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Broszeit S, Kron J, Leimbach T, Volkenandt J, Kron S. Vascular refilling in hemodialysis using feedback-controlled ultrafiltration profile. Int J Artif Organs 2024:3913988241264709. [PMID: 39097793 DOI: 10.1177/03913988241264709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2024]
Abstract
BACKGROUND The rate and the duration of ultrafiltration (UF) are considered the most important factors to affect vascular refilling. The aim of the study was to investigate whether a UF profile could improve the vascular refilling. METHODS Dialysis was delivered by a machine providing feedback control of ultrafiltration rates. Absolute blood volume (BV) was measured by dialysate bolus method. Vascular refilling volume (Vref) was calculated as UF volume - Δ absolute BV. RESULTS In 40 patients, refilling fraction (Vref/UF volume) was 30.5% in the first hour. Thereafter, refilling fraction steeply increased and reached maximum values in the third and fourth hour at about 95%. The cumulative refilling fraction was 68.5 ± 9.4% at the end. In 14 patients, refilling data from the feedback-controlled UF profile were compared to dialysis sessions with constant UF rates. In 12 of 14 patients, refilling fraction was significantly (p = 0.013) higher in sessions with UF profile (71.6% vs 64.4%).There was a significant negative correlation (r = -0.606; p = 0.002) between the blood volume to extracellular volume ratio and the refilling fraction. The sum of this ratio and the refilling fraction was 1.01 ± 0.06. CONCLUSIONS Despite significant differences, a feedback-controlled UF profile has no advantage over the previous refilling studies with regard to the refilling fraction because vascular refilling seems to depend mainly on the ratio of BV to ECV. This would explain the different results in studies using BV guided UF feedback programs.
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Affiliation(s)
- Stefanie Broszeit
- Department of Nephrology DRK Clinics Berlin-Köpenick, Berlin, Germany
| | - Joachim Kron
- KfH Kidney Center Berlin-Köpenick, Berlin, Germany
| | - Til Leimbach
- KfH Kidney Center Berlin-Köpenick, Berlin, Germany
| | - John Volkenandt
- Department of Nephrology DRK Clinics Berlin-Köpenick, Berlin, Germany
| | - Susanne Kron
- KfH Kidney Center Berlin-Köpenick, Berlin, Germany
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Kron J, Kron S. Estimation of Absolute Blood Volume Using Online Dialysate Dilution: When and How to Measure? ASAIO J 2024:00002480-990000000-00537. [PMID: 39088725 DOI: 10.1097/mat.0000000000002284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2024] Open
Abstract
Absolute blood volume can be calculated from the increase in relative blood volume after an infusion of a well-defined volume bolus of ultrapure dialysate into the extracorporeal circulation. Several working groups have applied this method in research and clinical practice. A critical analysis of differing blood volume data between working groups revealed methodologic problems of the measurement procedure and some important technical aspects. This paper presents a statement to standardize the method.
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Affiliation(s)
- Joachim Kron
- From the Kuratorium für Dialyse und Nierentransplantation (KfH) Kidney Center Berlin-Koepenick, Berlin, Germany
| | - Susanne Kron
- From the Kuratorium für Dialyse und Nierentransplantation (KfH) Kidney Center Berlin-Koepenick, Berlin, Germany
- Department of Nephrology, Deutsches Rotes Kreuz (DRK) Clinics Berlin-Koepenick, Berlin, Germany
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Jongejan M, Gelinck A, van Geloven N, Dekker FW, Vleming LJ. Effect of absolute blood volume measurement-guided fluid management on the incidence of intradialytic hypotension-associated events: a randomised controlled trial. Clin Kidney J 2024; 17:sfae128. [PMID: 38774440 PMCID: PMC11106788 DOI: 10.1093/ckj/sfae128] [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: 08/28/2023] [Indexed: 05/24/2024] Open
Abstract
Background Ultrafiltration to target weight during haemodialysis is complicated by intradialytic hypotension-associated adverse events (IHAAEs) in 10-30% of dialysis treatments. IHAAEs are caused by critical reductions in absolute blood volume (ABV), due to the interaction of ultrafiltration, refill and compensatory mechanisms. Non-randomised studies have suggested that ABV-guided treatment, using an indicator dilution technique employing the blood volume monitor on the dialysis machine, could reduce the incidence of IHAAEs. Methods We performed an open-label randomised controlled trial. Patients were randomly assigned to adjustment of target weight guided by ABV measurements or standard care. The primary outcome was the change in the incidence of IHAAEs from baseline, defined as the percentage of treatment episodes in a 4-week period where the patient had a systolic blood pressure <90 mmHg or symptoms of impending hypotension. ABV measurements were compared with anthropomorphometric estimation and the gold standard using isotope dilution. Results A total of 56 patients were randomised, of whom 29 were allocated to ABV-guided treatment and 27 to standard care. Overall baseline incidence of IHAAEs was 26.0%. ABV-guided treatment significantly reduced the incidence of IHAAEs compared with standard care, with a mean change from baseline of -9.6% [95% confidence interval (CI) -17.3 to -1.8) versus 2.4% (95% CI -2.3-7.2). The adjusted difference between the groups was 10.5% (95% CI 1.3-19.8; P = .026). ABV measurement had moderate agreement with other methods to estimate blood volume. The sensitivity for the previously suggested threshold of a post-dialysis normalised blood volume of 65 ml/kg was observed to be 74% in this study. Conclusions ABV-guided volume management significantly reduced IHAAEs compared with standard care. The clinical relevance of the previously suggested threshold of 65 ml/kg cannot be firmly concluded on the basis of our results. If confirmed in a larger trial, this intervention could potentially change dialysis practice and impact patient care in a clinically meaningful way.
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Affiliation(s)
- Micha Jongejan
- Department of Nephrology, HagaZiekenhuis, The Hague, The Netherlands
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Armin Gelinck
- Department of Nephrology, HagaZiekenhuis, The Hague, The Netherlands
| | - Nan van Geloven
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
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Vinje V, Bomholt T, Lundby C, Oturai P, Rix M, Lindhard K, Hornum M. Intravascular volumes and the influence on anemia assessed by a carbon monoxide rebreathing method in patients undergoing maintenance hemodialysis. Hemodial Int 2024; 28:40-50. [PMID: 37827985 DOI: 10.1111/hdi.13118] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 09/22/2023] [Accepted: 09/26/2023] [Indexed: 10/14/2023]
Abstract
INTRODUCTION Fluid overload is a major challenge in hemodialysis patients and might cause hypervolemia. We speculated that hemodialysis patients reaching dry weight could have undetected hypervolemia and low hemoglobin (Hb) concentration (g/dL) due to hemodilution. METHODS The study included hemodialysis patients (n = 22) and matched healthy controls (n = 22). Blood volume, plasma volume, red blood cell volume, and total Hb mass were determined using a carbon monoxide (CO)-rebreathing method in hemodialysis patients reaching dry weight and controls. Blood volume measurements were also obtained by a dual-isotope labeling technique in a subgroup for validation purposes. FINDINGS In the hemodialysis group, the median specific blood volume was 89.3 mL/kg (interquartile range [IQR]: 76.7-95.4 mL/kg) and was higher than in the control group (79.9 mL/kg [IQR: 70.4-88.0 mL/kg]; p < 0.037). The median specific plasma volume was 54.7 mL/kg (IQR: 47.1-61.0 mL/kg) and 44.0 mL/kg (IQR: 38.7-49.5 mL/kg) in the hemodialysis and control groups, respectively (p < 0.001). Hb concentration was lower in hemodialysis patients (p < 0.001), whereas no difference in total Hb mass was observed between groups (p = 0.11). A correlation was found between blood volume measured by the CO-rebreathing test and the dual-isotope labeling technique in the control group (r = 0.83, p = 0.015), but not the hemodialysis group (r = 0.25, p = 0.60). DISCUSSION The hemodialysis group had increased specific blood volume at dry weight due to high plasma volume, suggesting a hypervolemic state. However, correlation was not established against the dual-isotope labeling technique underlining that the precision of the CO-rebreathing test should be further validated. The total Hb mass was similar between hemodialysis patients and controls, unlike Hb concentration, which emphasizes that Hb concentration is an inaccurate marker of anemia among hemodialysis patients.
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Affiliation(s)
- Vårin Vinje
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Tobias Bomholt
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Carsten Lundby
- Centre for Physical Activity Research, Rigshospitalet, Copenhagen, Denmark
- Section for Health and Exercise Physiology, Faculty of Social and Health Sciences, Inland Norway University of Applied Sciences, Lillehammer, Norway
| | - Peter Oturai
- Department of Clinical Physiology and Nuclear Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Marianne Rix
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Kristine Lindhard
- Department of Nephrology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Mads Hornum
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Haddiya I, Valoti S. Current Knowledge of Beta-Blockers in Chronic Hemodialysis Patients. Int J Nephrol Renovasc Dis 2023; 16:223-230. [PMID: 37849744 PMCID: PMC10578177 DOI: 10.2147/ijnrd.s414774] [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: 03/29/2023] [Accepted: 09/29/2023] [Indexed: 10/19/2023] Open
Abstract
Beta-blockers include a large spectrum of drugs with various specific characteristics, and a well-known cardioprotective efficacy. They are recommended in heart failure, hypertension and arrhythmia. Their use in chronic hemodialysis patients is still controversial, mainly because of the lack of specific randomized clinical trials. Large observational studies and two important clinical trials have reported almost unanimously their efficacy in chronic hemodialysis patients, which seems to be related to their levels of dialyzability and cardioselectivity. A recent meta-analysis suggested that high dialyzable beta-blockers are correlated to a reduced risk of all-cause mortality and cardiovascular complications compared with low dialyzable beta-blockers. Despite their benefits, beta-blockers may have adverse effects, such as intradialytic hypotension with low dialyzability beta-blockers or the risk of sub-therapeutic plasma concentration of high dialyzable ones during dialysis sessions. Both cases are linked to adverse cardiovascular events. A solution for both high and low dialyzable drugs could be their administration after dialysis sessions. Futhermore, the bulk of existing literature seems to favor cardioselective beta-blockers with moderate-to-high dialyzability as the ideal agents in dialysis patients, but further, larger studies are needed. This review aims to analyze beta-blockers' characteristics, indications and evidence-based role in chronic hemodialysis patients.
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Affiliation(s)
- Intissar Haddiya
- Department of Nephrology, Faculty of Medicine and Pharmacy, University Mohamed Premier, Oujda, Morocco
- Laboratory of Epidemiology, Clinical Research and Public Health, Faculty of Medicine and Pharmacy, University Mohamed Premier, Oujda, Morocco
| | - Siria Valoti
- Department of Medicine, Faculty of Medicine, Università degli Studi di Milano Statale, Milano, Italia
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Kron J, Broszeit S, Volkenandt J, Leimbach T, Kron S. Vascular refilling depends on the ratio of blood volume to extracellular volume in hemodialysis patients. Int J Artif Organs 2023; 46:581-584. [PMID: 37749906 DOI: 10.1177/03913988231201905] [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: 09/27/2023]
Abstract
The ratio of blood volume to extracellular volume is approximately one to three under physiological conditions and also in stable chronic hemodialysis patients. Recently, it was found that this ratio remains unchanged during hemodialysis despite ultrafiltration. This would signify that the higher the ratio, the lower the refilling and vice versa. To test this hypothesis, treatment data of a previous study were re-analyzed. In 79 stable chronic hemodialysis patients, the refilling fraction was 0.749 ± 0.094. There was a significant negative correlation (r = -0.412; p < 0.001) between the blood volume to extracellular volume ratio and the refilling fraction. The blood volume to extracellular volume relationship seems to be a significant determinant of vascular refilling: the higher the ratio, the lower the refilling, and vice versa.
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Affiliation(s)
- Joachim Kron
- KfH Kidney Center Berlin-Köpenick, Berlin, Germany
| | - Stefanie Broszeit
- DRK Clinics Berlin-Köpenick, Department of Nephrology, Berlin, Germany
| | - John Volkenandt
- DRK Clinics Berlin-Köpenick, Department of Nephrology, Berlin, Germany
| | - Til Leimbach
- KfH Kidney Center Berlin-Köpenick, Berlin, Germany
| | - Susanne Kron
- KfH Kidney Center Berlin-Köpenick, Berlin, Germany
- DRK Clinics Berlin-Köpenick, Department of Nephrology, Berlin, Germany
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Schmiedecker M, Krenn S, Waller M, Paschen C, Mussnig S, Niknam J, Wabel P, Mayer CC, Hecking M, Schneditz D. Ultrafiltration-induced decrease in relative blood volume is larger in hemodialysis patients with low specific blood volume: Results from a dialysate bolus administration study. Hemodial Int 2023; 27:174-183. [PMID: 36703281 DOI: 10.1111/hdi.13066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 11/04/2022] [Accepted: 01/10/2023] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Prescribing the ultrafiltration in hemodialysis patients remains challenging and might benefit from the information on absolute blood volume, estimated by intradialytic dialysate bolus administration. Here, we aimed at determining the relationship between absolute blood volume, normalized for body mass (specific blood volume, Vs), and ultrafiltration-induced decrease in relative blood volume (∆RBV) as well as clinical parameters including body mass index (BMI). METHODS This retrospective analysis comprised 77 patients who had their dialysate bolus-based absolute blood volume extracted routinely with an automated method. Patient-specific characteristics and ∆RBV were analyzed as a function of Vs, dichotomizing the data above or below a previously proposed threshold of 65 ml/kg for Vs. Statistical methodology comprised descriptive analyses, two-group comparisons, and correlation analyses. FINDINGS Median Vs was 68.6 ml/kg (54.9 ml/kg [Quartile 1], 83.4 ml/kg [Quartile 3]). Relative blood volume decreased by 6.3% (2.6%, 12.2%) over the entire hemodialysis session. Vs correlated inversely with BMI (rs = -0.688, p < 0.001). ∆RBV was 9.8% in the group of patients with Vs <65 ml/kg versus 6.0% in the group of patients with Vs ≥65 ml/kg (p = 0.024). The two groups did not differ significantly regarding their specific ultrafiltration volume, normalized for body mass, which amounted to 34.1 ml/kg and 36.0 ml/kg in both groups, respectively (p = 0.630). ∆RBV correlated inversely with Vs (rs = -0.299, p = 0.008). DISCUSSION The present study suggests that patients with higher BMI and lower Vs experience larger blood volume changes, despite similar ultrafiltration requirements. These results underline the clinical plausibility and importance of dialysate bolus-based absolute blood volume determination in the assessment of target weight, especially in view of a previous study where intradialytic morbid events could be decreased when the target weight was adjusted, based on Vs.
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Affiliation(s)
- Michael Schmiedecker
- Department of Medicine III, Division of Nephrology & Dialysis, Medical University of Vienna, Vienna, Austria
| | - Simon Krenn
- Department of Medicine III, Division of Nephrology & Dialysis, Medical University of Vienna, Vienna, Austria.,Center for Public Health, Department of Epidemiology, Medical University of Vienna, Vienna, Austria.,AIT Austrian Institute of Technology, Center for Health & Bioresources, Medical Signal Analysis, Vienna, Austria
| | - Maximilian Waller
- Department of Medicine III, Division of Nephrology & Dialysis, Medical University of Vienna, Vienna, Austria.,Department of Nephrology, Klinik Favoriten Vienna, Vienna, Austria
| | - Christopher Paschen
- Department of Medicine III, Division of Nephrology & Dialysis, Medical University of Vienna, Vienna, Austria
| | - Sebastian Mussnig
- Department of Medicine III, Division of Nephrology & Dialysis, Medical University of Vienna, Vienna, Austria
| | - Janosch Niknam
- Department of Medicine III, Division of Nephrology & Dialysis, Medical University of Vienna, Vienna, Austria
| | | | - Christopher C Mayer
- AIT Austrian Institute of Technology, Center for Health & Bioresources, Medical Signal Analysis, Vienna, Austria
| | - Manfred Hecking
- Department of Medicine III, Division of Nephrology & Dialysis, Medical University of Vienna, Vienna, Austria
| | - Daniel Schneditz
- Otto Loewi Research Center, Division of Physiology, Medical University of Graz, Graz, Austria
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Schneditz D, Niemczyk L, Wojtecka A, Szamotulska K, Niemczyk S. Comparable Hemodilution with Hypertonic Glucose in Patients with and without Type-2 Diabetes Mellitus during Hemodialysis. Nutrients 2023; 15:nu15030536. [PMID: 36771243 PMCID: PMC9920628 DOI: 10.3390/nu15030536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/12/2023] [Accepted: 01/16/2023] [Indexed: 01/22/2023] Open
Abstract
(1) Background: It was examined whether glucose-induced changes in the relative blood volume are suitable to identify subjects with and without type-2 diabetes mellitus (T2D) during hemodialysis. (2) Methods: The relative blood volume was continuously recorded during hemodialysis and perturbed by the infusion of glucose comparable to the dose used for intravenous glucose tolerance tests. Indices of glucose metabolism were determined by the homeostatic model assessment (HOMA). Body composition was measured by a bioimpedance analysis. The magnitude and the time course of hemodilution were described by a modified gamma variate model and five model parameters. (3) Results: A total of 34 subjects were studied, 14 with and 20 without T2D. The magnitude of the hemodilution and the selected model parameters correlated with measures of anthropometry, body mass index, absolute and relative fat mass, volume excess, baseline insulin concentration, and HOMA indices such as insulin resistance and glucose disposition in a continuous analysis, but were not different in a dichotomous analysis of patients with and without T2D. (4) Conclusions: Even though the parameters of the hemodilution curve were correlated with measures of impaired glucose metabolism and body composition, the distinction between subjects with and without T2D was not possible using glucose-induced changes in the relative blood volume during hemodialysis.
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Affiliation(s)
- Daniel Schneditz
- Otto Loewi Research Center, Division of Physiology, Medical University of Graz, 8010 Graz, Austria
- Correspondence: ; Tel.: +43-316-385-7385
| | - Longin Niemczyk
- Department of Nephrology, Dialysis and Internal Diseases, Medical University of Warsaw, 02-097 Warsaw, Poland
| | - Anna Wojtecka
- Department of Internal Diseases, Nephrology and Dialysis, Military Institute of Medicine, 04-141 Warsaw, Poland
| | - Katarzyna Szamotulska
- Department of Epidemiology and Biostatistics, National Research Institute of Mother and Child, 01-211 Warsaw, Poland
| | - Stanisław Niemczyk
- Department of Internal Diseases, Nephrology and Dialysis, Military Institute of Medicine, 04-141 Warsaw, Poland
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Vascular refilling coefficient is not a good marker of whole-body capillary hydraulic conductivity in hemodialysis patients: insights from a simulation study. Sci Rep 2022; 12:15277. [PMID: 36088359 PMCID: PMC9464211 DOI: 10.1038/s41598-022-16826-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 07/18/2022] [Indexed: 12/03/2022] Open
Abstract
Refilling of the vascular space through absorption of interstitial fluid by micro vessels is a crucial mechanism for maintaining hemodynamic stability during hemodialysis (HD) and allowing excess fluid to be removed from body tissues. The rate of vascular refilling depends on the imbalance between the Starling forces acting across the capillary walls as well as on their hydraulic conductivity and total surface area. Various approaches have been proposed to assess the vascular refilling process during HD, including the so-called refilling coefficient (Kr) that describes the rate of vascular refilling per changes in plasma oncotic pressure, assuming that other Starling forces and the flow of lymph remain constant during HD. Several studies have shown that Kr decreases exponentially during HD, which was attributed to a dialysis-induced decrease in the whole-body capillary hydraulic conductivity (LpS). Here, we employ a lumped-parameter mathematical model of the cardiovascular system and water and solute transport between the main body fluid compartments to assess the impact of all Starling forces and the flow of lymph on vascular refilling during HD in order to explain the reasons behind the observed intradialytic decrease in Kr. We simulated several HD sessions in a virtual patient with different blood priming procedures, ultrafiltration rates, session durations, and constant or variable levels of LpS. We show that the intradialytic decrease in Kr is not associated with a possible reduction of LpS but results from the inherent assumption that plasma oncotic pressure is the only variable Starling force during HD, whereas in fact other Starling forces, in particular the oncotic pressure of the interstitial fluid, have an important impact on the transcapillary fluid exchange during HD. We conclude that Kr is not a good marker of LpS and should not be used to guide fluid removal during HD or to assess the fluid status of dialysis patients.
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Hu D, Krivitski NM, Salehpour F, Rivas L, Chahal Y, Aragon M. Active Circulating Blood Volume During Hemodialysis: A Bench Model. ASAIO J 2022; 68:972-977. [PMID: 35383581 DOI: 10.1097/mat.0000000000001709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Intradialytic hypotension due to excessive fluid removal is a common complication of hemodialysis. A bench model was constructed to evaluate quantification of active circulating blood volume (ACBV). The model included a central pump representing the heart and compartments to represent the central and peripheral circulation. A blood oxygenator was used to simulate lung volume and two containers represented fast and slow circulation compartments. A separate dialysis circuit with a blood pump and two ultrasound flow-dilution probes was incorporated. Vascular access was simulated with both a shunt (fistula or graft) and a central venous catheter. Hypertonic saline (5%) was circulated in the system. A bolus of isotonic saline was introduced in the dialysis circuit, which dispersed through the physiologic model. ACBV was measured by comparing the baseline dilution curve to the curve as it returned to the probes. To evaluate the sensitivity of this technique, we investigated changing cardiac output, central venous volume, shunt flow, vascular access type, and HD pump flow. Overall percentage error (mean ± SD) across all tests (n = 15 conditions, each in triplicate) was 2.6% ± 7.4%. This study demonstrates the ability to accurately measure ACBV on the bench.
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Affiliation(s)
- Dean Hu
- From the Outset Medical, San Jose, California
| | | | | | - Logan Rivas
- From the Outset Medical, San Jose, California
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11
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Kron S, Schneditz D, Leimbach T, Schneider J, Kron J. Dynamics of vascular refilling in extended nocturnal hemodialysis. Hemodial Int 2022; 26:540-547. [PMID: 35711103 DOI: 10.1111/hdi.13029] [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: 11/19/2021] [Revised: 04/06/2022] [Accepted: 05/30/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Long dialysis treatments are generally assumed to mitigate the ultrafiltration (UF) induced volume perturbation and to improve vascular refilling because of reduced UF rates and sufficient time for volume re-equilibration. The time course of vascular refilling was therefore examined during extended nocturnal dialysis. METHODS For each hour of dialysis, vascular refilling volume was calculated from the absolute blood volume changes and UF volume removed. Absolute blood volume was estimated by indicator dilution at the beginning of dialysis and then tracked with a relative blood volume monitor. The refilling fraction was defined as the ratio of refilling volume to UF volume. FINDINGS Ten stable chronic hemodialysis (HD) patients were studied during extended (7 h) nocturnal treatment sessions. Specific UF rate was 4.8 ± 1.8 ml/kg/h. In the 1 h, refilling volume amounted to only 23% of UF volume. Thereafter, refilling fraction steeply increased and reached maximum values in the 2, 3 and 4 h at about mean 90% (91.5%, 88.7%, and 91.1% respectively). From the 5 h on, refilling volume decreased (5 h 81.3%, 6 h 72.5%, 7 h 70.0% of UF volume). Cumulative refilling reached 73.6% of UF volume after 4 h of treatment time. This did not change during the further course of HD. Cumulative refilling volume showed a strong correlation (r = 0.94; p < 0.001) with UF volume. The ratio of blood volume to extracellular volume (Rbex ) was 0.306 ± 0.029 before and slightly but significantly increased to 0.326 ± 0.030 after UF. DISCUSSION In spite of low-UF rates and extended treatment times, overall refilling fraction reached only 74% and was not different from the refilling fraction observed in regular HD. This value seems to represent a point where UF-induced volume perturbation is adequately compensated by physiologic control mechanisms.
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Affiliation(s)
- Susanne Kron
- Department of Nephrology and Internal Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Daniel Schneditz
- Division of Physiology, Otto Loewi Research Center, Medical University of Graz, Graz, Austria
| | - Til Leimbach
- KfH Kidney Center Berlin-Köpenick, Berlin, Germany
| | - Johanna Schneider
- Department of Nephrology and Internal Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Joachim Kron
- KfH Kidney Center Berlin-Köpenick, Berlin, Germany
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12
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Kron S, Schneditz D, Kron J. The blood to extracellular volume relationship is stable and in the physiologic range in chronic haemodialysis patients. Nephrol Dial Transplant 2022; 37:2034-2036. [DOI: 10.1093/ndt/gfac151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Indexed: 11/12/2022] Open
Affiliation(s)
- Susanne Kron
- Department of Nephrology and Internal Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Daniel Schneditz
- Division of Physiology, Otto Loewi Research Centre, Medical University of Graz, Graz, Austria
| | - Joachim Kron
- KfH Kidney Centre Berlin-Köpenick, Berlin, Germany
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13
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Krenn S, Schmiedecker M, Schneditz D, Hödlmoser S, Mayer CC, Wassertheurer S, Omic H, Schernhammer E, Wabel P, Hecking M. Feasibility of Dialysate Bolus-Based Absolute Blood Volume Estimation in Maintenance Hemodialysis Patients. Front Med (Lausanne) 2022; 9:801089. [PMID: 35223900 PMCID: PMC8866453 DOI: 10.3389/fmed.2022.801089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 01/04/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Absolute blood volume (ABV) is a critical component of fluid status, which may inform target weight prescriptions and hemodynamic vulnerability of dialysis patients. Here, we utilized the changes in relative blood volume (RBV), monitored by ultrasound (BVM) upon intradialytic 240 mL dialysate fluid bolus-infusion 1 h after hemodialysis start, to calculate the session-specific ABV. With the main goal of assessing clinical feasibility, our sub-aims were to (i) standardize the BVM-data read-out; (ii) determine optimal time-points for ABV-calculation, "before-" and "after-bolus"; (iii) assess ABV-variation. METHODS We used high-level programming language and basic descriptive statistics in a retrospective study of routinely measured BVM-data from 274 hemodialysis sessions in 98 patients. RESULTS Regarding (i) and (ii), we automatized the processing of RBV-data, and determined an algorithm to select the adequate RBV-data points for ABV-calculations. Regarding (iii), we found in 144 BVM-curves from 75 patients, that the average ABV ± standard deviation was 5.2 ± 1.5 L and that among those 51 patients who still had ≥2 valid estimates, the average intra-patient standard deviation in ABV was 0.8 L. Twenty-seven of these patients had an average intra-patient standard deviation in ABV <0.5 L. CONCLUSIONS We demonstrate feasibility of ABV-calculation by an automated algorithm after dialysate bolus-administration, based on the BVM-curve. Based on our results from this simple "abridged" calculation approach with routine clinical measurements, we encourage the use of multi-compartment modeling and comparison with reference methods of ABV-determination. Hopes are high that clinicians will be able to use ABV to inform target weight prescription, improving hemodynamic stability.
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Affiliation(s)
- Simon Krenn
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Epidemiology, Center for Public Health, Medical University of Vienna, Vienna, Austria.,AIT Austrian Institute of Technology, Center for Health & Bioresources, Medical Signal Analysis, Vienna, Austria
| | - Michael Schmiedecker
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Daniel Schneditz
- Division of Physiology, Otto Loewi Research Center, Medical University of Graz, Graz, Austria
| | - Sebastian Hödlmoser
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Epidemiology, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Christopher C Mayer
- AIT Austrian Institute of Technology, Center for Health & Bioresources, Medical Signal Analysis, Vienna, Austria
| | - Siegfried Wassertheurer
- AIT Austrian Institute of Technology, Center for Health & Bioresources, Medical Signal Analysis, Vienna, Austria
| | - Haris Omic
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Eva Schernhammer
- Department of Epidemiology, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | | | - Manfred Hecking
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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14
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Nadal MÁ, Viera Ramírez ER, García Vallejo M, Martín Capón I, Fernández Lucas M. Effect of Beta-Blocker Cardioselectivity on Vascular Refilling in Hemodialysis Patients. Cardiorenal Med 2021; 11:237-242. [PMID: 34784588 DOI: 10.1159/000519661] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 09/11/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND β-Blockers are the most frequently prescribed cardioprotective drugs in hemodialysis (HD) patients, despite their weak evidence. We sought to evaluate the effects of β-blockers on vascular refilling during HD treatments and examine whether carvedilol, for being noncardioselective and poorly dialyzable, associates more impact than others. METHODS The study was performed in a cohort of maintenance HD patients from a tertiary center. All patients had previous β-blocker prescription. We conducted a prospective crossover study and measured vascular refilling volume (Vref) and vascular refilling fraction (Fref) in 2 circumstances: under β-blocker treatment (βb profile) and without β-blocker effect (non-βb profile). RESULTS Twenty patients were included, 10 of whom were treated with carvedilol. Predialysis values were comparable between the 2 profiles. Although the βb profile showed lower Vref and higher ABV drop, these differences did not reach statistical significance. Data showed an increase in Fref in the non-βb profile (70.01 ± 6.80% vs. 63.14 ± 11.65%; p = 0.015). The βb profile associated a significantly higher risk of intradialytic hypotension (IDH) (risk ratio 2.40; 95% CI: 1.04-5.55). When analyzing separately the carvedilol group, patients dialyzed under drug effect experienced a significant impairment in Vref, Fref, and refilling rate. CONCLUSIONS Administering β-blockers before HD associated a higher risk of IDH and a decrease in Fref. Patients dialyzed under carvedilol effect showed an impaired refilling, probably related to its noncardioselectivity and lower dializability.
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Affiliation(s)
- Marta Álvarez Nadal
- Department of Nephrology, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | | | - María García Vallejo
- Department of Nephrology, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Irene Martín Capón
- Department of Nephrology, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Milagros Fernández Lucas
- Department of Nephrology, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain.,Universidad de Alcalá, Madrid, Spain
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15
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Álvarez-Nadal M, Martín-Capón I, Viera-Ramírez ER, Fernández-Lucas M. Impact of dialysate sodium concentration on vascular refilling. Hemodial Int 2021; 26:30-37. [PMID: 34180118 DOI: 10.1111/hdi.12957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 05/31/2021] [Accepted: 06/10/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Although relationship between dialysate sodium concentration and hemodynamic stability has been well studied over the years, outcomes of absolute blood volume (ABV) maintenance and vascular refilling volume (Vref ) modifications were not included, as its analysis has not been easily accessible to direct investigation. However, recent studies report a simple and feasible methodology to assess ABV and Vref during hemodialysis (HD) treatments. It is the aim of this study to analyze whether sodium concentration in dialysate modifies ABV drop and Vref . METHODS The study was performed in 19 patients under HD. During three different sessions, sodium concentration in dialysate was randomized to three different profiles: low sodium concentration (LNa, 138 mEq/L), neutral sodium concentration (NNa, 140 mEq/L), and high sodium concentration (HNa, 143 mEq/L). ABV and Vref were calculated using Kron et al methodology. RESULTS Predialysis values of the measured parameters showed similar results for the three profiles. Sodium concentration showed an effect on ABV drop, Vref, and vascular refilling fraction (Fref ). Pair-wise comparison revealed mean ABV decreased 0.21 L less when using HNa profile versus LNa profile (p = 0.027), a mean Vref increase of 0.39 L (p = 0.038), and a mean Fref increase of 9.94% (p = 0.048). CONCLUSIONS This study shows that the use of HNa profiles increases Vref and Fref and reduces ABV drop during dialysis treatments when compared to LNa profiles.
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Affiliation(s)
- Marta Álvarez-Nadal
- Department of Nephrology, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Irene Martín-Capón
- Department of Nephrology, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | | | - Milagros Fernández-Lucas
- Department of Nephrology, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain.,Universidad de Alcalá, Madrid, Spain
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16
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Kron S, Schneditz D, Keane DF, Leimbach T, Kron J. An improved method to estimate absolute blood volume based on dialysate dilution. Artif Organs 2021; 45:E359-E363. [PMID: 33908065 DOI: 10.1111/aor.13970] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/09/2021] [Accepted: 04/12/2021] [Indexed: 12/01/2022]
Abstract
Online hemodiafiltration machines equipped with a blood volume monitor and the possibility to rapidly infuse exact amounts of ultrapure dialysate into the extracorporeal circulation can be used to determine absolute blood volume in clinical practice. The aim of the present study was to evaluate the reproducibility of such measurements. Intra-individual reproducibility was evaluated in four measurements taken in hourly intervals within the same dialysis treatment. Ten patients were studied. Absolute blood volumes measured at the beginning and after 1 hour of dialysis were significantly different (80.6 ± 14.5 and 63.9 ± 14.3 mL/kg, P < .001) and highly reproducible between the last three measurements (63.9 ± 14.3, 61.4 ± 13.8, and 60.9 ± 13.9 mL/kg, P = n.s.). Measurement of absolute blood volume after 1 hour of treatment is more precise than earlier measurements and might be better suited for guidance of ultrafiltration.
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Affiliation(s)
- Susanne Kron
- Department of Nephrology and Internal Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Daniel Schneditz
- Division of Physiology, Otto Loewi Research Center, Medical University of Graz, Graz, Austria
| | - David F Keane
- Department of Renal Medicine, Leeds Teaching Hospitals, Leeds, UK
| | - Til Leimbach
- KfH Kidney Center Berlin-Köpenick, Berlin, Germany
| | - Joachim Kron
- KfH Kidney Center Berlin-Köpenick, Berlin, Germany
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17
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Sugita C, Yamashita A, Tsutsumi S, Kai H, Sonoda T, Yoshida H, Yamamoto R, Asada Y, Kurokawa M. Brazilian propolis (AF-08) inhibits collagen-induced platelet aggregation without affecting blood coagulation. J Nat Med 2021; 75:975-984. [PMID: 33945121 DOI: 10.1007/s11418-021-01518-w] [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: 11/18/2020] [Accepted: 04/15/2021] [Indexed: 11/29/2022]
Abstract
Brazilian propolis (AF-08) is a dietary supplement containing a variety of flavonoids. It is used worldwide as a folk medicine. Flavonoids and a diet of fruits and vegetables containing them have been shown to reduce the risk of cardiovascular diseases (CVDs). Most of CVDs are caused by arterial thrombus formation. A thrombus is formed by the interaction between adhesion and aggregation of platelets to damaged blood vessels and blood coagulation consisting of extrisic and intrinsic pathways. Platelet aggregation and blood coagulation are closely linked to thrombosis. Therefore, we evaluated the effectiveness of AF-08 or its component flavonoids against thrombosis by examining their inhibition of platelet aggregation and blood coagulation. Human platelet-rich plasma was incubated with serial dilutions of AF-08 for 10 min to assess its inhibitory effect on platelet aggregation caused by collagen. The inhibitory effect of AF-08 on blood coagulation was evaluated by the prothrombin time (PT) and activated partial thromboplastin time (APTT), which reflect the coagulation function of extrinsic and intrinsic pathways, respectively. AF-08 significantly inhibited collagen-induced platelet aggregation but not PT and APTT, indicating that AF-08 inhibited platelet aggregation but not blood coagulation. Among three flavonoids contained in AF-08, apigenin and chrysin obviously inhibited platelet aggregation but the inhibitory effect of kaempferol was less effective. The three flavonoids did not affect PT and APTT. The inhibitory activity of AF-08 on human platelet aggregation without affecting blood coagulation was suggested to be partially due to apigenin and chrysin. AF-08 may be effective in suppressing platelet-based arterial thrombus formation and reducing the risk of CVDs.
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Affiliation(s)
- Chihiro Sugita
- Graduate School of Clinical Pharmacy, Kyushu University of Health and Welfare, 1714-1 Yoshino-cho, Nobeoka, Miyazaki, 882-8508, Japan
| | - Atsushi Yamashita
- Department of Pathology, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | | | - Hisahiro Kai
- Graduate School of Clinical Pharmacy, Kyushu University of Health and Welfare, 1714-1 Yoshino-cho, Nobeoka, Miyazaki, 882-8508, Japan
| | - Tohru Sonoda
- Department of Occupational Therapy, School of Health and Science, Kyushu University of Health and Welfare, 1714-1 Yoshino-cho, Nobeoka, Miyazaki, 882-8508, Japan
| | - Hiroki Yoshida
- Graduate School of Clinical Pharmacy, Kyushu University of Health and Welfare, 1714-1 Yoshino-cho, Nobeoka, Miyazaki, 882-8508, Japan
| | - Ryuichi Yamamoto
- Graduate School of Clinical Pharmacy, Kyushu University of Health and Welfare, 1714-1 Yoshino-cho, Nobeoka, Miyazaki, 882-8508, Japan
| | - Yujiro Asada
- Department of Pathology, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Masahiko Kurokawa
- Graduate School of Clinical Pharmacy, Kyushu University of Health and Welfare, 1714-1 Yoshino-cho, Nobeoka, Miyazaki, 882-8508, Japan.
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18
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Álvarez Nadal M, Martín Capón I, Viera Ramírez ER, Fernández Lucas M. Absolute blood volume variations during hemodialysis: Does dialysate temperature play a role? Semin Dial 2021; 34:309-314. [PMID: 33580986 DOI: 10.1111/sdi.12958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/14/2020] [Accepted: 01/12/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Vascular refilling occurs to preserve hemodynamic stability during hemodialysis (HD). Recent studies report a feasible and noninvasive method to determine absolute blood volume (ABV), and estimate vascular refilling during HD. The objective of this study is to analyze if lowering dialysate temperature modifies variations in ABV during HD. METHODS The study was performed in 50 patients under HD. During two different sessions, relative blood volume was assessed using dialysate temperatures of 35.5°C (cool dialysate) and 36.5°C (neutral dialysate). ABV and vascular refilling were calculated using Kron et al methodology. RESULTS Thirty-nine intradialytic morbid events (IMEs) were observed in 30 patients, 14 under cool dialysate and 25 during neutral dialysate. We did not found statistically differences in ABV or in refilling volume between cool and neutral temperature. When analyzing apart only those patients who presented IME, we observed lower drop in ABV in the 35.5°C dialysate treatments (0.57 L) versus 36.5°C dialysate treatments (0.71 L). When cool dialysate was used, the vascular refilling fraction tended to be higher, but data did not turn statistically significant. CONCLUSIONS In selected groups of patients the use of cool dialysate induces lower ABV variations that could improve hemodynamic stability during HD treatments.
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Affiliation(s)
- Marta Álvarez Nadal
- Department of Nephrology, IRYCIS, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Irene Martín Capón
- Department of Nephrology, IRYCIS, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Milagros Fernández Lucas
- Department of Nephrology, IRYCIS, Hospital Universitario Ramón y Cajal, Madrid, Spain.,Universidad de Alcalá, Madrid, Spain
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19
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Álvarez Nadal M, Viera Ramírez ER, Martín Capón I, Fernández Lucas M. Absolute blood volume variations and vascular refilling in hemodialysis patients. Semin Dial 2021; 34:229-234. [PMID: 33556227 DOI: 10.1111/sdi.12952] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 12/10/2020] [Indexed: 11/29/2022]
Abstract
The imbalance between ultrafiltration volume (UF) and vascular refilling is considered a major cause for intradialytic hypotension. Recent studies report a noninvasive method to estimate vascular refilling (VREF ) by determining absolute blood volume (ABV). It was the aim of the study to analyze variations in ABV in a group of hemodialysis (HD) patients and examine VREF . Thirty one stable chronic HD patients were studied, aged 71.07 ± 13.31 years. Dialysis duration and UF requirements were based on physician prescription. VREF was calculated as: VREF = VUF - ΔV where ΔV is ABV variation during dialysis treatment. ABV at the beginning of the dialysis was 6.00 ± 2.39 L (92.82 ± 33.17 ml/kg) and at the end 5.38 ± 2.32 L (82.07 ± 31.41 ml/kg). Prescribed UF was 2.64 ± 0.83 L. Mean VREF was 2.05 ± 0.80 L, with a refilling fraction of 75.75 ± 12.79%. VREF was strongly correlated with UF volume (r2 0.877), and with pre-dialysis volume overload (r2 0.617). Patients under beta-blocker treatment showed significantly lower FREF . ABV measurement is an easy and noninvasive method that allows us to study VREF during HD. We found a strong correlation between VREF and UF.
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Affiliation(s)
- Marta Álvarez Nadal
- Department of Nephrology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Irene Martín Capón
- Department of Nephrology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Milagros Fernández Lucas
- Department of Nephrology, Hospital Universitario Ramón y Cajal, Madrid, Spain.,Department of Nephrology, Facultad de Medicina, Universidad de Alcalá, IRYCIS, Madrid, Spain
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20
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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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21
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Canaud B, Chazot C, Koomans J, Collins A. Fluid and hemodynamic management in hemodialysis patients: challenges and opportunities. ACTA ACUST UNITED AC 2020; 41:550-559. [PMID: 31661543 PMCID: PMC6979572 DOI: 10.1590/2175-8239-jbn-2019-0135] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 07/08/2019] [Indexed: 02/07/2023]
Abstract
Fluid volume and hemodynamic management in hemodialysis patients is an essential component of dialysis adequacy. Restoring salt and water homeostasis in hemodialysis patients has been a permanent quest by nephrologists summarized by the ‘dry weight’ probing approach. Although this clinical approach has been associated with benefits on cardiovascular outcome, it is now challenged by recent studies showing that intensity or aggressiveness to remove fluid during intermittent dialysis is associated with cardiovascular stress and potential organ damage. A more precise approach is required to improve cardiovascular outcome in this high-risk population. Fluid status assessment and monitoring rely on four components: clinical assessment, non-invasive instrumental tools (e.g., US, bioimpedance, blood volume monitoring), cardiac biomarkers (e.g. natriuretic peptides), and algorithm and sodium modeling to estimate mass transfer. Optimal management of fluid and sodium imbalance in dialysis patients consist in adjusting salt and fluid removal by dialysis (ultrafiltration, dialysate sodium) and by restricting salt intake and fluid gain between dialysis sessions. Modern technology using biosensors and feedback control tools embarked on dialysis machine, with sophisticated analytics will provide direct handling of sodium and water in a more precise and personalized way. It is envisaged in the near future that these tools will support physician decision making with high potential of improving cardiovascular outcome.
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Affiliation(s)
- Bernard Canaud
- Montpellier University, Montpellier, France.,Senior Medical Scientist, Global Medical Office, FMC Deutschland, Bad Homburg, Germany
| | - Charles Chazot
- Head of Clinical Governance, NephroCare France, Fresnes, France
| | - Jeroen Koomans
- Maastricht University Medical Center, Department of Internal Medicine, Division of Nephrology, Netherlands
| | - Allan Collins
- University of Minnesota, Minneapolis Minnesota, USA.,Senior Medical Scientist, Global Medical Office, FMC North America, Waltham, MA, USA
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22
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Kron S, Schneditz D, Leimbach T, Kron J. Feedback control of absolute blood volume: A new technical approach in hemodialysis. Hemodial Int 2020; 24:344-350. [PMID: 32115891 DOI: 10.1111/hdi.12826] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 02/06/2020] [Accepted: 02/17/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The success of automatic feedback control systems to improve hemodynamic stability by preventing relative blood volume from dropping beyond a critical value during dialysis is limited. The aim of this study was to use one of these systems for control of absolute rather than relative blood volume to prevent volume-dependent morbid events. METHODS Dialysis was delivered by a machine providing feedback control of ultrafiltration rates, relative blood volume monitoring, and accurate bolus infusion of 240 mL of dialysate to measure absolute blood volume at the beginning of dialysis. Critical relative blood volume required by the control algorithm was calculated from absolute blood volume at the beginning and a critical absolute blood volume of 67 mL/kg. FINDINGS In 40 stable patients, ultrafiltration was guided by blood volume using the feedback algorithm of the integrated program. Blood volume was maintained in a narrow range above the prespecified minimal value of 67 mL/kg. At the end of dialysis, absolute blood volume ranged from 67.5 to 72.5 mL/kg (69.4 ± 1.3 mL/kg). No volume-dependent intradialytic morbid event occurred. DISCUSSION A feedback control system for relative blood volume-controlled ultrafiltration can be used for control of absolute blood volume. A prescribed target of absolute blood volume can be converted into relative blood volume, and this can subsequently be reached automatically with the integrated feedback system of the dialysis machine. Intradialytic morbid events could be considerably reduced. The whole procedure could be completely automated without altering the hardware of the dialysis device.
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Affiliation(s)
- Susanne Kron
- Department of Nephrology and Internal Intensive Care Medicine, Charite Universitätsmedizin Berlin, Berlin, Germany
| | - Daniel Schneditz
- Division of Physiology, Otto Loewi Research Center, Medical University of Graz, Graz, Austria
| | - Til Leimbach
- KfH Kidney Center Berlin-Köpenick, Berlin, Germany
| | - Joachim Kron
- KfH Kidney Center Berlin-Köpenick, Berlin, Germany
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23
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Bomholt T, Larsson S, Rix M, Rytter S, Feldt‐Rasmussen B, Hornum M, Lundby C. Intravascular volumes evaluated by a carbon monoxide rebreathing method in patients undergoing chronic hemodialysis. Hemodial Int 2020; 24:252-260. [DOI: 10.1111/hdi.12820] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 01/08/2020] [Accepted: 01/20/2020] [Indexed: 02/02/2023]
Affiliation(s)
- Tobias Bomholt
- Department of Nephrology, RigshospitaletUniversity of Copenhagen Copenhagen Denmark
| | - Sara Larsson
- Department of Nephrology, RigshospitaletUniversity of Copenhagen Copenhagen Denmark
| | - Marianne Rix
- Department of Nephrology, RigshospitaletUniversity of Copenhagen Copenhagen Denmark
| | - Sarah Rytter
- Department of Nephrology, RigshospitaletUniversity of Copenhagen Copenhagen Denmark
| | - Bo Feldt‐Rasmussen
- Department of Nephrology, RigshospitaletUniversity of Copenhagen Copenhagen Denmark
- Faculty of Health and Medical Sciences, Department of Clinical MedicineUniversity of Copenhagen Copenhagen Denmark
| | - Mads Hornum
- Department of Nephrology, RigshospitaletUniversity of Copenhagen Copenhagen Denmark
- Faculty of Health and Medical Sciences, Department of Clinical MedicineUniversity of Copenhagen Copenhagen Denmark
| | - Carsten Lundby
- Centre for Physical Activity Research, Rigshospitalet Copenhagen Denmark
- Inland Norway University of Applied Sciences Lillehammer Norway
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24
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Pstras L, Debowska M, Wojcik-Zaluska A, Zaluska W, Waniewski J. Hemodialysis-induced changes in hematocrit, hemoglobin and total protein: Implications for relative blood volume monitoring. PLoS One 2019; 14:e0220764. [PMID: 31404089 PMCID: PMC6690539 DOI: 10.1371/journal.pone.0220764] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 07/23/2019] [Indexed: 12/04/2022] Open
Abstract
Background Relative blood volume (RBV) changes during hemodialysis (HD) are typically estimated based on online measurements of hematocrit, hemoglobin or total blood protein. The aim of this study was to assess changes in the above parameters during HD in order to compare the potential differences in the RBV changes estimated by individual methods. Methods 25 anuric maintenance HD patients were monitored during a 1-week conventional HD treatment. Blood samples were collected from the arterial dialysis blood line at the beginning and at the end of each HD session. The analysis of blood samples was performed using the hematology analyzer Advia 2120 and clinical chemistry analyzer Advia 1800 (Siemens Healthcare). Results During the analyzed 30 HD sessions with ultrafiltration in the range 0.7–4.0 L (2.5 ± 0.8 L) hematocrit (HCT) increased by 9.1 ± 7.0% (mean ± SD), hemoglobin (HGB) increased by 10.6 ± 6.3%, total plasma protein (TPP) increased by 15.6 ± 9.5%, total blood protein (TBP) increased by 10.4 ± 5.8%, red blood cell count (RBC) increased by 10.8 ± 7.1%, while mean corpuscular red cell volume (MCV) decreased by 1.5 ± 1.1% (all changes statistically significant, p < 0.001). HGB increased on average by 1.5% more than HCT (p < 0.001). The difference between HGB and TBP increase was insignificant (p = 0.16). Conclusions Tracking HGB or TBP can be treated as equivalent for the purpose of estimating RBV changes during HD. Due to the reduction of MCV, the HCT-based estimate of RBV changes may underestimate the actual blood volume changes.
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Affiliation(s)
- Leszek Pstras
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
- * E-mail:
| | - Malgorzata Debowska
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
| | - Alicja Wojcik-Zaluska
- Department of Physical Therapy and Rehabilitation, Medical University of Lublin, Lublin, Poland
| | - Wojciech Zaluska
- Department of Nephrology, Medical University of Lublin, Lublin, Poland
| | - Jacek Waniewski
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
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Alayoud A, Belarabi M, Labrini F, Badaoui M, Zajjari Y, Maoujoud O, Arrayhani M, El Fillali K. Utility of a blood volume monitor in the management of anemia in dialysis by computing the total hemoglobin mass. Hemodial Int 2019; 23:419-425. [DOI: 10.1111/hdi.12776] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 07/08/2019] [Accepted: 07/13/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Ahmed Alayoud
- Department of Medicine, Division of NephrologyMilitary Hospital Agadir Morocco
- Faculty of Medicine and PharmacyIBN ZOHR University Agadir Morocco
| | - Marouane Belarabi
- Department of Medicine, Division of NephrologyMilitary Hospital Agadir Morocco
| | - Faycal Labrini
- Laboratory of HematologyMilitary Hospital Agadir Morocco
| | - Mohammed Badaoui
- Department of Medicine, Division of NephrologyMilitary Hospital Agadir Morocco
- Faculty of Medicine and PharmacyIBN ZOHR University Agadir Morocco
| | - Yassir Zajjari
- Department of NephrologyMilitary Hospital Mohammed V Rabat Morocco
| | - Omar Maoujoud
- Faculty of Medicine and PharmacyIBN ZOHR University Agadir Morocco
| | | | - Karim El Fillali
- Faculty of Medicine and PharmacyIBN ZOHR University Agadir Morocco
- Department of ReanimationMilitary Hospital Agadir Morocco
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Variable-Volume Kinetic Model to Estimate Absolute Blood Volume in Patients on Dialysis Using Dialysate Dilution. ASAIO J 2018; 64:77-85. [PMID: 28742531 DOI: 10.1097/mat.0000000000000608] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Long- and short-term adverse outcomes in hemodialysis (HD) have been associated with intradialytic hypotension, a common HD complication and significant cause of morbidity. It has been suggested that knowledge of absolute blood volume (ABV) could be used to significantly improve treatment outcomes. Different dilution-based protocols have been proposed for estimating ABV, all relying on the classic mono-exponential back-extrapolation algorithm (BEXP). In this paper, we introduce a dialysate dilution protocol and an estimation algorithm based on a variable-volume, two-compartment, intravascular blood water content kinetic model (VVKM). We compare ABV estimates derived using the two algorithms in a dialysate dilution study including three arterio-venous (AV) and three central-venous (CV) access patients, and multiple bolus injection tests (3-5) within each of several (2-6) HD treatments. The distribution of differences between ABV estimated from the two methods showed negligible systematic difference between the mean values of ABVs estimated from the BEXP and VVKM algorithms, however, the VVKM estimates were 53% and 42% more precise for the CV and AV patients, respectively. Good agreement was observed between measured and VVKM-estimated blood water concentration with the root-mean-square error (RMSE) less than 0.02 kg/kg (2%) and 0.03 kg/kg (3%) for AV and CV patients, respectively. The dilution protocol and the new VVKM-based estimation algorithm offer a noninvasive, inexpensive, safe, and practical approach for ABV estimation in routine HD settings.
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Abstract
PURPOSE OF REVIEW The aim of this article is to present current information on techniques for fluid status assessment in patients with kidney disease. The methods can be broadly categorized into biomarkers, ultrasound, blood volume monitoring, and bioimpedance. RECENT FINDINGS Biomarkers including atrial natriuretic peptide and B-type natriuretic peptide have been shown to provide information about relative changes in fluid status. Ultrasound is applied to measure inferior vena cava indices, pulmonary indicators, and vascular indicators of fluid overload. Relative blood volume monitoring is used to measure change in intravascular fluid during hemodialysis. While in principle appealing, measurement of absolute blood volume has seen limited use to date. Bioimpedance techniques such as vector analysis, whole body, and regional bioimpedance spectroscopy, have shown their ability to estimate fluid status. SUMMARY The interpretation of biomarkers is complicated by the presence of cardiac disease. All ultrasound methods have some correlation with fluid status; however, operator dependency limits their routine use. Bioimpedance methods and relative blood volume monitoring are increasingly used to assess fluid status in patients with acute or chronic kidney disease. Measurement of absolute blood volume holds promise for the future.
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Kron S, Schneditz D, Czerny J, Leimbach T, Budde K, Kron J. Adjustment of target weight based on absolute blood volume reduces the frequency of intradialytic morbid events. Hemodial Int 2017; 22:254-260. [DOI: 10.1111/hdi.12582] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Susanne Kron
- Department of Nephrology; Charité Universitätsmedizin Berlin; Berlin Germany
| | - Daniel Schneditz
- Institute of Physiology; Medical University of Graz; Graz Austria
| | - Jutta Czerny
- KfH Kidney Center Berlin-Köpenick; Berlin Germany
| | - Til Leimbach
- KfH Kidney Center Berlin-Köpenick; Berlin Germany
| | - Klemens Budde
- Department of Nephrology; Charité Universitätsmedizin Berlin; Berlin Germany
| | - Joachim Kron
- KfH Kidney Center Berlin-Köpenick; Berlin Germany
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Schneditz D, Niemczyk S, Sauseng N, Bachler I, Zierler E, Lackner HK, Hafner-Giessauf H. Osmotic and Hemodynamic Effects of Hypertonic Glucose During Hemodialysis. ASAIO J 2017; 63:824-831. [PMID: 28338477 DOI: 10.1097/mat.0000000000000574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
It was the purpose to quantify the hemodynamic effects of a bolus of hypertonic glucose injected into the extracorporeal system in a group of stable and nondiabetic patients during hemodialysis (HD). Glucose and electrolytes were measured in frequent intervals. Arterial blood pressures and heart rates were continuously recorded by noninvasive vascular unloading technique. Beat-to-beat stroke volume, cardiac output, and total peripheral resistance were determined by Modelflow method. Relative blood volumes were continuously measured by ultrasonic and optical means. Eight patients were studied in two treatments. Although arterial pressures and heart rates remained stable, stroke volume and cardiac output transiently increased above (19.2 ± 12.3%) and total peripheral resistance dropped below baseline (18.2 ± 8.6%) by a comparable magnitude. Relative blood volume transiently increased above baseline at 100% (104.9 ± 1.0%). Glucose concentrations were significantly related to relative blood volumes (r = 0.86, p < 0.001). In spite of a substantial increase in blood volume, a bolus of hypertonic glucose does not increase arterial pressures in nondiabetic patients because of concomitant vasodilatation. The relative increase in blood volume quantified by noninvasive HD technology follows the course of glucose and could be used as a surrogate to characterize patients with regard to their glucose metabolism during HD.
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Affiliation(s)
- Daniel Schneditz
- From the *Institute of Physiology, Medical University of Graz, Graz, Austria; †Department of Internal Diseases, Military Institute of Medicine, Warsaw, Poland; and ‡Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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Kron S, Schneditz D, Leimbach T, Aign S, Kron J. Vascular Refilling Is Not Reduced in Dialysis Sessions with Morbid Events. Blood Purif 2017; 43:309-314. [DOI: 10.1159/000453441] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 11/15/2016] [Indexed: 11/19/2022]
Abstract
Background: It is commonly believed that insufficient vascular refilling leads to hypovolemia during hemodialysis and contributes to intradialytic morbid events (IME). But data of refilling volumes at the time of IME are lacking. Methods: We compared the vascular refilling in 10 patients with IME with 14 stable patients with normal blood volume at the dialysis end (66-80 mL/kg). Results: The refilling characteristics in patients with IME did not differ from those in stable patients. The refilling fraction (refilling/ultrafiltration [UF] ratio) was 73.8 ± 9.4% in patients with IME, and 70.2 ± 6.4% in patients with normal blood volume at the end of the treatment. Refilling volume strongly correlated with UF volume in both patient groups (r2 = 0.93 and r2 = 0.81, respectively). Conclusion: IME are associated with a specific blood volume below 65 mL/kg. Vascular refilling is a constant fraction of UF in stable as well as in symptomatic dialysis sessions.
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Bourdenx JP, Fartoux L. Place des « outils embarqués » (BVM et BTM) dans la prise en charge de la surcharge hydro-sodée. Nephrol Ther 2016; 12:S17-S19. [DOI: 10.1016/s1769-7255(17)30023-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Maarek JMI, Rubinstein EH, Guo Y, Lane CJ, Campese VM, Holschneider DP. Measurement of Cardiac Output and Blood Volume During Hemodialysis with Fluorescent Dye Dilution Technique. Ann Biomed Eng 2016; 45:580-591. [PMID: 27539225 DOI: 10.1007/s10439-016-1711-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 08/10/2016] [Indexed: 11/24/2022]
Abstract
Intradialytic hypotensive events (IDH) accompanied by deleterious decreases of the cardiac output complicate up to 25% of hemodialysis treatments. Monitoring options available to track hemodynamic changes during hemodialysis have been found ineffective to anticipate the occurrence of IDH. We have assembled opto-electronic instrumentation that uses the fluorescence of a small bolus of indocyanine green dye injected in the hemodialysis circuit to estimate cardiac output and blood volume based on indicator dilution principles in patients receiving hemodialysis. The instrument and technique were tested in 24 adult end-stage renal failure subjects during 64 hemodialysis sessions. A single calibration factor could be used across subjects and across time. Intra-subject variability of the measurements over time was <10%. Stroke volume index (SVI) (mean ± SEM = 34 ± 1 vs. 39 ± 2 mL m-2) and central blood volume (CBV) index (783 ± 36 vs. 881 ± 33 mL m-2) were lower at the beginning of the sessions in which IDH eventually occurred. Cardiac index, SVI, and CBV index decreased with hemodialysis in all treatment sessions but the decrease was more intense in the IDH sessions. We conclude that hemodynamic monitoring can be implemented in patients receiving hemodialysis with minimal disruption of the treatment and could help understand intradialytic hypotension.
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Affiliation(s)
- Jean Michel I Maarek
- Department of Biomedical Engineering, University of Southern California, DRB 140, University Park, Los Angeles, CA, 90089-1111, USA.
| | - Eduardo H Rubinstein
- Department of Anesthesiology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Yumei Guo
- Department of Psychiatry & the Behavioral Sciences, University of Southern California, Los Angeles, CA, USA
| | - Christianne J Lane
- Southern California Clinical & Translational Science Institute, University of Southern California, Los Angeles, CA, USA
| | - Vito M Campese
- Division of Nephrology and Hypertension Center, Department of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Daniel P Holschneider
- Department of Biomedical Engineering, University of Southern California, DRB 140, University Park, Los Angeles, CA, 90089-1111, USA.,Department of Psychiatry & the Behavioral Sciences, University of Southern California, Los Angeles, CA, USA
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Kron S, Schneditz D, Leimbach T, Aign S, Kron J. Vascular refilling is independent of volume overload in hemodialysis with moderate ultrafiltration requirements. Hemodial Int 2016; 20:484-91. [DOI: 10.1111/hdi.12417] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Susanne Kron
- Department of Nephrology; Charité Universitätsmedizin Berlin; Berlin Germany
| | - Daniel Schneditz
- Institute of Physiology, Medical University of Graz; Graz Austria
| | - Til Leimbach
- KfH Kidney Center Berlin-Köpenick; Berlin Germany
| | - Sabine Aign
- KfH Kidney Center Berlin-Köpenick; Berlin Germany
| | - Joachim Kron
- KfH Kidney Center Berlin-Köpenick; Berlin Germany
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35
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Kron S, Schneditz D, Leimbach T, Czerny J, Aign S, Kron J. Determination of the critical absolute blood volume for intradialytic morbid events. Hemodial Int 2015; 20:321-6. [DOI: 10.1111/hdi.12375] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Susanne Kron
- Department of Nephrology; Charité Universitätsmedizin Berlin; Berlin Germany
| | - Daniel Schneditz
- Institute of Physiology; Medical University of Graz; Graz Austria
| | - Til Leimbach
- KfH Kidney Center Berlin-Köpenick; Berlin Germany
| | - Jutta Czerny
- KfH Kidney Center Berlin-Köpenick; Berlin Germany
| | - Sabine Aign
- KfH Kidney Center Berlin-Köpenick; Berlin Germany
| | - Joachim Kron
- KfH Kidney Center Berlin-Köpenick; Berlin Germany
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