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Jensen JSK, Jørgensen IH, Buus NH, Jensen JD, Peters CD. Hemodynamic effects of low versus high dialysate bicarbonate concentration in hemodialysis patients. Hemodial Int 2024; 28:290-303. [PMID: 38803230 DOI: 10.1111/hdi.13162] [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: 12/26/2023] [Revised: 03/23/2024] [Accepted: 05/10/2024] [Indexed: 05/29/2024]
Abstract
INTRODUCTION Hemodialysis treatment using standard dialysate bicarbonate concentrations cause transient metabolic alkalosis possibly associated with hemodynamic instability. The aim of this study was to perform a detailed comparison of high and low dialysate bicarbonate in terms of blood pressure, intradialytic hemodynamic parameters, orthostatic blood pressure, and electrolytes. METHODS Fifteen hemodialysis patients were examined in a single-blind, randomized, controlled, crossover study. Participants underwent a 4-h hemodialysis session with dialysate bicarbonate concentration of 30 or 38 mmol/L with 1 week between interventions. Blood pressure was monitored throughout hemodialysis, while cardiac output, total peripheral resistance, stroke volume, and central blood volume were assessed with ultrasound dilution technique (Transonic). Orthostatic blood pressure was measured pre- and post-hemodialysis. FINDINGS With similar ultrafiltration (UF) volume (2.6 L), systolic blood pressure (SBP) tended to decrease more during high dialysate bicarbonate compared to low dialysate bicarbonate; the mean (95% confidence interval) between treatment differences in SBP were: 8 (-4; 20) mmHg (end of hemodialysis) and 7 (0; 15) mmHg (post-hemodialysis). Stroke volume decreased whereas total peripheral resistance increased significantly more during high dialysate bicarbonate compared to low dialysate bicarbonate with mean between treatment differences: Stroke volume: 12 (1; 23) mL; Total peripheral resistance: -2.9 (-5.3; -0.5) mmHg/(L/min). Cardiac output tended to decrease more with high dialysate bicarbonate compared to low dialysate bicarbonate with mean between treatment difference 0.7 (0.0; 1.4) L/min. High dialysate bicarbonate caused alkalosis, hypocalcemia, and lower plasma potassium, whereas patients remained normocalcemic with normal pH during low dialysate bicarbonate. Orthostatic blood pressure response after dialysis did not differ significantly. DISCUSSION The use of high dialysate bicarbonate compared to low dialysate bicarbonate was associated with hypocalcemia, alkalosis, and a more pronounced hypokalemia. During hemodialysis with UF, a better preservation of blood pressure, stroke volume, and cardiac output may be achieved with low dialysate bicarbonate compared to high dialysate bicarbonate.
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Affiliation(s)
- Jonas Schandorph Kaalund Jensen
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Ina Hunnerup Jørgensen
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Niels Henrik Buus
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jens Dam Jensen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Renal Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Christian Daugaard Peters
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Molnar AO, Killin L, Bota S, McArthur E, Dixon SN, Garg AX, Harris C, Thompson S, Tennankore K, Blake PG, Bohm C, MacRae J, Silver SA. Association Between the Dialysate Bicarbonate and the Pre-dialysis Serum Bicarbonate Concentration in Maintenance Hemodialysis: A Retrospective Cohort Study. Can J Kidney Health Dis 2024; 11:20543581241256774. [PMID: 38827142 PMCID: PMC11141227 DOI: 10.1177/20543581241256774] [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: 01/05/2024] [Accepted: 04/23/2024] [Indexed: 06/04/2024] Open
Abstract
Background It is unclear whether the use of higher dialysate bicarbonate concentrations is associated with clinically relevant changes in the pre-dialysis serum bicarbonate concentration. Objective The objective is to examine the association between the dialysate bicarbonate prescription and the pre-dialysis serum bicarbonate concentration. Design This is a retrospective cohort study. Setting The study was performed using linked administrative health care databases in Ontario, Canada. Patients Prevalent adults receiving maintenance in-center hemodialysis as of April 1, 2020 (n = 5414) were included. Measurements Patients were grouped into the following dialysate bicarbonate categories at the dialysis center-level: individualized (adjustment based on pre-dialysis serum bicarbonate concentration) or standardized (>90% of patients received the same dialysate bicarbonate concentration). The standardized category was stratified by concentration: 35, 36 to 37, and ≥38 mmol/L. The primary outcome was the mean outpatient pre-dialysis serum bicarbonate concentration at the patient level. Methods We examined the association between dialysate bicarbonate category and pre-dialysis serum bicarbonate using an adjusted linear mixed model. Results All dialysate bicarbonate categories had a mean pre-dialysis serum bicarbonate concentration within the normal range. In the individualized category, 91% achieved a pre-dialysis serum bicarbonate ≥22 mmol/L, compared to 87% in the standardized category. Patients in the standardized category tended to have a serum bicarbonate that was 0.25 (95% confidence interval [CI] = -0.93, 0.43) mmol/L lower than patients in the individualized category. Relative to patients in the 35 mmol/L category, patients in the 36 to 37 and ≥38 mmol/L categories tended to have a serum bicarbonate that was 0.70 (95% CI = -0.30, 1.70) mmol/L and 0.87 (95% CI = 0.14, 1.60) mmol/L higher, respectively. There was no effect modification by age, sex, or history of chronic lung disease. Limitations We could not directly confirm that all laboratory measurements were pre-dialysis. Data on prescribed dialysate bicarbonate concentrations for individual dialysis sessions were not available, which may have led to some misclassification, and adherence to a practice of individualization could not be measured. Residual confounding is possible. Conclusions We found no significant difference in the pre-dialysis serum bicarbonate concentration irrespective of whether an individualized or standardized dialysate bicarbonate was used. Dialysate bicarbonate concentrations ≥38 mmol/L (vs 35 mmol/L) may increase the pre-dialysis serum bicarbonate concentration by 0.9 mmol/L.
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Affiliation(s)
- Amber O. Molnar
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Institute for Clinical Evaluative Sciences, London, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, McMaster University/Hamilton Health Sciences, ON, Canada
- St. Joseph’s Healthcare Hamilton, Hamilton, ON, Canada
| | - Lauren Killin
- Institute for Clinical Evaluative Sciences, London, ON, Canada
- Lawson Health Research Institute, London Health Sciences Centre, ON, Canada
| | - Sarah Bota
- Institute for Clinical Evaluative Sciences, London, ON, Canada
- Lawson Health Research Institute, London Health Sciences Centre, ON, Canada
| | - Eric McArthur
- Institute for Clinical Evaluative Sciences, London, ON, Canada
- Lawson Health Research Institute, London Health Sciences Centre, ON, Canada
| | - Stephanie N. Dixon
- Institute for Clinical Evaluative Sciences, London, ON, Canada
- Lawson Health Research Institute, London Health Sciences Centre, ON, Canada
| | - Amit X. Garg
- Institute for Clinical Evaluative Sciences, London, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Lawson Health Research Institute, London Health Sciences Centre, ON, Canada
- Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
- Department of Epidemiology, Western University, London, ON, Canada
| | - Claire Harris
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Stephanie Thompson
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Karthik Tennankore
- Division of Nephrology, Department of Medicine, Nova Scotia Health Authority, Halifax, Canada
| | - Peter G. Blake
- Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
| | - Clara Bohm
- Division of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Canada
| | - Jennifer MacRae
- Division of Nephrology, Department of Medicine, University of Calgary, AB, Canada
| | - Samuel A. Silver
- Institute for Clinical Evaluative Sciences, London, ON, Canada
- Division of Nephrology, Department of Medicine, Queen’s University, Kingston, ON, Canada
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3
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Vongchaiudomchoke T, Aviphan K, Sanyakeun N, Wachiraphansakul N, Sawangduan V, Nochaiwong S, Ruengorn C, Noppakun K. Randomized Trial on the Effects of Dialysate Potassium Concentration on Intradialytic Hypertension. Kidney Int Rep 2023; 8:1323-1331. [PMID: 37441490 PMCID: PMC10334342 DOI: 10.1016/j.ekir.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 03/08/2023] [Accepted: 04/04/2023] [Indexed: 07/15/2023] Open
Abstract
Introduction Intradialytic hypertension is not an uncommon condition during chronic hemodialysis. It is associated with unfavorable cardiovascular outcomes, including hospitalization and mortality. Several small studies have demonstrated the contradictory effects of different dialysate potassium concentrations on intradialytic blood pressure. This study is a randomized crossover trial aiming to evaluate the effects of different dialysate potassium concentrations on intradialytic hypertension. Methods A 24-week, 2-treatment, 4-sequence, multicenter, double-blinded, randomized, crossover study was conducted at Maharaj Nakorn Chiang Mai Hospital and Lampang Hospital in Thailand among stable patients receiving chronic hemodialysis who experienced intradialytic hypertension >30% of their sessions over the past 3 months. Each participant was randomly assigned to 1 of 4 treatment sequences. During each intervention period, patients were dialyzed with dialysate potassium of either 2 mmol/l (D-K2) or 3 mmol/l (D-K3) for 4 weeks according to their preassigned sequence, separated by a 2-week washout period. The primary outcome was the incidence of intradialytic hypertension. Results Forty eligible patients were recruited. The mean age was 61.4 ± 14.2 years and the mean systolic blood pressure (SBP) was 146.6 ± 11.2 mm Hg. Of the 40 patients, 95.5% had hypertension and their average number of antihypertensive drugs was 2.8 ± 1.9. A total of 1380 dialysis sessions were included in the analysis (695 sessions for D-K2 and 685 sessions for D-K3). The incidence of intradialytic hypertension was not significantly different between different dialysate potassium concentrations (D-K2 54.7% vs. D-K3 53.1%, P = 0.788). The changes in SBP, diastolic blood pressure (DBP), and mean arterial pressure (MAP) were not different between the 2 dialysate potassium groups. Conclusion Dialysate potassium concentration of 2 or 3 mmol/l did not affect the incidence of intradialytic hypertension in patients receiving chronic hemodialysis who frequently developed intradialytic hypertension.
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Affiliation(s)
| | - Kanawat Aviphan
- Department of Internal Medicine, Lampang Hospital, Lampang, Thailand
| | - Nopparat Sanyakeun
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | | | | | - Surapon Nochaiwong
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
- Pharmacoepidemiology and Statistics Research Center, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Chidchanok Ruengorn
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
- Pharmacoepidemiology and Statistics Research Center, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Kajohnsak Noppakun
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Pharmacoepidemiology and Statistics Research Center, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
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Ghoshal S, Freedman BI. Renal Replacement Therapy and Dialysis-associated Neurovascular Injury (DANI) in the Neuro ICU: a Review of Pathophysiology and Preventative Options. Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-020-00661-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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5
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Silva VB, Macedo TA, Braga TMS, Silva BC, Graciolli FG, Dominguez WV, Drager LF, Moysés RM, Elias RM. High Dialysate Calcium Concentration is Associated with Worsening Left Ventricular Function. Sci Rep 2019; 9:2386. [PMID: 30787343 PMCID: PMC6382760 DOI: 10.1038/s41598-019-38887-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 01/11/2019] [Indexed: 12/05/2022] Open
Abstract
Dialysate calcium concentration (d[Ca]) might have a cardiovascular impact in patients on haemodialysis (HD) since a higher d[Ca] determines better hemodynamic tolerability. We have assessed the influence of d[Ca] on global longitudinal strain (GLS) by two-dimensional echocardiography using speckle-tracking imaging before and in the last hour of HD. This is an observational crossover study using d[Ca] 1.75 mmol/L and 1.25 mmol/L. Ultrafiltration was the same between interventions; patients aged 44 ± 13 years (N = 19). The 1.75 mmol/L d[Ca] was associated with lighter drop of blood pressure. Post HD serum total calcium was higher with d[Ca] 1.75 than with 1.25 mmol/L (11.5 ± 0.8 vs. 9.1 ± 0.5 mg/dL, respectively, p < 0.01). In almost all segments strain values were significantly worse in the peak HD with 1.75 mmol/L d[Ca] than with 1.25 mmol/L d[Ca]. GLS decreased from −19.8 ± 3.7% at baseline to −17.3 ± 2.9% and −16.1 ± 2.6% with 1.25 d[Ca] and 1.75 d[Ca] mmol/L, respectively (p < 0.05 for both d[Ca] vs. baseline and 1.25 d[Ca] vs. 1.75 d[Ca] mmol/L). Factors associated with a worse GLS included transferrin, C-reactive protein, weight lost, and post dialysis serum total calcium. We concluded that d[Ca] of 1.75 mmol/L was associated with higher post dialysis serum calcium, which contributed to a worse ventricular performance. Whether this finding would lead to myocardial stunning needs further investigation.
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Affiliation(s)
- V B Silva
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - T A Macedo
- Heart Institute (InCor), Universidade de São Paulo, São Paulo, Brazil
| | - T M S Braga
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - B C Silva
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - F G Graciolli
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - W V Dominguez
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - L F Drager
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil.,Heart Institute (InCor), Universidade de São Paulo, São Paulo, Brazil
| | - R M Moysés
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil.,Universidade Nove de Julho (UNINOVE), São Paulo, Brazil
| | - R M Elias
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil. .,Universidade Nove de Julho (UNINOVE), São Paulo, Brazil.
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Basile C, Rossi L, Lomonte C. Dialysate bicarbonate concentration: Too much of a good thing? Semin Dial 2018; 31:576-582. [PMID: 29885083 DOI: 10.1111/sdi.12716] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Acid-base equilibrium is a complex and vital system whose regulation is impaired in chronic kidney disease (CKD). Metabolic acidosis is a common complication of CKD. It is typically due to the accumulation of sulfate, phosphorus, and organic anions. Metabolic acidosis is correlated with several adverse outcomes, such as morbidity, hospitalization and mortality. In patients undergoing hemodialysis, acid-base homeostasis depends on many factors: net acid production, amount of alkali given by the dialysate bath, duration of interdialytic period, as well as residual diuresis, if any. Recent literature data suggest that the development of postdialysis metabolic alkalosis may contribute to adverse clinical outcomes. Unfortunately, no randomized studies exist about the effect of different dialysate bicarbonate concentrations on hard outcomes, such as mortality. Like everything else in dialysis, the quest for the "ideal" dialysate bicarbonate concentration is far from over. The Latin aphorism "ne quid nimis" ie "nothing in excess" (excess of neither acid nor base) probably best summarizes our current state of knowledge in this field. For the present, the clinician should understand that target values for predialysis serum bicarbonate concentrations have been established primarily based on observational studies and expert opinion. On the basis of this information, we should keep predialysis serum bicarbonate concentrations at least at 22 mEq/L. Furthermore, a specific focus should be addressed to the clinical and nutritional status of the major outliers on both the acid and alkaline sides of the curve.
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Affiliation(s)
- Carlo Basile
- Division of Nephrology, Clinical Research Branch, Miulli General Hospital, Acquaviva delle Fonti, Italy.,Associazione Nefrologica Gabriella Sebastio, Martina Franca, Italy
| | - Luigi Rossi
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
| | - Carlo Lomonte
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
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Panesar M, Shah N, Vaqar S, Ivaturi K, Gudleski G, Muscarella M, Lambert J, Su W, Murray B. Changes in Serum Bicarbonate Levels Caused by Acetate-Containing Bicarbonate-Buffered Hemodialysis Solution: An Observational Prospective Cohort Study. Ther Apher Dial 2017; 21:157-165. [DOI: 10.1111/1744-9987.12510] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 09/20/2016] [Accepted: 10/18/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Mandip Panesar
- The Regional Center of Excellence for Transplantation & Kidney Care at Erie County Medical Center; Buffalo New York
- Department of Medicine, Jacobs School of Medicine; University at Buffalo; Buffalo New York
| | - Neal Shah
- Department of Medicine, Jacobs School of Medicine; University at Buffalo; Buffalo New York
| | - Sarosh Vaqar
- Department of Medicine, Jacobs School of Medicine; University at Buffalo; Buffalo New York
| | - Kaushik Ivaturi
- Department of Medicine, Jacobs School of Medicine; University at Buffalo; Buffalo New York
| | - Gregory Gudleski
- Department of Medicine, Jacobs School of Medicine; Statistics and Data Management Lab; Buffalo New York USA
| | - Mary Muscarella
- The Regional Center of Excellence for Transplantation & Kidney Care at Erie County Medical Center; Buffalo New York
| | - Judy Lambert
- The Regional Center of Excellence for Transplantation & Kidney Care at Erie County Medical Center; Buffalo New York
| | - Winnie Su
- The Regional Center of Excellence for Transplantation & Kidney Care at Erie County Medical Center; Buffalo New York
- Department of Medicine, Jacobs School of Medicine; University at Buffalo; Buffalo New York
| | - Brian Murray
- The Regional Center of Excellence for Transplantation & Kidney Care at Erie County Medical Center; Buffalo New York
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Chauveau P, Rigothier C, Combe C. Con: Higher serum bicarbonate in dialysis patients is protective. Nephrol Dial Transplant 2016; 31:1226-9. [PMID: 27411724 DOI: 10.1093/ndt/gfw255] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 04/15/2016] [Indexed: 11/13/2022] Open
Abstract
Metabolic acidosis is often observed in advanced chronic kidney disease, with deleterious consequences on the nutritional status, bone and mineral status, inflammation and mortality. Through clearance of the daily acid load and a net gain in alkaline buffers, dialysis therapy is aimed at correcting metabolic acidosis. A normal bicarbonate serum concentration is the recommended target in dialysis patients. However, several studies have shown that a mild degree of metabolic acidosis in patients treated with dialysis is associated with better nutritional status, higher protein intake and improved survival. Conversely, a high bicarbonate serum concentration is associated with poor nutritional status and lower survival. It is likely that mild acidosis results from a dietary acid load linked to animal protein intake. In contrast, a high bicarbonate concentration in patients treated with dialysis could result mainly from an insufficient dietary acid load, i.e. low protein intake. Therefore, a high pre-dialysis serum bicarbonate concentration should prompt nephrologists to carry out nutritional investigations to detect insufficient dietary protein intake. In any case, a high bicarbonate concentration should be neither a goal of dialysis therapy nor an index of adequate dialysis, whereas mild acidosis could be considered as an indicator of appropriate protein intake.
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Affiliation(s)
- Philippe Chauveau
- Service de Néphrologie Transplantation Dialyse, Centre Hospitalier Universitaire de Bordeaux, Bordeaux 33076, France AURAD Aquitaine, Gradignan 33170, France
| | - Claire Rigothier
- Service de Néphrologie Transplantation Dialyse, Centre Hospitalier Universitaire de Bordeaux, Bordeaux 33076, France Unité INSERM 1026 Bioingénierie tissulaire, Université de Bordeaux, Bordeaux 33000, France
| | - Christian Combe
- Service de Néphrologie Transplantation Dialyse, Centre Hospitalier Universitaire de Bordeaux, Bordeaux 33076, France Unité INSERM 1026 Bioingénierie tissulaire, Université de Bordeaux, Bordeaux 33000, France
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9
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Hompesch C, Ma TW, Neyra JA, Ripley L, Xiao G, Inrig J, Toto R, Van Buren PN. Comparison of Ambulatory Blood Pressure Patterns in Patients With Intradialytic Hypertension and Hemodialysis Controls. Kidney Blood Press Res 2016; 41:240-9. [PMID: 27100207 PMCID: PMC4919278 DOI: 10.1159/000443427] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2016] [Indexed: 01/22/2023] Open
Abstract
Background/Aims Intradialytic hypertension (IH) patients have higher mortality risk than other hemodialysis patients and have been shown to have higher ambulatory blood pressure (BP). We hypothesized that interdialytic BP patterns would differ in IH patients and hypertensive hemodialysis controls. Methods We consecutively screened hemodialysis patients at our university-affliated units. Based on pre and post-HD BP measurements during the prior 2 week period, we identified IH patients and demographically matched hemodialysis controls. We measured ambulatory interdialytic BP, fow-mediated vasodilation, and intradialytic endothelin-1 (ET-1). Using linear mixed-models, we compared BP slopes during the following intervals: 1–24 hours post-dialysis, 25–44 hours post-dialysis, and 1–44 hours post-dialysis. Results There were 25 case subjects with IH and 24 controls. Systolic BP during hours 1–44, 1–24, and 25–44 were 143.1 (16.5), 138.0 (21.2), and 150.8 (22.3) mmHg in controls. For IH subjects, they were 155.4 (14.2), 152.7 (22.8), and 156.5 (20.8) mmHg (p=0.008, 0.02, 0.4). In controls, the slopes were +0.6, +0.6, and +0.4 mmHg/hr. In IH subjects, they were +0.1, −0.3, and +0.3 mmHg/hr. The IH 1–24 hour slope differed from the IH 25–44 hour slope (p=0.001) and the control 1–24 hour slope (p=0.002). The change in ET-1 from pre to post dialysis was 0.5 (1.5) pg/mL in controls and 1.0 (2.3) pg/mL in IH patients (p=0.4). In a univariate model, there was an association with screening BP and BP slope (p=0.002 for controls and p=0.1 for IH patients). Conclusions Interdialytic BP patterns differ in IH patients and hemodialysis controls. The elevated post dialysis blood pressure persists for many hours in IH patients contributing to the overall increased BP burden.
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Affiliation(s)
- Catherine Hompesch
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
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10
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Basile C, Rossi L, Lomonte C. The choice of dialysate bicarbonate: do different concentrations make a difference? Kidney Int 2016; 89:1008-1015. [PMID: 26924048 DOI: 10.1016/j.kint.2016.01.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 01/07/2016] [Accepted: 01/13/2016] [Indexed: 10/22/2022]
Abstract
Metabolic acidosis is a common complication of chronic kidney disease; it is typically caused by the accumulation of sulfate, phosphorus, and organic anions. Metabolic acidosis is correlated with several adverse outcomes, such as morbidity, hospitalization, and mortality. Thus, correction of metabolic acidosis is fundamental for the adequate management of many systemic complications of chronic kidney disease. In patients undergoing hemodialysis, acid-base homeostasis depends on many factors including the following: net acid production, amount of alkali given by the dialysate bath, duration of the interdialytic period, and residual diuresis, if any. Recent literature data suggest that the development of metabolic alkalosis after dialysis may contribute to adverse clinical outcomes. Our review is focused on the potential effects of different dialysate bicarbonate concentrations on hard outcomes such as mortality. Unfortunately, no randomized studies exist about this issue. Acid-base equilibrium is a complex and vital system whose regulation is impaired in chronic kidney disease. We await further studies to assess the extent to which acid-base status is a major determinant of overall survival in patients undergoing hemodialysis. For the present, the clinician should understand that target values for predialysis serum bicarbonate concentration have been established primarily based on observational studies and expert opinion. Based on this, we should keep the predialysis serum bicarbonate level at least at 22 mmol/l. Furthermore, a specific focus should be addressed by the attending nephrologist to the clinical and nutritional status of the major outliers on both the acid and alkaline sides of the curve.
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Affiliation(s)
- Carlo Basile
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy.
| | - Luigi Rossi
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
| | - Carlo Lomonte
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
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Hung AM, Hakim RM. In Reply to ‘Dialysate and Serum Potassium in Hemodialysis’. Am J Kidney Dis 2016; 67:165. [DOI: 10.1053/j.ajkd.2015.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 10/28/2015] [Indexed: 11/11/2022]
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12
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Silva BC, Moyses RM, Elias RM. Dialysate and Serum Potassium in Hemodialysis. Am J Kidney Dis 2016; 67:165. [DOI: 10.1053/j.ajkd.2015.10.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 10/28/2015] [Indexed: 11/11/2022]
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13
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Silva BC, Moysés RMA, Silva VB, Freitas GRR, Elias RM. Parathyroidectomized patients have impaired capacity of peripheral vascular constriction during hemodialysis. Hemodial Int 2015; 20:50-5. [PMID: 25923250 DOI: 10.1111/hdi.12309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Parathyroidectomy (PTx) seems to improve cardiovascular outcomes and reduce blood pressure levels. However, the effect of PTx on hemodynamic changes during hemodialysis (HD) is still overlooked. This was a prospective cohort design. Patients with end-stage renal disease on maintenance HD were included. Diabetes and nonsinusal rhythm were exclusion criteria. History of PTx was recorded. Finometer monitor was used to access parameters immediately pre- and post-HD sessions. Cardiac index (CI) variation (ΔCI) and peripheral arterial resistance variation (ΔPAR) were the variables of interest. Biochemical and echocardiographic data were also obtained. PTx patients (n = 11) were matched to non-PTx patients (n = 20). ΔPAR was lower in PTx group in comparison with non-PTx group (P = 0.039), which was independent of parathyroid hormone (PTH) levels. Multiple regression analysis showed that PTx, ΔCI, and dialysate calcium remained independently associated with PAR variation and even adjusted for ultrafiltration rate (adjusted r(2) = 0.64). In conclusion, parathyroidectomized patients have impaired capacity of vasoconstriction in response to ultrafiltration, an effect independent of serum PTH levels. Further studies are needed to elucidate mechanisms explaining the interaction between PTx and systemic vascular tonus.
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Affiliation(s)
- Bruno C Silva
- Nephrology Division, Universidade de São Paulo, São Paulo, Brazil
| | - Rosa M A Moysés
- Nephrology Division, Universidade de São Paulo, São Paulo, Brazil.,UNINOVE, Universidade Nove de Julho, São Paulo, Brazil
| | - Vitor B Silva
- Nephrology Division, Universidade de São Paulo, São Paulo, Brazil
| | | | - Rosilene M Elias
- Nephrology Division, Universidade de São Paulo, São Paulo, Brazil
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