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Assessment of microcirculatory function during hemodialysis. Curr Opin Nephrol Hypertens 2022; 31:553-559. [PMID: 36172854 DOI: 10.1097/mnh.0000000000000831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Patients with chronic kidney disease characteristically exhibit microcirculatory dysfunction, in combination with vascular damage. Hemodialysis superimposes additional circulatory stress to the microvasculature (repetitive ischemic insults/cumulative damage) resulting in high mortality. Intradialytic monitoring and hemodialysis delivery is currently limited to macrovascular/systemic assessment and detection of intradialytic systemic hypotension. Monitoring of the microcirculation has the potential to provide valuable information on hemodialysis-induced circulatory stress likely to result in end-organ ischemia (with/without systemic hypotension) generating an opportunity to intervene before tissue injury occurs. RECENT FINDINGS Various noninvasive technologies have been used assessing the microcirculation in hemodialysis patients at rest. Some technologies have also been applied during hemodialysis studying the effects of treatment on the microcirculation. Despite the approach used, results are consistent. Hemodialysis patients have impaired microcirculations with treatment adding additional stress to inadequately regulated vascular beds. Utility/practicality/clinical relevance vary significantly between methodologies. SUMMARY Intradialytic monitoring of the microcirculation can provide additional insights into a patient's individual response to treatment. However, this valuable perspective has not been adopted into clinical practice. A microcirculatory view could provide a window of opportunity to enable a precision medicine approach to treatment delivery improving current woefully poor subjective and objective clinical outcomes.
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2
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Murugan R, Kazory A, Sgarabotto L, Ronco C. Fluid Overload and Precision Net Ultrafiltration in Critically Ill Patients. Cardiorenal Med 2022; 13:9-18. [PMID: 36202071 PMCID: PMC10076441 DOI: 10.1159/000527390] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 09/19/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Fluid overload is present in two-thirds of critically ill patients with acute kidney injury and is associated with morbidity, mortality, and increased healthcare resource utilization. Kidney replacement therapy (KRT) is frequently used for net fluid removal (i.e., net ultrafiltration [UFNET]) in patients with severe oliguric acute kidney injury. However, ultrafiltration has considerable risks associated with it, and there is a need for newer technology to perform ultrafiltration safely and to improve outcomes. SUMMARY Caring for a critically ill patient with oliguric acute kidney injury and fluid overload is one of the most challenging problems. Although diuretics are the first-line treatment for management of fluid overload, diuretic resistance is common. Various clinical practice guidelines support fluid removal using ultrafiltration during KRT. Emerging evidence from observational studies in critically ill patients suggests that both slow and fast rates of net fluid removal during continuous kidney replacement therapy are associated with increased mortality compared with moderate UFNET rates. In addition, fast UFNET rates are associated with an increased risk of cardiac arrhythmias. Randomized trials are required to examine whether moderate UFNET rates are associated with a reduced risk of hemodynamic instability, organ injury, and improved outcomes in critically ill patients. There is a need for newer technology for fluid removal in patients who do not meet traditional criteria for initiation of KRT. Emerging newer and miniaturized ultrafiltration devices may address an unmet clinical need. KEY MESSAGES Among critically ill patients with acute kidney injury and fluid overload requiring continuous kidney replacement therapy, use of higher and slower UFNET rates compared with moderate UFNET rates might be associated with poor outcomes. Newer minimally invasive technologies may allow for safe and efficient UFNET in patients with acute kidney injury who do not meet criteria for initiation of KRT.
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Affiliation(s)
- Raghavan Murugan
- The Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Amir Kazory
- Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida, Gainesville, Florida, USA
| | - Luca Sgarabotto
- Department of Medicine, Nephrology, Dialysis and Transplantation Unit, University of Padova, Italy
| | - Claudio Ronco
- Department of Medicine, University of Padova, International Renal Research Institute of Vicenza and Department of Clinical Nephrology, San Bortolo Hospital, Vicenza, Italy
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3
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Monitoring skin blood flow to rapidly identify alterations in tissue perfusion during fluid removal using continuous veno-venous hemofiltration in patients with circulatory shock. Ann Intensive Care 2021; 11:59. [PMID: 33855645 PMCID: PMC8046875 DOI: 10.1186/s13613-021-00847-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 03/29/2021] [Indexed: 12/13/2022] Open
Abstract
Background Continuous veno-venous hemofiltration (CVVH) can be used to reduce fluid overload and tissue edema, but excessive fluid removal may impair tissue perfusion. Skin blood flow (SBF) alters rapidly in shock, so its measurement may be useful to help monitor tissue perfusion. Methods In a prospective, observational study in a 35-bed department of intensive care, all patients with shock who required fluid removal with CVVH were considered for inclusion. SBF was measured on the index finger using skin laser Doppler (Periflux 5000, Perimed, Järfälla, Sweden) for 3 min at baseline (before starting fluid removal, T0), and 1, 3 and 6 h after starting fluid removal. The same fluid removal rate was maintained throughout the study period. Patients were grouped according to absence (Group A) or presence (Group B) of altered tissue perfusion, defined as a 10% increase in blood lactate from T0 to T6 with the T6 lactate ≥ 1.5 mmol/l. Receiver operating characteristic curves were constructed and areas under the curve (AUROC) calculated to identify variables predictive of altered tissue perfusion. Data are reported as medians [25th–75th percentiles]. Results We studied 42 patients (31 septic shock, 11 cardiogenic shock); median SOFA score at inclusion was 9 [8–12]. At T0, there were no significant differences in hemodynamic variables, norepinephrine dose, lactate concentration, ScvO2 or ultrafiltration rate between groups A and B. Cardiac index and MAP did not change over time, but SBF decreased in both groups (p < 0.05) throughout the study period. The baseline SBF was lower (58[35–118] vs 119[57–178] perfusion units [PU], p = 0.03) and the decrease in SBF from T0 to T1 (ΔSBF%) higher (53[39–63] vs 21[12–24]%, p = 0.01) in group B than in group A. Baseline SBF and ΔSBF% predicted altered tissue perfusion with AUROCs of 0.83 and 0.96, respectively, with cut-offs for SBF of ≤ 57 PU (sensitivity 78%, specificity 87%) and ∆SBF% of ≥ 45% (sensitivity 92%, specificity 99%). Conclusion Baseline SBF and its early reduction after initiation of fluid removal using CVVH can predict worsened tissue perfusion, reflected by an increase in blood lactate levels. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00847-z.
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4
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Murugan R, Bellomo R, Palevsky PM, Kellum JA. Ultrafiltration in critically ill patients treated with kidney replacement therapy. Nat Rev Nephrol 2021; 17:262-276. [PMID: 33177700 PMCID: PMC9826716 DOI: 10.1038/s41581-020-00358-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2020] [Indexed: 01/30/2023]
Abstract
Management of fluid overload is one of the most challenging problems in the care of critically ill patients with oliguric acute kidney injury. Various clinical practice guidelines support fluid removal using ultrafiltration during kidney replacement therapy. However, ultrafiltration is associated with considerable risks. Emerging evidence from observational studies suggests that both slow and fast rates of net fluid removal (that is, net ultrafiltration (UFNET)) during continuous kidney replacement therapy are associated with increased mortality compared with moderate UFNET rates. In addition, fast UFNET rates are associated with an increased risk of cardiac arrhythmias. Experimental studies in patients with kidney failure who were treated with intermittent haemodialysis suggest that fast UFNET rates are also associated with ischaemic injury to the heart, brain, kidney and gut. The UFNET rate should be prescribed based on patient body weight in millilitres per kilogramme per hour with close monitoring of patient haemodynamics and fluid balance. Dialysate cooling and sodium modelling may prevent haemodynamic instability and facilitate large volumes of fluid removal in patients with kidney failure who are treated with intermittent haemodialysis, but the effects of this strategy on organ injury are less well studied in critically ill patients treated with continuous kidney replacement therapy. Randomized trials are required to examine whether moderate UFNET rates are associated with a reduced risk of haemodynamic instability, organ injury and improved outcomes in critically ill patients.
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Affiliation(s)
- Raghavan Murugan
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Rinaldo Bellomo
- Department of Intensive Care Medicine, The University of Melbourne, Austin Hospital, Melbourne, Victoria, Australia
| | - Paul M Palevsky
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - John A Kellum
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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5
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Abstract
PURPOSE OF REVIEW The aim of this study was to discuss the implication of microvascular dysfunction in septic shock. RECENT FINDINGS Resuscitation of sepsis has focused on systemic haemodynamics and, more recently, on peripheral perfusion indices. However, central microvascular perfusion is altered in sepsis and these alterations often persist despite normalization of various macro haemodynamic resuscitative goals. Endothelial dysfunction is a key element in sepsis pathophysiology. It is responsible for the sepsis-induced hypotension. In addition, endothelial dysfunction is also implicated involved in the activation of inflammation and coagulation processes leading to amplification of the septic response and development of organ dysfunction. It also promotes an increase in permeability, mostly at venular side, and impairs microvascular perfusion and hence tissue oxygenation.Microvascular alterations are characterized by heterogeneity in blood flow distribution, with adequately perfused areas in close vicinity to not perfused areas, thus characterizing the distributive nature of septic shock. Such microvascular alterations have profound implications, as these are associated with organ dysfunction and unfavourable outcomes. Also, the response to therapy is highly variable and cannot be predicted by systemic hemodynamic assessment and hence cannot be detected by classical haemodynamic tools. SUMMARY Microcirculation is a key element in the pathophysiology of sepsis. Even if microcirculation-targeted therapy is not yet ready for the prime time, understanding the processes implicated in microvascular dysfunction is important to prevent chasing systemic hemodynamic variables when this does not contribute to improve tissue perfusion.
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Kooman JP, Stenvinkel P, Shiels PG, Feelisch M, Canaud B, Kotanko P. The oxygen cascade in patients treated with hemodialysis and native high-altitude dwellers: lessons from extreme physiology to benefit patients with end-stage renal disease. Am J Physiol Renal Physiol 2020; 320:F249-F261. [PMID: 33356957 DOI: 10.1152/ajprenal.00540.2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Patients treated with hemodialysis (HD) repeatedly undergo intradialytic low arterial oxygen saturation and low central venous oxygen saturation, reflecting an imbalance between upper body systemic oxygen supply and demand, which are associated with increased mortality. Abnormalities along the entire oxygen cascade, with impaired diffusive and convective oxygen transport, contribute to the reduced tissue oxygen supply. HD treatment impairs pulmonary gas exchange and reduces ventilatory drive, whereas ultrafiltration can reduce tissue perfusion due to a decline in cardiac output. In addition to these factors, capillary rarefaction and reduced mitochondrial efficacy can further affect the balance between cellular oxygen supply and demand. Whereas it has been convincingly demonstrated that a reduced perfusion of heart and brain during HD contributes to organ damage, the significance of systemic hypoxia remains uncertain, although it may contribute to oxidative stress, systemic inflammation, and accelerated senescence. These abnormalities along the oxygen cascade of patients treated with HD appear to be diametrically opposite to the situation in Tibetan highlanders and Sherpa, whose physiology adapted to the inescapable hypobaric hypoxia of their living environment over many generations. Their adaptation includes pulmonary, vascular, and metabolic alterations with enhanced capillary density, nitric oxide production, and mitochondrial efficacy without oxidative stress. Improving the tissue oxygen supply in patients treated with HD depends primarily on preventing hemodynamic instability by increasing dialysis time/frequency or prescribing cool dialysis. Whether dietary or pharmacological interventions, such as the administration of L-arginine, fermented food, nitrate, nuclear factor erythroid 2-related factor 2 agonists, or prolyl hydroxylase 2 inhibitors, improve clinical outcome in patients treated with HD warrants future research.
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Affiliation(s)
- Jeroen P Kooman
- Division of Nephrology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Peter Stenvinkel
- Division of Renal Medicine, Department of Clinical Science Technology and Intervention, Karolinska Institutet, Stockholm, Sweden
| | - Paul G Shiels
- Institute of Cancer Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Martin Feelisch
- Clinical and Experimental Sciences and Integrative Physiology and Critical Illness Group, Faculty of Medicine, Southampton General Hospital and Institute for Life Sciences, University of Southampton, Southampton, United Kingdom
| | - Bernard Canaud
- Montpellier University, School of Medicine, Montpellier, France & Global Medical Office, Fresenius Medical Care, Bad Homburg, Germany
| | - Peter Kotanko
- Renal Research Institute, New York, New York.,Icahn School of Medicine at Mount Sinai, New York, New York
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Koch J, Idzerda NMA, Ettema EM, Kuipers J, Dam W, van den Born J, Franssen CFM. An acute rise of plasma Na+ concentration associates with syndecan-1 shedding during hemodialysis. Am J Physiol Renal Physiol 2020; 319:F171-F177. [DOI: 10.1152/ajprenal.00005.2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Endothelial dysfunction (ED) contributes to the high incidence of cardiovascular events in patients undergoing hemodialysis. Syndecan-1 in the endothelial glycocalyx can be shed into the circulation, serving as a biomarker for ED. As Na+ is a trigger for glycocalyx shedding, we now tested whether hemodialysis, with higher dialysate Na+ concentrations, is associated with more syndecan-1 shedding compared with standard hemodialysis (SHD). In this crossover study in 29 patients, plasma syndecan-1 was repeatedly measured during SHD and during Hemocontrol hemodialysis (HHD), which is characterized by initially higher dialysate and plasma Na+ levels. Courses of syndecan-1 were compared with linear mixed models. Syndecan-1 shedding was assessed by area under the curve analysis. Plasma Na+ increased early after the start of SHD and HHD, with higher values during HHD (30 min: 142.3 vs. 139.9 mM, P < 0.001). Syndecan-1 increased significantly during both conditions, but the percent change was higher (42.9% vs. 19.5%) and occurred earlier (120 vs. 180 min) during HHD. Syndecan-1 levels were significantly higher at 120 min during HHD compared with SHD ( P < 0.05). Overall, syndecan-1 shedding was higher during HHD compared with SHD (means: 40.4 vs. 19.0 arbitrary units, P = 0.06). Lower predialysis plasma Na+ and osmolality were associated with greater intradialytic increases in syndecan-1 levels (both groups, P = 0.001). The rise in plasma syndecan-1 levels was more pronounced and occurred earlier during hemodialysis with higher plasma Na+ levels. Although we cannot prove that the rise in plasma syndecan-1 originates from the endothelial glycocalyx, our findings are compatible with Na+-driven endothelial glycocalyx-derived syndecan-1 shedding.
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Affiliation(s)
- Josephine Koch
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Nienke M. A. Idzerda
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Esmée M. Ettema
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Johanna Kuipers
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Wendy Dam
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jacob van den Born
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Casper F. M. Franssen
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Williams J, Gilchrist M, Strain D, Fraser D, Shore A. The systemic microcirculation in dialysis populations. Microcirculation 2020; 27:e12613. [PMID: 32065681 DOI: 10.1111/micc.12613] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 02/08/2020] [Accepted: 02/14/2020] [Indexed: 12/17/2022]
Abstract
In a rapidly expanding population of patients with chronic kidney disease, including 2 million people requiring renal replacement therapy, cardiovascular mortality is 15 times greater than the general population. In addition to traditional cardiovascular risk factors, more poorly defined risks related to uremia and its treatments appear to contribute to this exaggerated risk. In this context, the microcirculation may play an important early role in cardiovascular disease associated with chronic kidney disease. Experimentally, the uremic environment and dialysis have been linked to multiple pathways causing microvascular dysfunction. Coronary microvascular dysfunction is reflected in remote and more easily studied vascular beds such as the skin. There is increasing evidence for a correlation between systemic microvascular dysfunction and adverse cardiovascular outcomes. Systemic microcirculatory changes have not been extensively investigated across the spectrum of chronic kidney disease. Recent advances in non-invasive techniques studying the microcirculation in vivo in man are increasing the data available particularly in patients on hemodialysis. Here, we review current knowledge of the systemic microcirculation in dialysis populations, explore whether non-invasive techniques to study its function could be used to detect early stage cardiovascular disease, address challenges faced in studying this patient cohort and identify potential future avenues for research.
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Affiliation(s)
- Jennifer Williams
- Diabetes and Vascular Medicine Research Centre, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK.,NIHR Exeter Clinical Research Facility, Royal Devon and Exeter Foundation NHS Trust, Exeter, UK
| | - Mark Gilchrist
- Diabetes and Vascular Medicine Research Centre, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK.,NIHR Exeter Clinical Research Facility, Royal Devon and Exeter Foundation NHS Trust, Exeter, UK
| | - David Strain
- Diabetes and Vascular Medicine Research Centre, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK.,NIHR Exeter Clinical Research Facility, Royal Devon and Exeter Foundation NHS Trust, Exeter, UK
| | - Donald Fraser
- Wales Kidney Research Unit, Cardiff University, Cardiff, UK
| | - Angela Shore
- Diabetes and Vascular Medicine Research Centre, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK.,NIHR Exeter Clinical Research Facility, Royal Devon and Exeter Foundation NHS Trust, Exeter, UK
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9
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MacEwen C, Watkinson P, Tarassenko L, Pugh C. What lies downstream: Cellular oxygen delivery during hemodialysis. Semin Dial 2018; 32:232-236. [PMID: 30515918 DOI: 10.1111/sdi.12769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Hemodialysis has been linked to structural and functional damage to vital organs such as the brain and heart, possibly via repetitive intradialytic organ ischemia. There is increasing recognition that tissue ischemia can occur without changes in standard hemodynamic parameters such as blood pressure, leading to interest in more direct assessment of the adequacy of oxygen delivery to tissues. In this article, we discuss our current understanding of what happens to cellular oxygen delivery during hemodialysis: we review the underlying physiology, potential measurement techniques, and the clinical literature to date.
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Affiliation(s)
- Clare MacEwen
- Oxford Kidney Unit, Oxford University Hospitals NHS Trust, Oxford, UK.,Adult Intensive Care Unit, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Peter Watkinson
- Adult Intensive Care Unit, Oxford University Hospitals NHS Trust, Oxford, UK.,Kadoorie Centre for Critical Care Research and Education, Kadoorie Centre for Critical Care Research and Education, Oxford University, Oxford, UK
| | - Lionel Tarassenko
- Department of Engineering Science, Institute of Biomedical Engineering, Oxford University, Oxford, UK
| | - Christopher Pugh
- Oxford Kidney Unit, Oxford University Hospitals NHS Trust, Oxford, UK.,Nuffield Department of Medicine, Oxford University, Oxford, UK
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Marques LPJ, Marinho PRS, Rocco R, Martins CDA, Pereira HNC, Ferreira ACLB. Effect of ultrafiltration on placental-fetal blood flow in pregnancy of woman undergoing chronic hemodialysis. Hemodial Int 2017; 22:405-412. [PMID: 29227585 DOI: 10.1111/hdi.12624] [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: 11/29/2022]
Abstract
INTRODUCTION Patient who was undergoing hemodialysis (HD) thrice weekly usually gain 1 to 4 kg of weight in interdialytic period, mainly due to fluid accumulation by ingestion of water. Ultrafiltration (UF) during HD will be need to remove fluid excess to avoid severe medical complications secondary to fluid overload. However, in pregnant woman UF can increase the episodes of intradialytic hypotension which may lead to placental ischemic injury and predispose to fetal distress. There is little information about safe fluid amount withdrawn by UF during pregnancy. METHODS We prospectively study by obstetric Doppler ultrasonography the fluxometric parameters: pulsatility index (PI) and resistance index (RI) of fetal middle cerebral, uterine, and umbilical artery obtained at the beginning and the end of HD session, the acute and chronic effect of UF on placenta and fetus blood flow, as well as the fetal outcome in 1 pregnant woman on chronic HD. FINDINGS We did not observe any acute harmful effect on fetal middle cerebral, placental and umbilical artery blood flow when UF rate of 2.1 ± 0.04 L (6 < 8 mL/h/kg) during HD session, no significant statistical difference was observed when compared PI and RI before and after UF and also when we compared these data with reference value on normal pregnancy to the same gestational age. DISCUSSION UF rate of 6 < 8 mL/h/kg during HD did not bring any acute harmful effect on fetal middle cerebral, placental, and umbilical blood flow and the UF rate of 1.4 6 0.4 L (< 6 mL/h/kg) / HD session that was done in all others HD during pregnancy was safe, without any chronic fetal deleterious effect. Obstetric Doppler ultrasonography is a simple and noninvasive method to fetal follow-up and can aid to determine safe UF rate in pregnant women during gestation.
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Affiliation(s)
- Luiz Paulo José Marques
- Renal Unit of Gaffrèe and Guinle University Hospital, Department of Medicine, Federal University of Rio de Janeiro State, Rio de Janeiro, Brazil
| | - Paulo Roberto Silva Marinho
- Obstetric Unit of Gaffrèe and Guinle University Hospital, Department of Medicine, Federal University of Rio de Janeiro State, Rio de Janeiro, Brazil
| | - Regina Rocco
- Obstetric Unit of Gaffrèe and Guinle University Hospital, Department of Medicine, Federal University of Rio de Janeiro State, Rio de Janeiro, Brazil
| | - Caroline de Azevedo Martins
- Renal Unit of Gaffrèe and Guinle University Hospital, Department of Medicine, Federal University of Rio de Janeiro State, Rio de Janeiro, Brazil
| | - Henrique Novo Costa Pereira
- Renal Unit of Gaffrèe and Guinle University Hospital, Department of Medicine, Federal University of Rio de Janeiro State, Rio de Janeiro, Brazil
| | - Ana Clara Lopes Barbosa Ferreira
- Renal Unit of Gaffrèe and Guinle University Hospital, Department of Medicine, Federal University of Rio de Janeiro State, Rio de Janeiro, Brazil
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