Effect of Beta-Blocker Cardioselectivity on Vascular Refilling in Hemodialysis Patients

Vascular refilling in hemodialysis using feedback-controlled ultrafiltration profile

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.

Current Knowledge of Beta-Blockers in Chronic Hemodialysis Patients

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.

Vascular refilling depends on the ratio of blood volume to extracellular volume in hemodialysis patients

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.

Dynamics of vascular refilling in extended nocturnal hemodialysis

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 (R_bex ) 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.