random forest classifier is a Machine Learning method that can generate high accuracy and interpretability in the data analysis of various diseases. We attempted to apply Machine Learning to adjust dry weight, the appropriate volume status of patients undergoing hemodialysis, which requires a complex decision-making process considering multiple indicators and the patient's physical conditions. METHODS All medical data and 69,375 dialysis records of 314 Asian patients undergoing hemodialysis at a single dialysis center in Japan between July 2018 and April 2020 were collected from the electronic medical record system. Using the random forest classifier, we developed models to predict the probabilities of adjusting the dry weight at each dialysis session. RESULTS The areas under the receiver-operating-characteristic curves of the models for adjusting the dry weight upward and downward were 0.70 and 0.74, respectively. The average probability of upward adjustment of the dry weight had sharp a peak around the actual change over time, while the average probability of downward adjustment of the dry weight formed a gradual peak. Feature importance analysis revealed that median blood pressure decline was a strong predictor for adjusting the dry weight upward. In contrast, elevated serum levels of C-reactive protein and hypoalbuminemia were important indicators for adjusting the dry weight downward. CONCLUSIONS The random forest classifier should provide a helpful guide to predict the optimal changes to the dry weight with relative accuracy and may be useful in clinical practice.
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Affiliation(s)
- Hiroko Inoue
- Department of Nephrology, Graduate School of Medicine, Chiba University, Chuo-ku, Chiba, Japan
| | - Megumi Oya
- Department of Artificial Intelligence Medicine, Graduate School of Medicine, Chiba University, Chuo- ku, Chiba, Japan
- Advanced Data Science Project (ADSP), RIKEN Information R&D and Strategy Headquarters, RIKEN, Yokohama, Kanagawa, Japan
| | - Masashi Aizawa
- Department of Nephrology, Graduate School of Medicine, Chiba University, Chuo-ku, Chiba, Japan
| | - Kyogo Wagatsuma
- Department of Artificial Intelligence Medicine, Graduate School of Medicine, Chiba University, Chuo- ku, Chiba, Japan
- Advanced Data Science Project (ADSP), RIKEN Information R&D and Strategy Headquarters, RIKEN, Yokohama, Kanagawa, Japan
| | - Masatomo Kamimae
- Department of Artificial Intelligence Medicine, Graduate School of Medicine, Chiba University, Chuo- ku, Chiba, Japan
- Advanced Data Science Project (ADSP), RIKEN Information R&D and Strategy Headquarters, RIKEN, Yokohama, Kanagawa, Japan
| | - Yusuke Kashiwagi
- Department of Nephrology, Graduate School of Medicine, Chiba University, Chuo-ku, Chiba, Japan
| | - Masayoshi Ishii
- Department of Nephrology, Graduate School of Medicine, Chiba University, Chuo-ku, Chiba, Japan
- Department of Artificial Kidney, Chiba University Hospital, Chuo-ku, Chiba, Japan
| | - Hanae Wakabayashi
- Department of Nephrology, Graduate School of Medicine, Chiba University, Chuo-ku, Chiba, Japan
- Department of Artificial Kidney, Chiba University Hospital, Chuo-ku, Chiba, Japan
| | - Takayuki Fujii
- Department of Nephrology, Seirei Sakura Citizen hospital, Sakura, Chiba, Japan
| | - Satoshi Suzuki
- Department of Nephrology, Seirei Sakura Citizen hospital, Sakura, Chiba, Japan
| | - Noriyuki Hattori
- Department of Artificial Kidney, Chiba University Hospital, Chuo-ku, Chiba, Japan
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Narihito Tatsumoto
- Department of Nephrology, Graduate School of Medicine, Chiba University, Chuo-ku, Chiba, Japan
| | - Eiryo Kawakami
- Department of Artificial Intelligence Medicine, Graduate School of Medicine, Chiba University, Chuo- ku, Chiba, Japan.
- Advanced Data Science Project (ADSP), RIKEN Information R&D and Strategy Headquarters, RIKEN, Yokohama, Kanagawa, Japan.
| | - Katsuhiko Asanuma
- Department of Nephrology, Graduate School of Medicine, Chiba University, Chuo-ku, Chiba, Japan.
- Department of Artificial Kidney, Chiba University Hospital, Chuo-ku, Chiba, Japan.
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Singh AT, Yen TE, Mothi SS, Waikar SS, Mc Causland FR. Associations of Iron Sucrose and Intradialytic Blood Pressure. Am J Kidney Dis 2023; 81:647-654. [PMID: 36587889 PMCID: PMC10205679 DOI: 10.1053/j.ajkd.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 11/02/2022] [Indexed: 12/30/2022]
Abstract
RATIONALE & OBJECTIVE Intradialytic hypotension and intradialytic hypertension are associated with morbidity and mortality in hemodialysis (HD). Many factors can contribute to intra-HD blood pressure (BP) changes, such as drugs with vasoactive properties that can destabilize an already tenuous BP. Intravenous iron sucrose is commonly administered to correct iron deficiency; however, its reported associations with altered hemodynamics have not been consistent. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS 950 outpatients receiving maintenance HD. EXPOSURE Iron sucrose administered during HD. OUTCOME Intradialytic hypotension, intradialytic hypertension, systolic blood pressure parameters. ANALYTICAL APPROACH Unadjusted and adjusted Poisson and linear repeated measures regression models. RESULTS The mean age of patients included in the study was 53±22 years, 43% were female, and 38% were Black. Mean pre-HD SBP was 152±26 (SD) mm Hg. At baseline, the patients who received higher doses of iron sucrose tended to have diabetes, have longer HD sessions, and have a higher frequency of erythropoiesis-stimulating agent use, compared with those who did not receive iron sucrose. In adjusted models, higher doses of iron sucrose were associated with an 11% lower rate of intradialytic hypotension (incidence rate ratio [IRR] for iron sucrose≥100mg vs 0 mg, 0.89 [95% CI, 0.85-0.94]). In adjusted analyses, the administration of higher doses of iron sucrose during HD was associated with intradialytic hypertension (IRR for iron sucrose≥100mg vs 0 mg, 1.07 [95% CI, 1.04-1.10]). LIMITATIONS Nonavailability of the precise iron sucrose formulation (volume), laboratory data for each HD session, and outpatient medications. Objective measures of volume status, home medications, and symptom data were not recorded in this study. CONCLUSIONS We observed an independent association of intravenous iron sucrose administration during HD with a lower risk of intradialytic hypotension and higher risk of intradialytic hypertension. Future studies to better understand the mechanisms underlying these associations are warranted. PLAIN-LANGUAGE SUMMARY Intradialytic hypotension and intradialytic hypertension are common among patients on hemodialysis, and they are associated with morbidity and mortality. Although many factors may contribute to these risks, medications administered during hemodialysis play an important role. We studied the significance of the intravenous iron sucrose used to treat iron deficiency and the impact it may have on blood pressure during dialysis. In our study of 950 outpatient hemodialysis patients, we observed that administration of iron sucrose was associated with higher systolic blood pressure (during and after hemodialysis sessions) as well as a lower risk of intradialytic hypotension. We also observed that higher doses of iron sucrose are associated with the development of intradialytic hypertension.
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Affiliation(s)
- Anika T Singh
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Medical School, Boston, Massachusetts.
| | - Timothy E Yen
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Medical School, Boston, Massachusetts
| | | | - Sushrut S Waikar
- Section of Nephrology, Department of Medicine, School of Medicine, and Boston Medical Center, Boston University, Boston, Massachusetts
| | - Finnian R Mc Causland
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Medical School, Boston, Massachusetts
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Li J, Xing Y, Zhang Y, Cui C, Wang J, Li J, Liu C. Evaluation of autonomic nervous system activity in intradialytic hypotension using entropy and skin sympathetic nerve activity. Front Neurosci 2023; 17:1196750. [PMID: 37255747 PMCID: PMC10225985 DOI: 10.3389/fnins.2023.1196750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 04/24/2023] [Indexed: 06/01/2023] Open
Abstract
Introduction The function of the autonomic nervous system (ANS) is crucial in the development of intradialytic hypotension (IDH). This study introduced the entropy of heart rate variability (HRV) and skin sympathetic nerve activity (SKNA) to provide a complementary nonlinear and dynamic perspective for evaluating ANS function concerning IDH. Methods 93 patients undergoing hemodialysis (HD) were enrolled, and the baseline data, electrocardiogram (ECG), and SKNA were collected. The patients were separated into the IDH and nonIDH groups based on the thresholds, which were characterized as reductions in systolic blood pressure (SBP) of at least 20 mm Hg or mean arterial pressure (MAP) of at least 10 mm Hg. We developed a logistic regression model for IDH after analyzing the changes in the time domain, frequency domain, the entropy of HRV, and SKNA indices during HD. Results After 4-h HD, the detected results for heart rate, the ratio of low frequency and high frequency (LF/HF), and average SKNA (aSKNA) all increased in both groups. Nine out of the ten HRV indices and aSKNA in the nonIDH group were higher than those in the IDH group at most moments. aSKNA was positively correlated with heart rate (p = 0.0001) and LF/HF (p = 0.0005) in the nonIDH group, while the correlation disappeared in the IDH group, which indicated a worse ANS response in IDH patients. The logistic regression model exhibited the results of initial SBP [odds ratio (OR) 1.076; p = 0.001], and the difference between the last and first segments (DLF) of heart rate [OR 1.101; p =0.012] and LF/HF [OR 0.209; p =0.034], as well as the extreme value of the difference between other segments and the first segments (EOF) of aSKNA [OR 2.908; p =0.017], which were independent indicators for IDH. Discussion The new nonlinear and dynamic assessment perspectives provided by the entropy of HRV and SKNA help to distinguish differences in ANS patterns between IDH patients and nonIDH patients and have the potential to be used in clinical monitoring for HD patients.
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Affiliation(s)
- Jiayi Li
- State Key Laboratory of Digital Medical Engineering, School of Instrument Science and Engineering, Southeast University, Nanjing, China
| | - Yantao Xing
- State Key Laboratory of Digital Medical Engineering, School of Instrument Science and Engineering, Southeast University, Nanjing, China
| | - Yike Zhang
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Chang Cui
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jing Wang
- Division of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jianqing Li
- State Key Laboratory of Digital Medical Engineering, School of Instrument Science and Engineering, Southeast University, Nanjing, China
| | - Chengyu Liu
- State Key Laboratory of Digital Medical Engineering, School of Instrument Science and Engineering, Southeast University, Nanjing, China
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14
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Gamboa JL, Mambungu CA, Clagett AR, Nian H, Yu C, Ikizler TA, Brown NJ. Bradykinin B 2 receptor blockade and intradialytic hypotension. BMC Nephrol 2023; 24:134. [PMID: 37170244 PMCID: PMC10176680 DOI: 10.1186/s12882-023-03192-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 04/30/2023] [Indexed: 05/13/2023] Open
Abstract
INTRODUCTION Intradialytic hypotension (IDH) is a common clinical complication and is associated with increased morbidity and mortality in patients undergoing maintenance hemodialysis (MHD). The pathogenesis of IDH has been attributed to the rapid reduction of plasma volume during hemodialysis and the inadequate compensatory mechanisms in response to hypovolemia, such as the lack of vasoconstriction. This may be due to the increased production of vasodilators, such as bradykinin. In this study we test the hypothesis that bradykinin B2 receptor blockade prevents intradialytic hypotension. METHODS We performed a post-hoc analysis of a double-blind, placebo-controlled, randomized, 2 × 2 crossover clinical trial comparing the continuous infusion of icatibant, a bradykinin B2 receptor blocker, and placebo during hemodialysis. Icatibant or placebo was infused for 30 min before and during hemodialysis in 11 patients on MHD. RESULTS Seven of the patients had IDH, defined as a reduction of systolic blood pressure equal to or greater than 20 mmHg during hemodialysis. Stratified analysis, based on the presence of IDH, revealed that icatibant prevented the decrease in blood pressure compared to placebo in patients with IDH [blood pressure at average nadir (2.5 h after hemodialysis): Placebo,114.3 ± 8.9 vs. icatibant, 125.6 ± 9.1 mmHg, mean ± S.E.M]. Icatibant did not affect blood pressure in the group of patients without IDH. CONCLUSION Bradykinin B2 receptor blocker may prevent the occurrence of IDH. Further studies should evaluate the hemodynamic effects of icatibant during hemodialysis and the symptomatology associated with IDH.
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Affiliation(s)
- Jorge L Gamboa
- Department of Medicine, Division of Clinical Pharmacology, Vanderbilt University Medical Center, 2222 Pierce Avenue 561B-PRB, Nashville, TN, 37232-6602, USA.
| | - Cindy A Mambungu
- Veterans Administration Tennessee Valley Healthcare System, Nashville, TN, USA
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Adrienne R Clagett
- Veterans Administration Tennessee Valley Healthcare System, Nashville, TN, USA
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hui Nian
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chang Yu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - T Alp Ikizler
- Veterans Administration Tennessee Valley Healthcare System, Nashville, TN, USA
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nancy J Brown
- Department of Medicine, Division of Clinical Pharmacology, Vanderbilt University Medical Center, 2222 Pierce Avenue 561B-PRB, Nashville, TN, 37232-6602, USA
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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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Chan RJ, Helmeczi W, Canney M, Clark EG. Management of Intermittent Hemodialysis in the Critically Ill Patient. Clin J Am Soc Nephrol 2023; 18:245-255. [PMID: 35840348 PMCID: PMC10103228 DOI: 10.2215/cjn.04000422] [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] [Indexed: 11/23/2022]
Abstract
Intermittent hemodialysis remains a cornerstone of extracorporeal KRT in the intensive care unit, either as a first-line therapy for AKI or a second-line therapy when patients transition from a continuous or prolonged intermittent therapy. Intermittent hemodialysis is usually provided 3 days per week in this setting on the basis that no clinical benefits have been demonstrated with more frequent hemodialysis. This should not detract from the importance of continually assessing and refining the hemodialysis prescription (including the need for extra treatments) according to dynamic changes in extracellular volume and other parameters, and ensuring that an adequate dose of hemodialysis is being delivered to the patient. Compared with other KRT modalities, the cardinal challenge encountered during intermittent hemodialysis is hemodynamic instability. This phenomenon occurs when reductions in intravascular volume, as a consequence of ultrafiltration and/or osmotic shifts, outpace compensatory plasma refilling from the extravascular space. Myocardial stunning, triggered by intermittent hemodialysis, and independent of ultrafiltration, may also contribute. The hemodynamic effect of intermittent hemodialysis is likely magnified in patients who are critically ill due to an inability to mount sufficient compensatory physiologic responses in the context of multiorgan dysfunction. Of the many interventions that have undergone testing to mitigate hemodynamic instability related to KRT, the best evidence exists for cooling the dialysate and raising the dialysate sodium concentration. Unfortunately, the evidence supporting routine use of these and other interventions is weak owing to poor study quality and limited sample sizes. Intermittent hemodialysis will continue to be an important and commonly used KRT modality for AKI in patients with critical illness, especially in jurisdictions where resources are limited. There is an urgent need to harmonize the definition of hemodynamic instability related to KRT in clinical trials and robustly test strategies to combat it in this vulnerable patient population.
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Affiliation(s)
- Ryan J. Chan
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Wryan Helmeczi
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Mark Canney
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Edward G. Clark
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Niemczyk L, Romejko K, Szamotulska K, Schneditz D, Niemczyk S. Changes of Hemodynamic Parameters after Intradialytic Glucose Injection. Nutrients 2023; 15:nu15020437. [PMID: 36678308 PMCID: PMC9865591 DOI: 10.3390/nu15020437] [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: 12/01/2022] [Revised: 12/28/2022] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Intradialytic hypotension (IDH) is a frequent complication of hemodialysis (HD). Current methods of IDH prevention are insufficient. METHODS We analyzed the intradialytic time course of systolic (SBP), diastolic (DBP), mean arterial (MAP), pulse pressure (PP), and heart rate (HR) in a group of chronic kidney disease (CKD) patients. First, 30 min into HD, a 40% glucose solution was injected into the venous line of the extracorporeal circulation at a dose of 0.5 g/kg of dry weight. Pressures and HR were measured in frequent intervals. Relative volume overload was determined by bioimpedance spectroscopy. RESULTS Thirty-five participants were studied. SBP increased after 5, 10, and 20 min of glucose infusion. DBP increased after 2 and 3 h and also at the end of HD. PP increased after 5, 10, and 20 min of glucose infusion and fell after the 2nd and 3rd hour and also at the end of HD. MAP increased after 2 and 3 h of glucose injection and at the end of HD. Significant interactions of the time course of SBP, DBP, MAP, with HR at baseline and of the time course of PP with fluid overload were observed. Symptomatic hypotensive episodes were absent. CONCLUSIONS Glucose infusions during HD prevent symptomatic IDH and do not cause severe hypertensive episodes.
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Affiliation(s)
- Longin Niemczyk
- Department of Nephrology, Dialysis and Internal Diseases, Medical University of Warsaw, 1a Banacha Street, 02-097 Warsaw, Poland
| | - Katarzyna Romejko
- Department of Internal Diseases, Nephrology and Dialysis, Military Institute of Medicine, 128 Szaserów Street, 04-141 Warsaw, Poland
- Correspondence:
| | - Katarzyna Szamotulska
- Department of Epidemiology and Biostatistics, Institute of Mother and Child, 17 a Kasprzaka Street, 01-211 Warsaw, Poland
| | - Daniel Schneditz
- Otto Loewi Research Center, Division of Physiology, Medical University of Graz, Neue Stiftingtalstrasse 6/V, 8010 Graz, Austria
| | - Stanisław Niemczyk
- Department of Internal Diseases, Nephrology and Dialysis, Military Institute of Medicine, 128 Szaserów Street, 04-141 Warsaw, Poland
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Chinese Clinical Practice Guideline for the Management of "CKD-PeriDialysis"-the Periods Prior to and in the Early-Stage of Initial Dialysis. Kidney Int Rep 2022; 7:S531-S558. [PMID: 36567827 PMCID: PMC9782818 DOI: 10.1016/j.ekir.2022.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/26/2022] [Accepted: 10/03/2022] [Indexed: 12/14/2022] Open
Abstract
The National Experts Group on Nephrology have developed these guidelines to improve the management of pre-dialysis and initial dialysis patients with chronic kidney disease (CKD) (two periods contiguous with dialysis initiation termed here 'PeriDialysis CKD'). The pre-dialysis period is variable, whereas the initial dialysis period is more fixed at 3 months to 6 months after initiating dialysis. The new concept and characteristics of 'CKD-PeriDialysis' are proposed in the guideline. During the CKD-PeriDialysis period, the incidence rate of complications, mortality and treatment cost significantly increases and the glomerular filtration rate (GFR) rapidly decreases, which requires intensive management. The guideline systematically and comprehensively elaborates the recommendations for indicators to be used in for disease evaluation, timing and mode selection of renal replacement therapy, dialysis adequacy evaluation, and diagnosis and treatment of common PeriDialysis complications. Finally, future research directions of CKD-PeriDialysis are proposed. CKD-PeriDialysis management is a difficult clinical issue in kidney disease, and the development and implementation of these guidelines is important to improve the management of CKD-PeriDialysis patients in China, which could ultimately improve survival rates and quality of life, and reduce the medical burden.
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Allinovi M, Palazzini G, Lugli G, Gianassi I, Dallari L, Laudicina S, Gregori M, Rossi F, Giannerini D, Cutruzzulà R, Dervishi E, Biagini M, Cirami CL. Pre-Dialysis B-Line Quantification at Lung Ultrasound Is a Useful Method for Evaluating the Dry Weight and Predicting the Risk of Intradialytic Hypotension. Diagnostics (Basel) 2022; 12:diagnostics12122990. [PMID: 36552997 PMCID: PMC9776885 DOI: 10.3390/diagnostics12122990] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/22/2022] [Accepted: 11/26/2022] [Indexed: 12/02/2022] Open
Abstract
Intradialytic hypotension (IDH) is a frequent and well-known complication of hemodialysis, occurring in about one third of patients. An integrated approach with different methods is needed to minimize IDH episodes and their complications. In this prospective observational study, recruited patients underwent a multiparametric evaluation of fluid status through a lung ultrasound (LUS) with the quantification of B-lines, a physical examination, blood pressure, NT-proBNP and chest X-rays. The evaluation took place immediately before and at the end of the dialysis session, and the patients were divided into IDH and no-IDH groups. We recruited a total of 107 patients. A pre-dialysis B-line number ≥ 15 showed a high sensitivity in fluid overload diagnosis (94.5%), even higher than a chest X-ray (78%) or physical examination (72%) alone. The identification at the beginning of dialysis of <8 B-lines in the overall cohort or <20 B-lines in patients with NYHA 3−4 class are optimal thresholds for identifying those patients at higher risk of experiencing an IDH episode. In the multivariable analysis, the NYHA class, a low pre-dialysis systolic BP and a low pre-dialysis B-line number were independent risk factors for IDH. At the beginning of dialysis, the B-line quantification at LUS is a valuable and reliable method for evaluating fluid status and predicting IDH episodes. A post-dialysis B-line number <5 may allow for an understanding of whether the IDH episode was caused by dehydration, probably due to due to an overestimation of the dry weight.
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Affiliation(s)
- Marco Allinovi
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
- Correspondence:
| | - Giulia Palazzini
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
- Department of Biomedical Experimental and Clinical Sciences “Mario Serio”, University of Florence, 50121 Florence, Italy
| | - Gianmarco Lugli
- Department of Biomedical Experimental and Clinical Sciences “Mario Serio”, University of Florence, 50121 Florence, Italy
- Nephrology Unit, Meyer Children’s Hospital, 50139 Florence, Italy
| | - Iacopo Gianassi
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
| | - Lorenzo Dallari
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
- Department of Biomedical Experimental and Clinical Sciences “Mario Serio”, University of Florence, 50121 Florence, Italy
| | - Selene Laudicina
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
- Department of Biomedical Experimental and Clinical Sciences “Mario Serio”, University of Florence, 50121 Florence, Italy
| | - Marco Gregori
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin University Hospital, 33076 Bordeaux, France
| | - Francesco Rossi
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
| | - Daniele Giannerini
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
| | - Roberta Cutruzzulà
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
| | - Egrina Dervishi
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
| | - Maria Biagini
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
| | - Calogero Lino Cirami
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
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Moderator Effect of Hypoalbuminemia in Volume Resuscitation and Plasma Expansion with Intravenous Albumin Solution. Int J Mol Sci 2022; 23:ijms232214175. [PMID: 36430652 PMCID: PMC9695189 DOI: 10.3390/ijms232214175] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/13/2022] [Accepted: 11/15/2022] [Indexed: 11/18/2022] Open
Abstract
Intravenous administration of crystalloid or colloid solutions is the most common intervention for correcting hypovolemia in intensive care unit patients. In critical illness, especially sepsis and severe trauma, vascular wall permeability increases, and trans-endothelial escape of serum albumin, the major oncotic plasma constituent, contributes to the development of hypoalbuminemia and edema formation. The volume effects of intravenous human albumin solution exceed those of crystalloid solutions. If hypoalbuminemia is an effect moderator, the crystalloid-to-albumin ratio of fluid resuscitation volumes is not well characterized. Randomized controlled trials have confirmed that intravenous administration of human albumin solutions for volume resuscitation results in a lower net fluid balance compared with crystalloids, and smaller infusion volumes may be sufficient for hemodynamic stabilization when human albumin solutions are used. This narrative review summarizes the current evidence and conclusions drawn regarding the role of hypoalbuminemia in volume resuscitation. In the 'Saline versus Albumin Fluid Evaluation' study using 4% human albumin solution or saline, the saline-to-albumin ratio of study fluids was significantly higher in patients with baseline serum albumin concentrations of 25 g/L or less as compared to patients with baseline serum albumin concentrations of more than 25 g/L. In patients receiving renal replacement therapy, intravenous administration of 20-25% human albumin solution reduces intradialytic hypotension and improves fluid removal better than saline if serum albumin levels are similarly reduced. These data suggest that hypoalbuminemia acts as an effect moderator in volume resuscitation and plasma expansion with albumin solution. The volume effectiveness of intravenous human albumin solution in resuscitation appears to be greater when the serum albumin levels are low. In clinical situations, serum albumin concentrations per se may inform when and how to include intravenous albumin in fluid resuscitation if large amounts of crystalloids are needed, which requires further studies.
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Aronson D. The interstitial compartment as a therapeutic target in heart failure. Front Cardiovasc Med 2022; 9:933384. [PMID: 36061549 PMCID: PMC9428749 DOI: 10.3389/fcvm.2022.933384] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 07/15/2022] [Indexed: 12/23/2022] Open
Abstract
Congestion is the single most important contributor to heart failure (HF) decompensation. Most of the excess volume in patients with HF resides in the interstitial compartment. Inadequate decongestion implies persistent interstitial congestion and is associated with worse outcomes. Therefore, effective interstitial decongestion represents an unmet need to improve quality of life and reduce clinical events. The key processes that underlie incomplete interstitial decongestion are often ignored. In this review, we provide a summary of the pathophysiology of the interstitial compartment in HF and the factors governing the movement of fluids between the interstitial and vascular compartments. Disruption of the extracellular matrix compaction occurs with edema, such that the interstitium becomes highly compliant, and large changes in volume marginally increase interstitial pressure and allow progressive capillary filtration into the interstitium. Augmentation of lymph flow is required to prevent interstitial edema, and the lymphatic system can increase fluid removal by at least 10-fold. In HF, lymphatic remodeling can become insufficient or maladaptive such that the capacity of the lymphatic system to remove fluid from the interstitium is exceeded. Increased central venous pressure at the site of the thoracic duct outlet also impairs lymphatic drainage. Owing to the kinetics of extracellular fluid, microvascular absorption tends to be transient (as determined by the revised Starling equation). Therefore, effective interstitial decongestion with adequate transcapillary plasma refill requires a substantial reduction in plasma volume and capillary pressure that are prolonged and sustained, which is not always achieved in clinical practice. The critical importance of the interstitium in the congestive state underscores the need to directly decongest the interstitial compartment without relying on the lowering of intracapillary pressure with diuretics. This unmet need may be addressed by novel device therapies in the near future.
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Affiliation(s)
- Doron Aronson
- Department of Cardiology, Rambam Health Care Campus, B. Rappaport Faculty of Medicine, Technion Medical School, Haifa, Israel
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22
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Alirezaei T, Jebreil Moosavi MJ, Irilouzadian R, Taziki E. Elevated Cardiac Troponin I following Asymptomatic Intradialytic Hypotension: A Pilot Study with a 2-Year Follow-Up. Int J Clin Pract 2022; 2022:4214429. [PMID: 35966145 PMCID: PMC9359825 DOI: 10.1155/2022/4214429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 06/25/2022] [Accepted: 07/12/2022] [Indexed: 11/18/2022] Open
Abstract
Background Intradialytic hypotension (IDH) has been recognized as a serious and frequent complication during hemodialysis (HD) of end-stage renal disease (ESRD) patients, but the effect of asymptomatic IDH on cardiac troponin I (cTnI) levels is not definitively elucidated. Methods 70 asymptomatic HD patients with negative predialysis cTnI were included. They were on maintenance HD thrice weekly. All patients were monitored during the HD session for hemodynamic changes and symptoms related to IDH. Patients were followed for two years, and their outcomes are noted as an acute coronary syndrome (ACS), cardiac death, no ACS, noncardiac death, and kidney transplant. Results Compared with the baseline blood pressure values, there was a drop in systolic blood pressure for all subjects, but according to the 2007 European Best Practice Guidelines on hemodynamic instability, asymptomatic IDH was defined in 27 (38.6%) patients. The results demonstrated a significant correlation (r = 0.492) (p < 0.05) between asymptomatic IDH and elevated postdialysis levels of cTnI. In 2-year follow-up of patients, ACS and cardiac death happened more in patients with elevated cTnI. Conclusion The results of our study suggest that asymptomatic IDH affects cTnI levels. Given that cTnI is a marker of myocardial damage and a predictor of cardiovascular mortality in ESRD patients, these findings recommend that considering the asymptomatic decrease in blood pressure levels during HD is very important and critical.
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Affiliation(s)
- Toktam Alirezaei
- Clinical Research Development Unit of Shohada-e Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mir Jafar Jebreil Moosavi
- Clinical Research Development Unit of Shohada-e Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Rana Irilouzadian
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Elahe Taziki
- Clinical Research Development Unit of Shohada-e Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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23
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Using the Intelligent System to Improve the Delivered Adequacy of Dialysis by Preventing Intradialytic Complications. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:8160269. [PMID: 35783584 PMCID: PMC9246598 DOI: 10.1155/2022/8160269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 03/30/2022] [Accepted: 05/26/2022] [Indexed: 01/26/2023]
Abstract
Acute kidney failure patients while detoxificated by hemodialysis (HD) mostly or continuously faced regular problems such as low blood pressure (hypotension), muscle cramps, nausea, or vomiting. Higher intradialytic symptom leads to low-quality HD treatment. Although more known therapeutic interventions are used to relieve the HD side effects, this study was designed to investigate how intelligent systems can make highly beneficial alterations in dialysis facilities and equipment to ease intradialytic complications and help the staff deliver high-quality treatment. A search was performed among relevant research articles based on nonpharmacological intervention methods considered to prevent adverse effects of renal replacement therapy until 2020 in the PubMed databases using the terms “intradialytic complications,” “intradialytic complication interventions,” “nonpharmacological interventions,” “intradialytic exercises,” and “adequacy calculation methods.” Studies included the prevalence of intradialytic complications, different strategies with the aim of preventing complications, the outcome of intradialytic exercises on dialysis symptoms, and dialysis dose calculation methods. The results showed the incidence of hypotension varying between 5% and 30%, fatigue, muscular cramps, and vomiting as the most common complications during dialysis, which greatly affect the outcome of HD sessions. To prevent hypotension, ultrafiltration profiling, sodium modeling, low dialysate temperature, and changing the position to Trendelenburg are some strategies. Urea reduction ratio (URR), formal urea kinetic modeling (FUKM), formal single-pool urea kinetics, and online clearance monitoring (OCM) are methods for calculating the delivered dose of dialysis in which OCM is a low-cost and accessible way to monitor regularly the quality of dialysis delivered. Integration of the chair and HD machine which is in direct contact with the patient provides an intelligent system that improves the management of the dialysis session to enhance the quality of healthcare service.
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24
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Mizuiri S, Nishizawa Y, Doi T, Yamashita K, Shigemoto K, Usui K, Arita M, Naito T, Doi S, Masaki T. Coronary artery calcification is a risk factor for intradialytic hypotension in patients undergoing hemodialysis. Hemodial Int 2022; 26:335-344. [DOI: 10.1111/hdi.13016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 01/27/2022] [Accepted: 03/25/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Sonoo Mizuiri
- Division of Nephrology Ichiyokai Harada Hospital Hiroshima Japan
| | | | - Toshiki Doi
- Division of Nephrology Ichiyokai Harada Hospital Hiroshima Japan
- Department of Nephrology Hiroshima University Hospital Hiroshima Japan
| | | | | | - Koji Usui
- Ichiyokai Ichiyokai Clinic Hiroshima Japan
| | | | | | - Shigehiro Doi
- Department of Nephrology Hiroshima University Hospital Hiroshima Japan
| | - Takao Masaki
- Department of Nephrology Hiroshima University Hospital Hiroshima Japan
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25
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Yang X, Zhao D, Yu F, Heidari AA, Bano Y, Ibrohimov A, Liu Y, Cai Z, Chen H, Chen X. An optimized machine learning framework for predicting intradialytic hypotension using indexes of chronic kidney disease-mineral and bone disorders. Comput Biol Med 2022; 145:105510. [DOI: 10.1016/j.compbiomed.2022.105510] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 04/07/2022] [Accepted: 04/07/2022] [Indexed: 11/03/2022]
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Canaud B, Kooman JP, Selby NM, Taal M, Maierhofer A, Kopperschmidt P, Francis S, Collins A, Kotanko P. Hidden risks associated with conventional short intermittent hemodialysis: A call for action to mitigate cardiovascular risk and morbidity. World J Nephrol 2022; 11:39-57. [PMID: 35433339 PMCID: PMC8968472 DOI: 10.5527/wjn.v11.i2.39] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 10/30/2021] [Accepted: 03/23/2022] [Indexed: 02/06/2023] Open
Abstract
The development of maintenance hemodialysis (HD) for end stage kidney disease patients is a success story that continues to save many lives. Nevertheless, intermittent renal replacement therapy is also a source of recurrent stress for patients. Conventional thrice weekly short HD is an imperfect treatment that only partially corrects uremic abnormalities, increases cardiovascular risk, and exacerbates disease burden. Altering cycles of fluid loading associated with cardiac stretching (interdialytic phase) and then fluid unloading (intradialytic phase) likely contribute to cardiac and vascular damage. This unphysiologic treatment profile combined with cyclic disturbances including osmotic and electrolytic shifts may contribute to morbidity in dialysis patients and augment the health burden of treatment. As such, HD patients are exposed to multiple stressors including cardiocirculatory, inflammatory, biologic, hypoxemic, and nutritional. This cascade of events can be termed the dialysis stress storm and sickness syndrome. Mitigating cardiovascular risk and morbidity associated with conventional intermittent HD appears to be a priority for improving patient experience and reducing disease burden. In this in-depth review, we summarize the hidden effects of intermittent HD therapy, and call for action to improve delivered HD and develop treatment schedules that are better tolerated and associated with fewer adverse effects.
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Affiliation(s)
- Bernard Canaud
- Global Medical Office, Fresenius Medical Care, Bad Homburg 61352, Germany
- Department of Nephrology, Montpellier University, Montpellier 34000, France
| | - Jeroen P Kooman
- Department of Internal Medicine, Maastricht University, Maastricht 6229 HX, Netherlands
| | - Nicholas M Selby
- Centre for Kidney Research and Innovation, Academic Unit for Translational Medical Sciences, School of Medicine, University of Nottingham, Derby DE22 3DT, United Kingdom
| | - Maarten Taal
- Centre for Kidney Research and Innovation, Academic Unit for Translational Medical Sciences, School of Medicine, University of Nottingham, Derby DE22 3DT, United Kingdom
| | - Andreas Maierhofer
- Global Research Development, Fresenius Medical Care, Schweinfurt 97424, Germany
| | | | - Susan Francis
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham NG7 2RD, United Kingdom
| | - Allan Collins
- Global Medical Office, Fresenius Medical Care, Bad Homburg 61352, Germany
| | - Peter Kotanko
- Renal Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10065, United States
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Geer KD. Reconsidering the Trendelenburg position during intradialytic hypotension. Nursing 2022; 52:41-44. [PMID: 35196283 DOI: 10.1097/01.nurse.0000820060.94663.86] [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: 06/14/2023]
Abstract
ABSTRACT Intradialytic hypotension (IDH) is the most common complication that patients experience during hemodialysis. This article discusses IDH and its emergency management, focusing on Trendelenburg position, which may create more risks than benefits.
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Affiliation(s)
- Kristine D Geer
- Kristine D. Geer is an RN with the Rochester Regional Health System in New York, N.Y
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Aoyama Y, Kajimoto K, Hori M, Otsubo S, Nitta K. Predicting factors of intradialytic hypotension in the last half of hemodialysis therapy. RENAL REPLACEMENT THERAPY 2021. [DOI: 10.1186/s41100-021-00336-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Intradialytic hypotension (IDH) is one of the most frequent complications of hemodialysis. IDH alters a patient’s quality of life and has a strong association with mortality. IDH mainly occurs when ultrafiltration during hemodialysis exceeds the pace of the plasma refill. Ultrasonography has been used to evaluate the intravascular volume status. We evaluated the association between IDH and baseline laboratory data or ultrasound findings during IDH during the latter half of a hemodialysis session.
Methods
Sixty-two patients who underwent hemodialysis were enrolled in this study. The peak early mitral inflow wave velocity (peak E-velocity), the inferior vena cava (IVC) dimensions, and number of B-lines were estimated at two time points (just after the start and at the midpoint of the hemodialysis session). We compared the parameters between the patients without IDH throughout the hemodialysis session (non-IDH group) and patients with IDH only during the latter half of the hemodialysis session (IDH in the latter half group).
Results
Of the 62 study participants, 28 patients were in non-IDH group, and 16 patients were in IDH in the latter half group. The serum sodium level was significantly lower in the IDH in the latter half group (135 ± 4 mEq/L) than in the non-IDH group (138 ± 4 mEq/L) (P = 0.015). The rate of decrease of the peak E-velocity was significantly higher in the IDH in the latter half group (0.33 ± 0.13) than in the non-IDH group (0.24 ± 0.14) (P = 0.037). The best cutoff point of the serum level of sodium was 137 mEq/L, with a sensitivity of 68.8% and specificity of 64.3%. The area under the receiver operating characteristic (ROC) curve was 0.71. The best cutoff point of the rate of decrease of the peak E-velocity was 0.295, with a sensitivity of 73.3% and a specificity of 71.4%. The area under the ROC curve was 0.71.
Conclusions
A low serum level of sodium at baseline and an early decrease in the peak E-velocity during hemodialysis may be related to intradialytic hypotension in the latter half of a hemodialysis session. Careful observation may be needed in the hemodialysis patients in whom the serum level of sodium is below 137 mEq/L or the rate of decrease of the peak E-velocity is over 0.295.
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Poorzand H, Sharifipour F, Kerachian A, Ghaderi F, Alimi H, Bigdelu L, Fazlinejad A, Morovatdar N, Ataei B. Echocardiographic parameters in patients with and without hypotension during dialysis. J Cardiovasc Thorac Res 2021; 13:228-233. [PMID: 34630971 PMCID: PMC8493227 DOI: 10.34172/jcvtr.2021.41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 07/08/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Hypotension during dialysis is a common complication of hemodialysis and is associated with increased patient mortality and morbidity. Intradialytic hypotension is a decrease in systolic BP ≥20 mm Hg or a reduction in mean arterial pressure by 10 mm Hg along with clinical events and the need for correction. This study compares cardiac function, using transthoracic echocardiography with strain modality in patients with intradialytic hypotension with those without hypotension during dialysis. Methods: We studied 60 patients with chronic renal failure undergoing regular hemodialysis from April 2018 to February 2019. We compared thirty patients in the intradialytic hypotension group, with the remaining 30 patients in the control group. We did transthoracic echocardiography a day after hemodialysis using conventional, tissue doppler, and strain imaging. Results: Early diastolic mitral annulus velocity (e’) was lower in the intradialytic hypotension group in comparison with the control group which their difference was statistically significant (5.540 ± 1.51 versus 6.920 ± 1.98, P value:0.007) Left Ventricular Ejection Fraction (LVEF) was also significantly lower in the intradialytic hypotension group (51.07 ± 8.714 versus 59.43 ± 4.133, P value < 0.001). Global Longitudinal Strain (GLS) was significantly lower in the intradialytic hypotension group (-14.17 ± 2.79 versus -18.99 ± 2.25, P value < 0.001). The receiver operator characteristics (ROC) curve point-coordinates that GLS of -16.85 and lower (more positive) has 83% sensitivity and 87% specificity for intradialytic hypotension. Conclusion: The echocardiographic assessment could be used as a tool for the prediction of hypotension during dialysis.
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Affiliation(s)
- Hoorak Poorzand
- Vascular and Endovascular Surgery Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Farzaneh Sharifipour
- Kidney Transplantation Research Center, Department of Internal Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Abdollah Kerachian
- Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fereshteh Ghaderi
- Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hedieh Alimi
- Vascular and Endovascular Surgery Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Leila Bigdelu
- Department of Cardiology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Afsoon Fazlinejad
- Department of Cardiology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Negar Morovatdar
- Clinical Research Unit, Faculty of Medicine,Mashhad University of Medical Sciences, Mashhad, Iran
| | - Banafsheh Ataei
- Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Zschätzsch S, Stauss-Grabo M, Gauly A, Braun J. Integrating Monitoring of Volume Status and Blood Volume-Controlled Ultrafiltration into Extracorporeal Kidney Replacement Therapy. Int J Nephrol Renovasc Dis 2021; 14:349-358. [PMID: 34511978 PMCID: PMC8416185 DOI: 10.2147/ijnrd.s319911] [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: 05/12/2021] [Accepted: 08/13/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Volume management in hemodialysis (HD) requires the ability to assess volume status objectively and determine treatment strategies that achieve euvolemia without compromising hemodynamic stability. The aim of this study was to compare dialysis with and without blood volume-controlled ultrafiltration (UF) in combination with body composition monitoring, and to evaluate indicators for adequate dialysis (Kt/V), ultrafiltration volume, fluid status, and the occurrence of intradialytic morbid events (IME). Patients and Methods Patients undergoing hemodialysis or on-line hemodiafiltration with support of a blood volume monitor (BVM) - a feedback control device integrated into the 5008 and 6008 HD systems - were enrolled. Patients received treatment for four weeks using the 6008 CAREsystem and the BVM (6008+). Data on dialysis dose (Kt/V), UF volume and predialysis fluid status were documented. This data was also documented retrospectively for four weeks with (5008+) and without (5008-) the use of the BVM with the 5008 system. Comparisons were analyzed using linear mixed models. Results Twenty-four patients were enrolled. Kt/V was unaffected by blood volume-controlled UF (5008- vs 5008+: p=0.230) and was equally achieved with both HD systems (5008+ vs 6008+: p=0.922). The UF volume and fluid status achieved were comparable, independent of the use of UF control with BVM (5008- vs 5008+; UF volume: p=0.166; fluid overload: p=0.390) or the HD system (5008+ vs 6008+: UF volume: p=0.003; fluid overload: p=0.838), except for UF volume being higher in the 6008+ phase. IMEs occurred in less than 3% of treatments, with no difference between study phases. Conclusion This study demonstrates that a clinical approach to kidney replacement therapy that tracks volume status and manages intradialytic fluid removal by blood volume-controlled UF delivers adequate dialysis without compromising fluid removal. It maintains volume status and ensures low incidence of IMEs.
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Affiliation(s)
- Sebastian Zschätzsch
- Center for Kidney and Blood Pressure Diseases, Georg-Haas-Dialysis Center, Giessen, Germany
| | | | - Adelheid Gauly
- Fresenius Medical Care, Global Medical Office, Bad Homburg, Germany
| | - Jennifer Braun
- Fresenius Medical Care, Global Medical Office, Bad Homburg, Germany
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Agarwal KA, Patel H, Agrawal N, Cardarelli F, Goyal N. Cardiac Outcomes in Isolated Heart and Simultaneous Kidney and Heart Transplants in the United States. Kidney Int Rep 2021; 6:2348-2357. [PMID: 34514196 PMCID: PMC8418976 DOI: 10.1016/j.ekir.2021.06.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 05/27/2021] [Accepted: 06/29/2021] [Indexed: 02/08/2023] Open
Abstract
Introduction Kidney dysfunction is not uncommon in patients with advanced heart failure. Simultaneous kidney and heart transplants (SKHTs) have gained acceptance as a treatment for patients with end-stage heart failure and severe kidney dysfunction. United States saw a rise of 650% in SKHT from 2000 to 2019. Despite increasing number of SKHT, the selection criteria remain poorly defined and vary across transplant centers. Methods We evaluated patient and cardiac allograft survival for SKHT and heart transplant alone (HTA) using the United Network for Organ Sharing (UNOS) database. We then performed a subgroup analysis in recipients with post-transplant acute kidney injury requiring renal replacement therapy (RRT) and compared outcomes between SKHT and HTA recipients. Results Although patient survival was comparable between SKHT and HTA groups (12.4 vs. 11.3 years), patients dependent on dialysis pretransplant derived greater survival advantage from SKHT as compared with HTA (12.4 vs. 9.9 years). Cardiac graft survival was better in SKHT (12.5 vs. 11.2 years). Among patients who developed acute kidney injury requiring RRT postoperatively, SKHT recipients had a significantly better survival (11.9 vs. 2.7 years). Conclusion Our data support consideration of SKHT in dialysis-dependent heart transplant candidates and suggest that patients who are at increased risk of requiring RRT after heart transplant may benefit from SKHT.
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Affiliation(s)
- Krishna Adit Agarwal
- Division of Nephrology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Het Patel
- Division of Nephrology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Nikhil Agrawal
- Division of Nephrology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Francesca Cardarelli
- Division of Nephrology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Nitender Goyal
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
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Yu J, Chen X, Li Y, Wang Y, Cao X, Liu Z, Shen B, Zou J, Ding X. Pro-inflammatory cytokines as potential predictors for intradialytic hypotension. Ren Fail 2021; 43:198-205. [PMID: 33459124 PMCID: PMC7833080 DOI: 10.1080/0886022x.2021.1871921] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background Intradialytic hypotension (IDH) is a common complication in maintaining hemodialysis (MHD) patients. Immune activation might be part of the mechanisms. However, the association between pro-inflammatory cytokines and blood pressure (BP) has not been deeply explored. So we aim to evaluate the potential role of pro-inflammatory cytokines in IDH. Methods MHD patients starting hemodialysis before January 2016 were enrolled in our retrospective study. Patients' characteristics, laboratory results, and intradialytic BP were collected. IDH was defined as nadir systolic BP ≤ 90 mmHg during hemodialysis. The definition of IDH group was that those who suffered from more than one hypotensive event during one month after the enrollment (10% of dialysis treatments). Spearman correlation analysis and logistic regression were employed to explore the relationship between pro-inflammatory cytokines and IDH. Results Among 390 patients, 72 were identified with IDH (18.5%). High levels of serum tumor necrosis factor-α (TNF-α) and interleukin-1β (IL-1β) were observed in the IDH group (p < 0.001). Both TNF-α and IL-1β positively correlated with predialysis BP (p < 0.01). Receiver operating characteristic curve (ROC) analysis was used to evaluate the diagnostic accuracy of serum IL-1β and TNF-α for IDH. The area under the curve of IL-1β was 0.772 (95% CI: 0.708-0.836, p < 0.01), and that of TNF-α was 0.701 (95% CI: 0.620-0.781, p < 0.01). After adjusting for patients' characteristics, biochemical parameters, comorbid conditions, predialysis BP, and medications, elevated TNF-α and IL-1β were still risk factors for IDH. Conclusion Pro-inflammatory cytokines (TNF-α and IL-1β) could be potential predictors for IDH.
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Affiliation(s)
- Jinbo Yu
- Division of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, PR China.,Shanghai Institute of Kidney Disease and Dialysis, Shanghai, PR China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, PR China
| | - Xiaohong Chen
- Division of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, PR China.,Shanghai Institute of Kidney Disease and Dialysis, Shanghai, PR China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, PR China
| | - Yang Li
- Division of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, PR China.,Shanghai Institute of Kidney Disease and Dialysis, Shanghai, PR China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, PR China
| | - Yaqiong Wang
- Division of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, PR China.,Shanghai Institute of Kidney Disease and Dialysis, Shanghai, PR China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, PR China
| | - Xuesen Cao
- Division of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, PR China.,Shanghai Institute of Kidney Disease and Dialysis, Shanghai, PR China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, PR China
| | - Zhonghua Liu
- Division of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, PR China.,Shanghai Institute of Kidney Disease and Dialysis, Shanghai, PR China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, PR China
| | - Bo Shen
- Division of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, PR China.,Shanghai Institute of Kidney Disease and Dialysis, Shanghai, PR China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, PR China
| | - Jianzhou Zou
- Division of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, PR China.,Shanghai Institute of Kidney Disease and Dialysis, Shanghai, PR China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, PR China
| | - Xiaoqiang Ding
- Division of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, PR China.,Shanghai Institute of Kidney Disease and Dialysis, Shanghai, PR China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, PR China
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Use of Sertraline in Hemodialysis Patients. MEDICINA-LITHUANIA 2021; 57:medicina57090949. [PMID: 34577872 PMCID: PMC8470022 DOI: 10.3390/medicina57090949] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 08/29/2021] [Accepted: 09/06/2021] [Indexed: 11/25/2022]
Abstract
Depression and anxiety are the most common psychiatric disorders in end-stage renal disease (ESRD) patients treated with hemodialysis (HD) and may correlate with lower quality of life and increased mortality. Depression treatment in HD patients is still a challenge both for nephrologists and psychiatrists. The possible treatment of depressive disorders can be pharmacological and non-pharmacological. In our article, we focus on the use of sertraline, the medication which seems to be relatively safe and efficient in the abovementioned population, taking under consideration several limitations regarding the use of other selective serotonin reuptake inhibitors (SSRIs). In our paper, we discuss different aspects of sertraline use, taking into consideration possible benefits and side effects of drug administration like impact on QTc (corrected QT interval) prolongation, intradialytic hypotension (IDH), chronic kidney disease-associated pruritus (CKD-aP), bleeding, sexual functions, inflammation, or fracture risk. Before administering the medication, one should consider benefits and possible side effects, which are particularly significant in the treatment of ESRD patients; this could help to optimize clinical outcomes. Sertraline seems to be safe in the HD population when provided in proper doses. However, we still need more studies in this field since the ones performed so far were usually based on small samples and lacked placebo control.
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Comparative analysis of therapeutic effects between medium cut-off and high flux dialyzers using metabolomics and proteomics: exploratory, prospective study in hemodialysis. Sci Rep 2021; 11:17335. [PMID: 34462546 PMCID: PMC8405670 DOI: 10.1038/s41598-021-96974-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 08/10/2021] [Indexed: 12/03/2022] Open
Abstract
In this single-center prospective study of 20 patients receiving maintenance hemodialysis (HD), we compared the therapeutic effects of medium cut-off (MCO) and high flux (HF) dialyzers using metabolomics and proteomics. A consecutive dialyzer membrane was used for 15-week study periods: 1st HF dialyzer, MCO dialyzer, 2nd HF dialyzer, for 5 weeks respectively. 1H-nuclear magnetic resonance was used to identify the metabolites and liquid chromatography-tandem mass spectrometry (LC–MS/MS) analysis was used to identify proteins. To compare the effects of the HF and MCO dialyzers, orthogonal projection to latent structure discriminant analysis (OPLS-DA) was performed. OPLS-DA showed that metabolite characteristics could be significantly classified by 1st HF and MCO dialyzers. The Pre-HD metabolites with variable importance in projection scores ≥ 1.0 in both 1st HF versus MCO and MCO versus 2nd HF were succinate, glutamate, and histidine. The pre-HD levels of succinate and histidine were significantly lower, while those of glutamate were significantly higher in MCO period than in the HF period. OPLS-DA of the proteome also substantially separated 1st HF and MCO periods. Plasma pre-HD levels of fibronectin 1 were significantly higher, and those of complement component 4B and retinol-binding protein 4 were significantly lower in MCO than in the 1st HF period. Interestingly, as per Ingenuity Pathway Analysis, an increase in epithelial cell proliferation and a decrease in endothelial cell apoptosis occurred during the MCO period. Overall, our results suggest that the use of MCO dialyzers results in characteristic metabolomics and proteomics profiles during HD compared with HF dialyzers, which might be related to oxidative stress, insulin resistance, complement-coagulation axis, inflammation, and nutrition.
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Sohn P, Narasaki Y, Rhee CM. Intradialytic hypotension: is timing everything? Kidney Int 2021; 99:1269-1272. [PMID: 34023027 DOI: 10.1016/j.kint.2021.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Intradialytic hypotension (IDH) is a major complication of hemodialysis, leading to myocardial stunning, cerebral hypoperfusion, gut ischemia, loss of residual kidney function, high symptom burden, and death. This study by Keane et al. provides new data on the incidence of IDH over well-defined time intervals during the hemodialysis treatment session, clinical parameters associated with the timing of IDH onset, and whether timing of IDH impacts survival in a nationally representative hemodialysis cohort.
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Affiliation(s)
- Peter Sohn
- Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Yoko Narasaki
- Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Connie M Rhee
- Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA.
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36
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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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Covic A, Siriopol D. Assessment and Management of Volume Overload Among Patients on Chronic Dialysis. Curr Vasc Pharmacol 2021; 19:34-40. [PMID: 32096744 DOI: 10.2174/1570161118666200225093827] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 01/30/2020] [Accepted: 01/31/2020] [Indexed: 12/11/2022]
Abstract
Volume overload is the most common complication in end-stage renal disease (ESRD) patients, being directly related to numerous complications including resistant hypertension, cardiac hypertrophy, congestive heart failure or arterial stiffness, among others. Therefore, volume overload is now considered an important risk factor for hard outcomes, like all-cause or cardiovascular mortality. Relying solely on clinical examination for assessing volume overload in ESRD patients lacks sensitivity and specificity. Numerous efforts have been made to identify new methods that could objectively assess volume status; however, each of them has important limitations. This review aims to discuss the most frequently used methods (biomarkers, inferior vena cava assessment, lung ultrasonography, bioimpedance analysis and blood volume monitoring) and to compare the advantage of each method vs. the overall/ clinical strategy.
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Affiliation(s)
- Adrian Covic
- Nephrology Department, "Grigore T. Popa" University of Medicine and Pharmacy Iasi, Iasi 700115, Romania
| | - Dimitrie Siriopol
- Nephrology Department, "Grigore T. Popa" University of Medicine and Pharmacy Iasi, Iasi 700115, Romania
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38
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Keane D, Glyde M, Dasgupta I, Gardiner C, Lindley E, Mitra S, Palmer N, Dye L, Wright M, Sutherland E. Patient perspectives of target weight management and ultrafiltration in haemodialysis: a multi-center survey. BMC Nephrol 2021; 22:188. [PMID: 34016069 PMCID: PMC8138996 DOI: 10.1186/s12882-021-02399-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 04/30/2021] [Indexed: 12/29/2022] Open
Abstract
Background Decisions around planned ultrafiltration volumes are the only part of the haemodialysis prescription decided upon at every session. Removing too much fluid or too little is associated with both acute symptoms and long-term outcomes. The degree to which patients engage with or influence decision-making is not clear. We explored patient perspectives of prescribing ultrafiltration volumes, their understanding of the process and engagement with it. Methods A questionnaire developed for this study was administered to 1077 patients across 10 UK Renal Units. Factor analysis reduced the dataset into factors representing common themes. Relationships between survey results and factors were investigated using regression models. ANCOVA was used to explore differences between Renal Units. Results Patients generally felt in control of their fluid management and that they were given the final say on planned ultrafiltration volumes. Around half of the respondents reported they take an active role in their treatment. However, respondents were largely unable to relate signs and symptoms to fluid management practice and a third said they would not report common signs and symptoms to clinicians. A fifth of patients reported not to know how ultrafiltration volumes were calculated. Patients responded positively to questions relating to healthcare staff, though with significant variation between units, highlighting differences in perception of care. Conclusions Despite a lack of formal acknowledgement in fluid management protocols, patients have significant involvement in decisions regarding fluid removal during dialysis. Furthermore, substantial gaps remain in patient knowledge and engagement. Formalizing the role of patients in these decisions, including patient education, may improve prescription and achievement of target weights. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-021-02399-7.
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Affiliation(s)
- David Keane
- Renal Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK. .,Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
| | - Megan Glyde
- School of Psychology, University of Leeds, Leeds, UK
| | - Indranil Dasgupta
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | | - Sandip Mitra
- Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK.,Devices for Dignity, NIHR MedTech & In-vitro Diagnostics Co-operative, Sheffield, UK
| | | | - Louise Dye
- School of Psychology, University of Leeds, Leeds, UK
| | - Mark Wright
- Renal Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ed Sutherland
- School of Psychology, University of Leeds, Leeds, UK
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Hryciw N, Joannidis M, Hiremath S, Callum J, Clark EG. Intravenous Albumin for Mitigating Hypotension and Augmenting Ultrafiltration during Kidney Replacement Therapy. Clin J Am Soc Nephrol 2021; 16:820-828. [PMID: 33115729 PMCID: PMC8259476 DOI: 10.2215/cjn.09670620] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Among its many functions, owing to its oversized effect on colloid oncotic pressure, intravascular albumin helps preserve the effective circulatory volume. Hypoalbuminemia is common in hospitalized patients and is found especially frequently in patients who require KRT either for AKI or as maintenance hemodialysis. In such patients, hypoalbuminemia is strongly associated with morbidity, intradialytic hypotension, and mortality. Intravenous albumin may be administered in an effort to prevent or treat hypotension or to augment fluid removal, but this practice is controversial. Theoretically, intravenous albumin administration might prevent or treat hypotension by promoting plasma refilling in response to ultrafiltration. However, clinical trials have demonstrated that albumin administration is not nearly as effective a volume expander as might be assumed according to its oncotic properties. Although intravenous albumin is generally considered to be safe, it is also very expensive. In addition, there are potential risks to using it to prevent or treat intradialytic hypotension. Some recent studies have suggested that hyperoncotic albumin solutions may precipitate or worsen AKI in patients with sepsis or shock; however, the overall evidence supporting this effect is weak. In this review, we explore the theoretical benefits and risks of using intravenous albumin to mitigate intradialytic hypotension and/or enhance ultrafiltration and summarize the current evidence relating to this practice. This includes studies relevant to its use in patients on maintenance hemodialysis and critically ill patients with AKI who require KRT in the intensive care unit. Despite evidence of its frequent use and high costs, at present, there are minimal data that support the routine use of intravenous albumin during KRT. As such, adequately powered trials to evaluate the efficacy of intravenous albumin in this setting are clearly needed.
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Affiliation(s)
- Nicole Hryciw
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Swapnil Hiremath
- Division of Nephrology, Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Jeannie Callum
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Edward G. Clark
- Division of Nephrology, Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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40
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Aoun MH, Hilal N, Beaini C, Sleilaty G, Hajal J, Boueri C, Chelala D. Effects of Caffeinated and Decaffeinated Coffee on Hemodialysis-Related Headache (CoffeeHD): A Randomized Multicenter Clinical Trial. J Ren Nutr 2021; 31:648-660. [PMID: 33715955 DOI: 10.1053/j.jrn.2021.01.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/30/2020] [Accepted: 01/23/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES Historically, headache was reported in up to 76% of hemodialysis patients. Some authors suggested that headache resulted from caffeine withdrawal. This study aims to compare the incidence of headache and hypotension between patients drinking regular or decaffeinated coffee during dialysis. METHODS One-hundred fifty-six patients were enrolled in this randomized, double-blind, placebo-controlled, multicenter study. Patients with atrial fibrillation were excluded. Group A was given 80 mL of regular coffee and group B 80 mL of decaffeinated coffee (placebo) in the middle of the session for 12 consecutive sessions. Ultrafiltration rate was fixed to a maximum of 13 mL/kg/hour. The primary outcome was the incidence of headache during dialysis. RESULTS A total of 139 patients completed the trial (6.4% vs. 15.4% of withdrawal in Groups A and B, respectively). The number of sessions with headache was not significantly different between Group A and B (33.3% vs. 37.1% respectively, P = .522), nor the number of sessions with hypotension (27% vs. 26% respectively, P = .539). In a subgroup analysis, headache tended to be more frequent in Group B (P = .06) in 2 categories of patients: those with the highest potassium dialysate (K = 2) and the non-hypertensive patients. CONCLUSIONS Headache occurred in 35% of patients during their chronic hemodialysis sessions. Caffeine intake did not prevent headache occurrence in these patients.
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Affiliation(s)
- Mabel H Aoun
- Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon; Department of Nephrology, Saint-Georges Hospital, Ajaltoun, Lebanon.
| | - Najla Hilal
- Department of Nephrology, Saint-Georges Hospital, Ajaltoun, Lebanon
| | - Chadia Beaini
- Department of Nephrology, Bellevue Medical Center, Mansourieh, Lebanon
| | - Ghassan Sleilaty
- Department of Biostatistics and Clinical Research Center, Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon; Department of Cardiovascular Surgery, Hôtel-Dieu de France Hospital, Beirut, Lebanon
| | - Joseph Hajal
- Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon; Department of Nephrology, Hôtel-Dieu de France Hospital, Beirut, Lebanon
| | - Celine Boueri
- Department of Nephrology, Saint-Georges Hospital, Ajaltoun, Lebanon
| | - Dania Chelala
- Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon; Department of Nephrology, Hôtel-Dieu de France Hospital, Beirut, Lebanon
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Tangvoraphonkchai K, Davenport A. Changes in extracellular water with hemodialysis and fall in systolic blood pressure. Int J Artif Organs 2021; 45:140-145. [PMID: 33611962 PMCID: PMC8793311 DOI: 10.1177/0391398821995503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Introduction: Intra-dialytic hypotension (IDH) remains the most common complication with outpatient hemodialysis (HD) sessions. As fluid is removed during HD, there is contraction of the extracellular volume (ECW). We wished to determine whether the fall in ECW was associated with a fall in systolic blood pressure (SBP). Methods: We retrospectively reviewed the records of adult dialysis outpatients attending for their midweek sessions who had corresponding pre- and post-HD bioimpedance measurements of ECW. Result: We reviewed 736 patients, median age 67 (54–76) years, 62.8% male, 45.7% diabetic with a median dialysis vintage of 24.4 (9.2–56.8) months. The percentage fall in ECW (ECW%) was associated with post-dialysis systolic blood pressure (SBP) (r = −0.14, p < 0.001). Patients with SBP falls of >20 mmHg had a greater fall in ECW% compared to patients with stable SBP 7.6 (4.6–10.1) vs 6.0 (4.0–8.5), p < 0.001). Patients with greater dialyzer urea clearance had greater fall in ECW% (r = 0.19, p < 0.001). In a logistic model an increased fall in ECW% was associated with weight loss (odds ratio (OR) 1.88, 95% confidence limits (CL) 1.62–2.176, p < 0.001), and session duration (OR 1.45 (CL 1.05–1.99), p = 0.024), and negatively with hemodiafiltration compared to hemodialysis (OR 0.37 (0.19–0.74) p = 0.005 and dialysate sodium to plasma gradient (OR 0.95 (CL 0.90–0.99), p = 0.021). Conclusion: We observed an association between the reduction in ECW and SBP with dialysis. Our results would advocate monitoring ECW changes during dialysis and developing biofeedback devices to control ultrafiltration and dialysate sodium to reduce the risk of IDH.
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Affiliation(s)
| | - Andrew Davenport
- UCL Department of Nephrology, Royal Free Hospital, University College London, London, UK
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Keane DF, Raimann JG, Zhang H, Willetts J, Thijssen S, Kotanko P. The time of onset of intradialytic hypotension during a hemodialysis session associates with clinical parameters and mortality. Kidney Int 2021; 99:1408-1417. [PMID: 33607178 PMCID: PMC8165353 DOI: 10.1016/j.kint.2021.01.018] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 12/17/2020] [Accepted: 01/13/2021] [Indexed: 02/06/2023]
Abstract
Intradialytic hypotension (IDH) is a common complication of hemodialysis, but there is no data about the time of onset during treatment. Here we describe the incidence of IDH throughout hemodialysis and associations of time of hypotension with clinical parameters and survival by analyzing data from 21 dialysis clinics in the United States to include 785682 treatments from 4348 patients. IDH was defined as a systolic blood pressure of 90 mmHg or under while IDH incidence was calculated in 30-minute intervals throughout the hemodialysis session. Associations of time of IDH with clinical and treatment parameters were explored using logistic regression and with survival using Cox-regression. Sensitivity analysis considered further IDH definitions. IDH occurred in 12% of sessions at a median time interval of 120-149 minutes. There was no notable change in IDH incidence across hemodialysis intervals (range: 2.6-3.2 episodes per 100 session-intervals). Relative blood volume and ultrafiltration volume did not notably associate with IDH in the first 90 minutes but did thereafter. Associations between central venous but not arterial oxygen saturation and IDH were present throughout hemodialysis. Patients prone to IDH early as compared to late in a session had worse survival. Sensitivity analyses suggested IDH definition affects time of onset but other analyses were comparable. Thus, our study highlights the incidence of IDH during the early part of hemodialysis which, when compared to later episodes, associates with clinical parameters and mortality.
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Affiliation(s)
- David F Keane
- Research Division, Renal Research Institute, New York, New York, USA; Medical Physics and Engineering, Leeds Teaching Hospitals NHS Trust, Leeds, UK; Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
| | - Jochen G Raimann
- Research Division, Renal Research Institute, New York, New York, USA
| | - Hanjie Zhang
- Research Division, Renal Research Institute, New York, New York, USA
| | - Joanna Willetts
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts, USA
| | - Stephan Thijssen
- Research Division, Renal Research Institute, New York, New York, USA
| | - Peter Kotanko
- Research Division, Renal Research Institute, New York, New York, USA; Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Abstract
PURPOSE OF REVIEW The aim of this study was to summarize the current evidence around the impact of individualizing patient care following an episode of acute kidney injury (AKI) in the ICU. RECENT FINDINGS Over the last years, evidence has demonstrated that the follow-up care after episodes of AKI is lacking and standardization of this process is likely needed. Although this is informed largely by large retrospective cohort studies, a few prospective observational trials have been performed. Medication reconciliation and patient/caregiver education are important tenants of follow-up care, regardless of the severity of AKI. There is evidence the initiation and/or reinstitution of renin-angiotensin-aldosterone agents may improve patient's outcomes following AKI, although they may increase the risk for adverse events, especially when reinitiated early. In addition, 3 months after an episode of AKI, serum creatinine and proteinuria evaluation may help identify patients who are likely to develop progressive chronic kidney disease over the ensuing 5 years. Lastly, there are emerging differences between those who do and do not require renal replacement therapy (RRT) for their AKI, which may require more frequent and intense follow-up in those needing RRT. SUMMARY Although large scale evidence-based guidelines are lacking, standardization of post-ICU-AKI is needed.
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Cedeño S, Desco M, Aleman Y, Macías N, Fernández-Pena A, Vega A, Abad S, López-Gómez JM. Intradialytic hypotension and relationship with cognitive function and brain morphometry. Clin Kidney J 2020; 14:1156-1164. [PMID: 33841861 PMCID: PMC8023187 DOI: 10.1093/ckj/sfaa070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 03/31/2020] [Indexed: 12/15/2022] Open
Abstract
Background The haemodynamic stress brought about by dialysis could justify the loss of structural and functional integrity of the central nervous system (CNS). The main objective of this study was to analyse the relationship between intradialytic hypotension (IDH) and cognitive function and brain morphometry. Methods The cross-sectional KIDBRAIN study (Cohort Study of Morphological Changes of the Brain by MRI in Chronic Kidney Disease Patients) included 68 prevalent patients with no history of neurological disorders (cerebrovascular disease and cognitive impairment) undergoing haemodialysis (HD). We analysed 18 non-consecutive dialysis sessions (first three of each month over a 6-month period) and various definitions of IDH were recorded. Global cognitive function (GCF) was assessed using the Mini-Mental State Examination (MMSE) and parameters of structural integrity of the CNS were obtained using volume morphometry magnetic resonance imaging analysis [grey matter (GM), white matter (WM) and hippocampus). Results A greater number of sessions with IDH were associated with less volume of WM (r = −0.359,P = 0.003) and hippocampus (r = −0.395, P = 0.001) independent of cardiovascular risk factors according to multivariable linear regression models (β = −0.198, P = 0.046 for WM; β = −0.253, P = 0.017 for hippocampus). The GCF by the MMSE was 27.3 ± 7.3.1 and was associated with WM volume (β = 0.403, P = 0.001) independent of GM and hippocampus volume. Symptomatic IDH was associated with GCF (r = −0.420, P < 0.001) in adjusted analysis (β = −0.339, P = 0.008). Conclusions Even when asymptomatic, IDH is associated with a lower WM and hippocampus volume and reduced GCF in patients undergoing HD, thus suggesting greater vulnerability of the brain to the haemodynamic stress that may be generated by a dialysis session.
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Affiliation(s)
- Santiago Cedeño
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Manuel Desco
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Yasser Aleman
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Nicolás Macías
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Almudena Vega
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Soraya Abad
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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45
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Canaud B, Kooman JP, Selby NM, Taal MW, Francis S, Maierhofer A, Kopperschmidt P, Collins A, Kotanko P. Dialysis-Induced Cardiovascular and Multiorgan Morbidity. Kidney Int Rep 2020; 5:1856-1869. [PMID: 33163709 PMCID: PMC7609914 DOI: 10.1016/j.ekir.2020.08.031] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 08/27/2020] [Indexed: 12/14/2022] Open
Abstract
Hemodialysis has saved many lives, albeit with significant residual mortality. Although poor outcomes may reflect advanced age and comorbid conditions, hemodialysis per se may harm patients, contributing to morbidity and perhaps mortality. Systemic circulatory "stress" resulting from hemodialysis treatment schedule may act as a disease modifier, resulting in a multiorgan injury superimposed on preexistent comorbidities. New functional intradialytic imaging (i.e., echocardiography, cardiac magnetic resonance imaging [MRI]) and kinetic of specific cardiac biomarkers (i.e., Troponin I) have clearly documented this additional source of end-organ damage. In this context, several factors resulting from patient-hemodialysis interaction and/or patient management have been identified. Intradialytic hypovolemia, hypotensive episodes, hypoxemia, solutes, and electrolyte fluxes as well as cardiac arrhythmias are among the contributing factors to systemic circulatory stress that are induced by hemodialysis. Additionally, these factors contribute to patients' symptom burden, impair cognitive function, and finally have a negative impact on patients' perception and quality of life. In this review, we summarize the adverse systemic effects of current intermittent hemodialysis therapy, their pathophysiologic consequences, review the evidence for interventions that are cardioprotective, and explore new approaches that may further reduce the systemic burden of hemodialysis. These include improved biocompatible materials, smart dialysis machines that automatically may control the fluxes of solutes and electrolytes, volume and hemodynamic control, health trackers, and potentially disruptive technologies facilitating a more personalized medicine approach.
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Affiliation(s)
- Bernard Canaud
- Montpellier University, Montpellier, France
- GMO, FMC, Bad Homburg, Germany
| | - Jeroen P. Kooman
- Maastricht University Medical Centre, Department of Internal Medicine, Maastricht, Netherlands
| | - Nicholas M. Selby
- Centre for Kidney Research and Innovation, Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, UK
| | - Maarten W. Taal
- Centre for Kidney Research and Innovation, Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, UK
| | - Susan Francis
- Sir Peter Mansfield Imaging Centre, University of Nottingham, UK
| | | | | | | | - Peter Kotanko
- Renal Research Institute, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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46
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Huang JC, Tsai YC, Wu PY, Lien YH, Chien CY, Kuo CF, Hung JF, Chen SC, Kuo CH. Predictive modeling of blood pressure during hemodialysis: a comparison of linear model, random forest, support vector regression, XGBoost, LASSO regression and ensemble method. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2020; 195:105536. [PMID: 32485511 DOI: 10.1016/j.cmpb.2020.105536] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 04/30/2020] [Accepted: 05/08/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Intradialytic hypotension (IDH) is commonly occurred and links to higher mortality among patients undergoing hemodialysis (HD). Its early prediction and prevention will dramatically improve the quality of life. However, predicting the occurrence of IDH clinically is not simple. The aims of this study are to develop an intelligent system with capability of predicting blood pressure (BP) during HD, and to further compare different machine learning algorithms for next systolic BP (SBP) prediction. METHODS This study presented comprehensive comparisons among linear regression model, least absolute shrinkage and selection operator (LASSO), tree-based ensemble machine learning models (random forest [RF] and extreme gradient boosting [XGBoost]), and support vector regression to predict the BP during HD treatment based on 200 and 48 maintenance HD patients containing a total of 7,180 and 2,065 BP records for the training and test dataset, respectively. Ensemble method also was computed to obtain better predictive performance. We compared the developed models based on R2, root mean square error (RMSE) and mean absolute error (MAE). RESULTS We found that RF (R2=0.95, RMSE=6.64, MAE=4.90) and XGBoost (R2=1.00, RMSE=1.83, MAE=1.29) had comparable predictive performance on the training dataset. However, RF (R2=0.49, RMSE=16.24, MAE=12.14) had more accurate than XGBoost (R2=0.41, RMSE=17.65, MAE=13.47) on testing dataset. Among these models, the ensemble method (R2=0.50, RMSE=16.01, MAE=11.97) had the best performance on testing dataset for next SBP prediction. CONCLUSIONS We compared five machine learning and an ensemble method for next SBP prediction. Among all studied algorithms, the RF and the ensemble method have the better predictive performance. The prediction models using ensemble method for intradialytic BP profiling may be able to assist the HD staff or physicians in individualized care and prompt intervention for patients' safety and improve care of HD patients.
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Affiliation(s)
- Jiun-Chi Huang
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Chun Tsai
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pei-Yu Wu
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | | | | | - Chih-Feng Kuo
- Graduate Institute of Science Education and Environmental Education, National Kaohsiung Normal University, Kaohsiung, Taiwan
| | - Jeng-Fung Hung
- Graduate Institute of Science Education and Environmental Education, National Kaohsiung Normal University, Kaohsiung, Taiwan
| | - Szu-Chia Chen
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
| | - Chao-Hung Kuo
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
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47
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Liu KD, Forni LG, Heung M, Wu VC, Kellum JA, Mehta RL, Ronco C, Kashani K, Rosner MH, Haase M, Koyner JL. Quality of Care for Acute Kidney Disease: Current Knowledge Gaps and Future Directions. Kidney Int Rep 2020; 5:1634-1642. [PMID: 33102955 PMCID: PMC7569680 DOI: 10.1016/j.ekir.2020.07.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 07/07/2020] [Accepted: 07/28/2020] [Indexed: 12/18/2022] Open
Abstract
Acute kidney injury (AKI) and acute kidney disease (AKD) are common complications in hospitalized patients and are associated with adverse outcomes. Although consensus guidelines have improved the care of patients with AKI and AKD, guidance regarding quality metrics in the care of patients after an episode of AKI or AKD is limited. For example, few patients receive follow-up laboratory testing of kidney function or post-AKI or AKD care through nephrology or other providers. Recently, the Acute Disease Quality Initiative developed a consensus statement regarding quality improvement goals for patients with AKI or AKD specifically highlighting efforts regarding quality and safety of care after hospital discharge after an episode of AKI or AKD. The goal is to use these measures to identify opportunities for improvement that will positively affect outcomes. We recommend that health care systems quantitate the proportion of patients who need and actually receive follow-up care after the index AKI or AKD hospitalization. The intensity and appropriateness of follow-up care should depend on patient characteristics, severity, duration, and course of AKI of AKD, and should evolve as evidence-based guidelines emerge. Quality indicators for discharged patients with dialysis requiring AKI or AKD should be distinct from end-stage renal disease measures. Besides, there should be specific quality indicators for those still requiring dialysis in the outpatient setting after AKI or AKD. Given the limited preexisting data guiding the care of patients after an episode of AKI or AKD, there is ample opportunity to establish quality measures and potentially improve patient care and outcomes. This review will provide specific evidence-based and expert opinion–based guidance for the care of patients with AKI or AKD after hospital discharge.
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Affiliation(s)
- Kathleen D Liu
- Division of Nephrology, Departments of Medicine and Anesthesia, University of California, San Francisco, California, USA
- Division of Critical Care Medicine, Departments of Medicine and Anesthesia, University of California, San Francisco, California, USA
| | - Lui G Forni
- Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Michael Heung
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Vin-Cent Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ravindra L Mehta
- Division of Nephrology, Department of Medicine, University of California, San Diego Medical Center, San Diego, San Diego, California, USA
| | - Claudio Ronco
- Department of Medicine (DIMED), University of Padova, Padova, Italy
- Department of Nephrology, Dialysis and Transplantation, and International Renal Research Institute, San Bortolo Hospital, Vicenza, Italy
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mitchell H Rosner
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Michael Haase
- Medical Faculty, Otto-von-Guericke University Magdeburg and Diaverum MVZ, Potsdam, Germany
| | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
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48
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Thongdee C, Phinyo P, Patumanond J, Satirapoj B, Spilles N, Laonapaporn B, Tantiyavarong P, Tasanarong A. Ultrafiltration rates and intradialytic hypotension: A case-control sampling of pooled haemodialysis data. J Ren Care 2020; 47:34-42. [PMID: 32730693 DOI: 10.1111/jorc.12340] [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: 12/22/2019] [Revised: 02/13/2020] [Accepted: 02/14/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Intradialytic hypotension (IDH) is one of the most critical adverse events during maintenance haemodialysis. Previous studies reported the association of fluid removal rate with the occurrence of IDH. OBJECTIVE We aimed to identify the optimal threshold of ultrafiltration rate to prevent the occurrence of IDH events. DESIGN, PARTICIPANTS AND MEASUREMENTS: Prognostic factor research with a retrospective case-control design was conducted. Patient data were gathered from four haemodialysis units from January to December 2017. All the haemodialysis records were independently justified, whether IDH occurred or not, based on the standard definition. A total of 10 haemodialysis sessions were sampled from each patient's pool based on the incidence of events. The association of ultrafiltration rates and IDH events was explored by multivariable multilevel logistic regression. RESULTS A total of 1080 haemodialysis sessions from 108 patients were included: 149 (13.8%) with IDH and 931 (86.2%) without IDH. After adjusting for all pre-specified risk factors and imbalance baselines, the odds ratio of IDH were 1.22 (95% confidence interval [CI]: 0.59, 2.52) for rate 10-12 ml/kg/h; 2.52 (95% CI: 1.20, 5.29) for rate 12-14 ml/kg/h; 4.02 (95% CI: 1.61, 10.03) for rate 14-16 ml/kg/h; and 7.41 (95% CI: 2.53, 21.68) for rate >16 ml/kg/h comparing to the referent rate of <10 ml/kg/h. CONCLUSION The ultrafiltration rate should be limited to 12 ml/kg/h. If a higher rate of fluid removal was indicated, it should not exceed 16 ml/kg/h to avoid the occurrence of IDH.
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Affiliation(s)
- Chitrada Thongdee
- Haemodialysis division, Dialysis Center, Nopparat Rajathanee Hospital, Bangkok, Thailand
| | - Phichayut Phinyo
- Center of Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Jayanton Patumanond
- Center of Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Bancha Satirapoj
- Department of Medicine, Nephrology division, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - Nantana Spilles
- Haemodialysis division, Dialysis Center, Nopparat Rajathanee Hospital, Bangkok, Thailand
| | - Boonruksa Laonapaporn
- Haemodialysis division, Dialysis Center, Nopparat Rajathanee Hospital, Bangkok, Thailand
| | - Pichaya Tantiyavarong
- Department of Medicine, Nephrology division, Faculty of Medicine, Thammasat University, Khlong Luang, Thailand
| | - Adis Tasanarong
- Department of Medicine, Nephrology division, Faculty of Medicine, Thammasat University, Khlong Luang, Thailand
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49
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Schoutteten MK, Vranken J, Lee S, Smeets CJP, De Cannière H, Van Hoof C, Peeters J, Groenendaal W, Vandervoort PM. Towards personalized fluid monitoring in haemodialysis patients: thoracic bioimpedance signal shows strong correlation with fluid changes, a cohort study. BMC Nephrol 2020; 21:264. [PMID: 32652949 PMCID: PMC7353684 DOI: 10.1186/s12882-020-01922-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 07/01/2020] [Indexed: 12/19/2022] Open
Abstract
Background Haemodialysis (HD) patients are burdened by frequent fluid shifts which amplify their comorbidities. Bioimpedance (bioZ) is a promising technique to monitor changes in fluid status. The aim of this study is to investigate if the thoracic bioZ signal can track fluid changes during a HD session. Methods Prevalent patients from a single centre HD unit were monitored during one to six consecutive HD sessions using a wearable multi-frequency thoracic bioZ device. Ultrafiltration volume (UFV) was determined based on the interdialytic weight gain and target dry weight set by clinicians. The correlation between the bioZ signal and UFV was analysed on population level. Additionally regression models were built and validated per dialysis session. Results 66 patients were included, resulting in a total of 133 HD sessions. Spearman correlation between the thoracic bioZ and UFV showed a significant strong correlation of 0.755 (p < 0.01) on population level. Regression analysis per session revealed a strong relation between the bioZ value and the UFV (R2 = 0.982). The fluid extraction prediction error of the leave-one-out cross validation was very small (56.2 ml [− 121.1–194.1 ml]) across all sessions at all frequencies. Conclusions This study demonstrated that thoracic bioZ is strongly correlated with fluid shifts during HD over a large range of UFVs. Furthermore, leave-one-out cross validation is a step towards personalized fluid monitoring during HD and could contribute to the creation of autonomous dialysis.
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Affiliation(s)
- Melanie K Schoutteten
- UHasselt, Faculty of Medicine and Life Sciences, Limburg Clinical Research Center/Mobile Health Unit, Agoralaan, 3590, Diepenbeek, Belgium. .,Ziekenhuis Oost-Limburg, Department of Future Health, Limburg Clinical Research Center/Mobile Health Unit, Ziekenhuis Oost Limburg Genk, Schiepse Bos 6, 3600, Genk, Belgium. .,imec the Netherlands/Holst Centre, Connected Health Solutions Department, High Tech Campus 31, Eindhoven, the Netherlands.
| | - Julie Vranken
- UHasselt, Faculty of Medicine and Life Sciences, Limburg Clinical Research Center/Mobile Health Unit, Agoralaan, 3590, Diepenbeek, Belgium.,Ziekenhuis Oost-Limburg, Department of Future Health, Limburg Clinical Research Center/Mobile Health Unit, Ziekenhuis Oost Limburg Genk, Schiepse Bos 6, 3600, Genk, Belgium
| | - Seulki Lee
- imec the Netherlands/Holst Centre, Connected Health Solutions Department, High Tech Campus 31, Eindhoven, the Netherlands
| | - Christophe J P Smeets
- UHasselt, Faculty of Medicine and Life Sciences, Limburg Clinical Research Center/Mobile Health Unit, Agoralaan, 3590, Diepenbeek, Belgium.,Ziekenhuis Oost-Limburg, Department of Future Health, Limburg Clinical Research Center/Mobile Health Unit, Ziekenhuis Oost Limburg Genk, Schiepse Bos 6, 3600, Genk, Belgium.,imec the Netherlands/Holst Centre, Connected Health Solutions Department, High Tech Campus 31, Eindhoven, the Netherlands
| | - Hélène De Cannière
- UHasselt, Faculty of Medicine and Life Sciences, Limburg Clinical Research Center/Mobile Health Unit, Agoralaan, 3590, Diepenbeek, Belgium.,Ziekenhuis Oost-Limburg, Department of Future Health, Limburg Clinical Research Center/Mobile Health Unit, Ziekenhuis Oost Limburg Genk, Schiepse Bos 6, 3600, Genk, Belgium
| | - Chris Van Hoof
- imec Leuven, Kapeldreef 75, 3001, Leuven, Belgium.,Katholieke Universiteit Leuven-ESAT, Kasteelpark Arenberg 10 postbus 2440, 3001, Leuven, Belgium
| | - Jacques Peeters
- UHasselt, Faculty of Medicine and Life Sciences, Limburg Clinical Research Center/Mobile Health Unit, Agoralaan, 3590, Diepenbeek, Belgium.,Ziekenhuis Oost-Limburg, Department of Nephrology, Schiepse Bos 6, 3600, Genk, Belgium
| | - Willemijn Groenendaal
- imec the Netherlands/Holst Centre, Connected Health Solutions Department, High Tech Campus 31, Eindhoven, the Netherlands
| | - Pieter M Vandervoort
- UHasselt, Faculty of Medicine and Life Sciences, Limburg Clinical Research Center/Mobile Health Unit, Agoralaan, 3590, Diepenbeek, Belgium.,Ziekenhuis Oost-Limburg, Department of Future Health, Limburg Clinical Research Center/Mobile Health Unit, Ziekenhuis Oost Limburg Genk, Schiepse Bos 6, 3600, Genk, Belgium.,Ziekenhuis Oost-Limburg, Department of Cardiology, Schiepse Bos 6, 3600, Genk, Belgium
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50
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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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